Public Disclosure Authorized Managementdocuments.worldbank.org/curated/en/435561468046745273/pdf/multi0page.pdf · Purpose of the POA ... HCV Hepatitis C Virus HCWM Health Care Waste

E714Volume 3

Malawi Government

Health Care WasteManagement

Five Year Strategic Plan of ActionJuly 2003 -June 2008

Ministry of Health and Population

Lilongwe

4h July 2003

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GOVERNMENT OF MALAWI

HEALTH CARE WASTE MANAGEMENT

PLAN OF ACTION

JuIY 2003 -June 2008

MINISTRY OF HEALTH AND POPULATION

DEPARTMENT OF PREVENTIVE HEALTH SERVICES

4'* July2003

HCWM Strategic Plan of Action 2003-2008 Ministry of Health and Population

Table of ContentsTable of Contents ..................................... 2ABBREVIATION AND ACRONYMS ..................................... 5FOREWORD ..................................... 6Acknowledgement ..................................... 7EXECUTIVE SUMMARY ................................... . .8

Key findings: ..................................... 8Purpose of the POA .................................... 8Summary of Budget By Strategy Per Year .................................... . 10

1.0 INTRODUCTION.. I I1.1 Background .. 11.2 Geographical And Socioeconomic Situation .. 11.3 The National Health System .11.4 Main Areas Of Emphasis For The Five Year Strategic Plan Of Action . .12

1.4.1 Institutional and legal framework .121.4.2 Capacity Building And Training .131.4.3 IEC And Advocacy On Community Involvement In HCWM .131.4.5 Improvement of HCW Collection, Treatment And Disposal .13

2.0 OBJECTIVES AND STRATEGIES OF THE PLAN OF ACTION . . 152.2.1 Institutional and Legal frame work . . .152.2.2 Capacity Building And Training On HCWM . . .152.2.3 Improvement Of Health Care Waste Collection, Treatment, Transportation AndDisposal...152.2.4 Information, Communication, Education and advocacy for community involvement inHCWM...162.2.5 Public Private Partnership . . .162.2.6 Monitoring and evaluation . . .16

3.0 PROGRAM SEQUENCING .173.1 Immediate Activities ................................................................. 173.2 Short term Activities: ................................................................. 173.3 Mediun/longer Term Activities: ................................................................ 17

4.0 INSTITUTIONAL ARRANGEMENTS ................................................................ 184.1 Improvement Of The Institutional And Legal Framework .................................................... 184.2 Training ................................................................ 184.3 Improvement Of Health Care Waste Collection, Treatment, And Disposal ...................... 184.4 Public Awareness ................................................................ 184.5 Private Sector Involvement .................................................... ; 184.6 Control and Monitoring of the POA ................................................... 184.7 Evaluation And Supervision Of The POA ................................................... 18

5.0 PARTNERSHIP FRAMEWORK .195.1 Potential Partners And Field Of Intervention ............................................... 195.2 Involvement Of Private Companies In HCWM .............................................. 196.0 COST OF THE HCWM PLAN .............................................. 21

7.0 ENVIRONMENTAL AND SOCIAL CONSIDERATIONS . . ............................ 227.1 Measures For Reduction Of Incinerators And Landfill Negative Impacts .227.2 Measures For Mitigating Negative Social hnpact .......................................... 22

8.0 LOGICAL FRAME WORK ON HEALTH CARE WASTE MANAGEMENT 2003 -2008 . 238.1: Institutional And Legal Framework [2.2.1] . .................................................. 238.2 Capacity Building On Health Care Waste Management [2.2.2] . .............................................. 258.3 Improvement of HCW collection, treatment and disposal[2.2.3] . .................................................. 27

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8.4 Information, Education Communication and Advocacy for Community Involvement inHCWM[2.2.4] .................................................................... 31

9.0 FIVE YEAR STRATEGIC PLAN OF ACTION FOR HEALTH CARE WASTEMANAGEMENT 2003 -2008 .................................................................... 34

9.1.0 Institution and Legal Framework ..................................................................... 349.1.1 Strengthening HCWM legal framework .................................................................... 349.1.2 Strengthening Institutional Framework Of HCWM At All Levels . . 34

9.2.0 Capacity Building and Training on HCWM .................................................................... 369.2.1 Involvement Of Training Institution And Regulatory Bodies In Capacity Building OnHCWM ................................................................... 369.2.2 In-Service Training Of Relevant Health Worker And Auxiliary Staff On HCWM ...... 36

9.3.0 Improvement Of HCW Collection, Treatment, Trahsportation And Disposal In AllHealth Facilities .................................................................. 38

9.3.1 Mobilization of supplies and equipment .................................................................. 389.3.2 Installation of appropriate infrastructure of HCW treatment and disposal facilities inrelevant institutions ................................................................... 399.3.3 Setting up health facility waste management procedures ................................................. 40

9.4.0 Information, Communication, Education and advocacy on community involvement in HCWM.429.4.1 Dissemination of information on HCWM through mass media . ..................................... 42

9.5.0 Public Private Partnership .................................................................... 439.5.1 Promotion of business opportunities in HCWM . ............................................................... 43

9.6.0 Monitoring and Evaluation .................................................................... 449.6.1 Continuously monitor and evaluate HCWM activities at all levels ................................ 44

Annex 1 ...................................................................... 45A. 1 Roles And Responsibilities .................................................................... 45

A. 1.1 Ministry of Health and Population .................................................................... 45A. 1.2 National HCWM Coalition in ICC . .................................................................... 45A. 1.3 District HCWM Committee ..................................................................... 45A. 1.4 Health centres HCWM Committee . .................................................................... 46A.1.5 District, Town and City Assemblies . ................................................................... 46A. 1.6 - MLG, CHAM and Private and Company Health Facilities .......................................... 46A. 1.7 Ministry of Water Development and MNREA .46A. 1.8 Regulatory Bodies (MCM, NMCM, MPMPB, MBS) .46A. 1.9 Health Training Institutions (COM, KCN, MCHS, CHAM Institutions) .47A.1.10 Non-Governmental Organisations .47A.1.11 Composition and responsibilities of the HCW Management team .47

Annex 2.0 Treatment Systems and Technologies .48A..2.1 SOLID WASTES TREATMENT .48A.2.2 Liquid Wastes Treatment .53A.2.3 Choice Of Landfill Sites .54A.2.4 Decision Tree Scenario .54

Annex 3: Training and Public Awareness Strategy . . ................................... 56A.3.1 OBJECTIVE .56A.3.2 TARGET GROUPS .56A.3.3 TRAINING STRATEGY .57A.3.4 Population Awareness Strategy .59

Annex 4 Decision Trees .62Annex 4.1 Urban area with access to a modern waste treatment facility ... 62Annex 4.2: Urban Area Without Access To Modern Waste Treatment Facility .................. 62Annex 4.2: Urban Area Without Access To Modern Waste Treatment Facility ... 63Annex 4.3: Peri-Urban Area ......................................................... . 63

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Annex 4.3: Pen-Urban Area ......................................................... 64Annex 4.4: Rural Area Without Access To Modem Waste Treatment ........................... 65Annex 4.5: Rural Area With Access To Modern Waste Treatment .................................. 66

Annex 5: Model of "WHO" incinerator made with local materials ....................................................... 67Annex 5 Calculation of Unit Cost for Activities included in the POA ...................................................... 68Annpx 6 Distribution of Health Facilities by type & Ownership ......................................................... 70

HCWM Strategic Plan of Action 2003-2008 Minist"y of Health and Population

ABBREVIATION AND ACRONYMS

AD Auto-Disable (type of syringe)AIDS Acquired Immuno Deficiency SyndromeBCG Bacille Calmette GuerinBCI Behaviour Change InterventionCBO Community Based OrganizationCHAM Christian Health Association of MalawiCOM College of MedicineDEA Department of Environmental AffairsDFID Department for International DevelopmentDPHS Department of Preventive Health servicesEHS Environmental Health ServicesEPH Essential Health PackageEPI Expanded Programme on ImmunisationHBV Hepatitis B VirusHCV Hepatitis C VirusHCWM Health Care Waste ManagementHiB Haemophilus Influenza type BHIV Human Immunodeficiency VirusIEC Information Education and CommunicationICC Inter-agency Co-ordinating CommitteeIMCI Integrated Management of Child IllnessIS Injection SafetyHCWMU Health Care Waste management UnitKCN Kamuzu College of NursingMBS Malawi Bureau of StandardsMCH Maternal and child HealthMCHS Malawi College of Health SciencesMCM Medical Council of MalawiMLG Ministry of Local GovernmentMNREA Ministry of Natural Resources and Environmental AffairsMOHP Ministry of Health and PopulationNHP National Health PlanNGO Non-Governmental OrganisationNMCM Nurses and Midwives Council of MalawiRHU Reproductive Health UnitSTD Sexually Transmitted DiseasesSTI Sexually Transmitted InfectionsUNFPA United Nations Population FundUNICEF United Nations Children's FundUSAID United States Agency for International DevelopmentWB World BankWHO World Health Organisation

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FOREWORD

Health care services inevitably generate waste that may be hazardous to health or haveharmful environmental effects. Some of them, such as sharps or infected blood carry ahigher potential for infection and injury than any other type of waste. Their impropermanagement can cause direct health impacts on the personnel working in the healthcare facilities or on the communities. Sound management of health care waste (HCW) isthus a crucial component of environmental health protection.

In both the short and the long term, the actions involved in implementing effective health-care waste management programs require multi-sectoral co-operation and interaction atall levels. Policies should be generated and co-coordinated nationally. Establishment ofa natlonal policy and legal framework, training of personnel and raising public awarenessare essentlal elements of successful health-care waste management. Improved publicawareness of the problem is essential in encouraging community participation ingenerating and implementing policies.

To achieve this aim, the Ministry of Health and Population in collaboration with itspartners: UNICEF, WHO, World Bank set up a consultancy team to assess health-carewaste management and develop a Policy and Strategic Plan for HCWM for Malawi. Thisdocument, the result of their efforts, is intended to be a comprehensive yet concise,"user-friendly' strategic five year plan oriented towards practical management of health-care waste in local facilities. It outlines the short, medium and long-term activities forlegal and institutional framework, capacity building & training of personnel, raising publicawareness, public private partnership and monitoring and evaluation to be implementedin a sustainable and effective manner in health-care waste management programs inMalawi

This strategic plan of action has been reviewed and approved during a NationalConsultative Workshop held by the Ministry of Health and Population in May- June 2003.It is my hope that the plan of action backed up by the Health Care Waste ManagementPolicy will stimulate collaborated efforts to implement the strategies so that effectivehealth-care waste management system can be achieved in Malawi

Honourable Yusuf Mwawa M.PMinister of Health and Population

4 h July 2003.

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Acknowledgement

The Ministry of Health and Population is indebted to many individuals and organizationswithout whose support and collaboration, the development of this Plan of Action (POA)would have not been possible. We thank the following key informants for sharing theirinsights regarding health care waste management in Malawi: Dr. Mbewe (college ofmedicine);Lunah Ncube (JHPEIGO) S. Kachingwe (Kamuzu College of Nursing); WiseChauluka (National AIDS Commission); E.S Gumbo (Medical Council of Malawi); SisterNymph (CHAM secretariat) E.M. Chatipwa (Nurses & Midwife Council) M. Nyirongo(USAID); D. Lazaro (UNFPA); Chalira (Pharmacy, Medicines and Poisons Board); C.Phiri & S. Mshana (DFID health section); R. Chisenga (National Paramedical PrivatePractitioners of Malawl). D. Chokazinga (Malawi Bireau of Standards) and C. Theka(Environment Affairs Department).

We are sincerely grateful to the participants during the National Consultative Workshopsfor the constructive contributions: Dr H. Somanje, A. M. Mulogera, Dr B. K.Khoza,George C Jabu, Dr. A.Phoya , Lycester Bandawe, Chettie M Mkandawire,Rodrick Namkungwi, Sheila N Bandazi, Blessius T. Tauzie, Samuel M. A. Zabula, , MrsAgness. Katsulukuta, Steven Kalikokha, M. V. Valle, Maria Chalanda, R M A Champiti,Dr J. Muita, Chritine Kimes, Dr Getrude Kalanda, Enos Lloyd Kaudza, Elma Nachamba,John Wesley Nyirenda, Brighton F. Zumazuma, A.D. Kwanjana, Edwin M. F. Nkhono,Lunah Ncube, Maston Zaunda, D. G. Ngoma, M. M. Kanyuka, D. R. Chirombo, C. V.Chaheka, and 0. B Ching'oma,

Further, we are extremely indebted to the following people: Dr. H. Somanje, Dr. I. Idana,D. Chokazinga , K.I.J Moffat, L. Ncube, B. T. Tauzie, A Katsulukuta, S. Bandazi . J. W.Nyirenda, M. Mzumara ,S. Taulo D.B. M Nyirenda, R. M. Kanjedza, D. Kwanjana, T.Mbale , who committed themselves on Saturdays and Sundays to concise and finalizethe document and make it operational on time, and to the consultants for their technicalinputs;

Finally we acknowledge the dedication, and direction of Dr. H. Somanje, Dr Ann Phoya,Mrs S. Bandazi, Mrs A. Katsulukuta. and Mr B. T. Tauzie towards the realization of thisplan of action and also recognize the important role played by our partners UNICEF,WHO and World Bank for funding all the activities.

Dr Richard B. PendameSecretary for Health and Population

4th July 2003.

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EXECUTIVE SUMMARY

Introduction

This strategic plan of action is a result of the assessment of HCWM and injection safetyInitiated by the Ministry of Health and Population and its partners UNICEF, WHO, andWorld Bank in Nov 2002 - Jan 2003 in response to introduction of AD syringes and thesubsequent formulation of HCWM Policy. The HCWM policy focused on four mainpriority areas: institutional and legal framework, capacity building and training,infrastructure , and public awareness and involvement of public sector in HCWM. Inorder to adequately address these priority areas and put in place a sustainable healthcare waste management system, a five year strategic implementation plan of the policyhas been developed.

The Strategic plan outlines the rationale, national goal and steps in achieving theobjectives of clean environment for all Malawians. The strategic plan has beensummarized in two logical frameworks. The first logical framework is a summary fiveyear implementation framework which explains the objectives, key targets, objectivelyverified indicators and their means of verification, expected total cost of activity over fiveyears and further identifies sources of funding. The second logic framework outlines thestrategies and their specific yearly targets and budgeted activities.

In the Initial years, the strategic plan of action has taken into consideration the gaps inthe current health care waste management system as revealed in the findings of theHCWM assessment and the thrust of HCWM and Injection Safety policies.

Key findings:HCWM Assessment

* HCWM is not a specific priority in the national health policy* The institutional and legal framework is deficient* Organization and equipment are not performing* Behavior and practices of the health workers are generally mediocre* Private sector are not involved in HCWM.* Financial resources allocated to HCWM are insufficientInjection Safety Assessment* Training and capacity building in injection safety is minimal* Injection equipment is mainly procured as single equipment except in EPI where

"bundling" is practised.* Injection practices are poor exposing patients, health workers, and community to

unnecessary risks

Purpose of the POAThe goal of the POA is to prevent and mitigate the environmental and health impact ofhealth care waste and protect health staff, patients and the general public from theirrisks. In order to achieve this goal, the following strategic objectives will be carried out

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Objectives

Objective 1To establish HCWM legal frame work through strengthening HCWM legal andinstitutional frame works.

Objective 2To improve health workers skills in HCWM at all levels of health care delivery bymainstreaming HCWM in pre-service training and conducting in-service training ofhealth workers.

Objective 3To improve the delivery of health care waste management by mobilizing supplies andequipment timely and installation of appropriate infrastructure for HCW treatment anddisposal

Objective 4To improve information, education, and communication of the communities on HCWMthrough mass media and relevant communication channels.

Objective 5To promote public private partnership on HCWM through facilitating waste managementrecycling programmes and off-site HCWM practices.

Objective 6To improve compliance on the implementation of guidelines and regulation on healthcare waste management by intensifying supportive supervision and continuousmonitoring and evaluation at all levels of health care delivery.

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Budget For Implementing The HCWM Plan Of ActionBelow is an outline of budget to effectively implement the HCWM in the initial five bystrategy and year.

Summary of Budget By Strategy Per Year_ Strategy I Year 1 Year 2 Year3 Year 4 Year 5 TotalA. Institution and Legal Framework

1 Strengthening HCWM legal $ $ -$ $ $ $framework 52,223.00 27,500.00 0 0 0 79,723.00

2 Strengthening institutional $ $ $ $ $ $framework of HCWM at all 7,022.22 0 0 0 0 7,022.22level I

sub total $ $ S S 0 $ 0 $ 86,745.22_ __ _ _ _ _ _ _ _ _ _ 59,245.22 27,500.00 0 _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

B Capacity Building on health care waste management.1 Involvement of training

institution and regulatory $ $ $ $ $ $bodies in capacity building on 69,570.00 1,330.00 5,830.00 1,330.00 1,330.00 79,390.00

_ HCWM2 In-service training of

relevant health worker $ $ $ $ $ $and auxiliary staff on 294,000.00 541,500.00 96,000.00 46,500.00 46,500.00 -1,024,500.00

_ HCWM I I I I I_ _

Subtotal $ $ S $ 47,830.00 $ $363,570.00 542,830.00 101,830.00 0 * 47,830.00 1,103,890.00

C Improvement of health care waste collection, treatment and disposal in all health facilities1 Mobilization of supplies $ $ $ $ $ $

and equipment 948,375.00 941,375.00 941,375.00 941,375.00 941,375.00 4,713,875.00

2 Installation of infrastructureof HCW treatment and $ $ $ $ 182 760.00 $ $disposal facillties In 81,125.00 275,760.00 290,260.00 , . 15,500.00 845,405.00relevant institutions

3 Setting up HCWM $ $ $ $ $procedures 39,000.00 $ 39,000.00

Subtotal $ $ $ $ $_1,068,500.00 1,217,135.00 1,231,635.00 1,124,135.00 956,875.00 5,598,280.00

D IEC and advocacy on community involvement in HCWM1 Dissemination of $ $ $

informatlon on HCWM 46,944.00 15,430.00 11,344.00 $ 7,344.00 6,858.00 87,920.00through mass media

E Public Private Partners ipPromotion of business $ $ F 1$ $ 5300o $ | $opportunities in HCWM 29,000.00 39,000.00 4 2,000.00 | '5 53,500.00 217,000.00

F Monitoring and Evaluation1 Monitor & evaluate HCWM l $ S $ I $ 24300 $

activities at all levels 14,300.00 14,300.00 22,800.00 12,800.00 | 24_300[00 88,500.00

G HCWM Plan of Action.Grand Total $ $ $ $ $ $

11,536,659.2211,850,295.001 1,403,709.0 11,239,709.0011,083,463.0017,113,835.22

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HCWM Strategic Plan of Action 2003-2008 Ministy of Health and Population

1.0 INTRODUCTION

Health related activities produce a considerable amount of waste on a daily basis as aresult of preventive, curative and rehabilitative service delivery. The composition ofwaste produced is in the form of sharps (needles, syringes), non-sharps blood and otherbody fluids, chemicals, pharmaceuticals and medical devices. Health workers, wastehandlers, users of health facilities and the community are all exposed to health carerelated waste that could cause ill health as a result of poor management. A good healthcare waste management plan results in healthier communities, thereby reducing the costof health care, as well as creating opportunities for waste re-use and eventual wasterecovery.

A few important principles of sound management of health care related waste include:(1) definition of a policy framework, (2) assignment of legal responsibility for safemanagement of waste disposal to the waste producers, (3) allocation of adequatefinancial resources and cost recovery mechanisms, and (4) high level of awareness onproper waste disposal among all health workers in all cadres and among the generalpublic.

1.1 Background

MOHP commissioned a medical waste and injection safety assessment in mid-2002 withfunding from UNICEF, WHO and World Bank. This assessment was carried out inNovember 2002 to January 2003 and was based on a participatory and consultativemethodology. The assessment report facilitated the development of HCWM policy andthe preparation of this five - year plan of action for Health Care Waste Management andInjection Safety.

1.2 Geographical And Socioeconomic Situation

Malawi is a sub-Saharan country in South-Eastern Africa, with 94,276 square km ofland. Annual rainfall ranges from 700 to 1800mm. It has a population of 9,838,486representing 104 people per square km and a population growth rate of 1.9% per year.In 1995, Malawi was ranked as the ninth poorest country in the world in terms of GNPper capita (USD 170). It still suffers from serious inequities in the distribution of income,with over sixty percent of the population living below the absolute poverty line.Agriculture is and will remain the mainstay of economic growth in Malawi. The country'shealth indicators are among the worst in the world. Life expectancy at birth has fallen tobelow 39 years. The infant mortality rate of 134 per 1,000 live births has only marginallyimproved in the last 10 years. Under-five mortality is 234 per 1,000 live births and isexpected to rise as a result of HIV/AIDS epidemic. Under-five mortality is mostly due tomalnutrition, anemia, pneumonia and diarrhea diseases.

1.3 The National Health System

Health care services in Malawi are provided by three main agencies: the Ministry ofHealth and Population (MOHP) provides 60%; the Christian Health Association ofMalawi (CHAM) provides 37%, and the Ministry of Local Government provides 1%.Other providers, namely private practitioners, commercial companies, Army and Police,provide 2% of health services.

HCWM Strategic Plan of Action 2003-2008 Ministry of Health and Populaton

The country has 585 health facilities for CHAM and the public. Of these 43 are bighospitals, 4 referral hospitals, 22 district hospitals and 17 CHAM hospitals, 2 mentalhospitals and the rest are health centres and dispensaries. There are 147 privateregistered health facilities in addition to those for MOHP and CHAM. The dispensariesand health centres provide primary health care while the district hospitals providesecondary health care and referral hospitals provide tertiary health care. At the primaryhealth care level the services are mainly out patients and integrated management ofchild health including EPI, disease surveillance, family planning, and antenatal clinics. AMedical Assistant, a Nurse, an Assistant Environmental Health Officer and HealthSurveillance Assistant technically run these services at this level.

The secondary health care acts as a referral centre for primary health care facilitiesrunning admission facilities ranging from 150 to 250 beds. At this level there is integratedservices, paediatrics, maternity, medical, laboratory and radiology departments. At leastone medical officer, several clinical officers and medical assistants, laboratorytechnicians, nurses and midwives, radiographer and assistant environmental healthofficers technically man these facilities.

The tertiary health care offers specialist and consultant service in paediatrics, medicines,surgery, obstetrics and gynaecology, ophthalmology, dentistry, intensive care, andanaesthesiology. At this level the diagnostic capacity is higher than the secondary healthcare. The bed capacity ranges 350 to 1,500 beds.

The public health service has approximately 16,0001 staff of which about7,000 technicalstaff. The staffs for CHAM and the Private are not known. The MOHP takes leadership in,policy making, direction and co-ordinating health care system. To ensure efficiency,accountability and reduce duplications the Ministry is in the process of introducing sectorwide approach to health development. Decentralisation of management of physical,financial and human resource to districts will allow the Ministry to concentrate on policyformulation and co-ordination.

1.4 Main Areas Of Emphasis For The Five Year Strategic Plan Of Action

1.4.1 Institutional and legal frameworkThe institutional and legal framework on HCWM is weak. HCWM is not a specific priorityin the National Health policy. The institutional framework is characterized by a lack ofnational strategy. There is no policy or document or any formal management procedurefor health care wastes. The legal framework, characterized mainly by an absence ofinternal regulations in the health facilities, does not ensure sustainable HCWM, as theroles, responsibilities and field competency of actors involved in HCWM are not definedin a clear and precise way. The proposed law and regulations on HCWM is beingprepared without a proper policy framework and do not allow a standardization of HCWcollection, transportation, storage and treatment procedures. It would therefore, bepreferable to develop an institutional and legal package, including policy document, tooutline national goals and the key steps to achieve these goals before preparing aHCWM law. To make the legal documents more operational, there is need to reinforcethe technical guidelines for HCWM, define a specific regulation for each level of healthfacility and specify control procedures.

'Payroll May 2003 Ministry of Health and Population.

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HCWM Strategic Plan of Action 2003-2008 Ministry of Health and Populaton

1.4.2 Capacity Building And TrainingWhile the paramedical staff has knowledge and fairly good behavior in HCWM, auxiliarystaff , waste collectors, health workers (supply staff) and waste handlers are in a muchweaker position and higher risk from HCWM. Mostly these are at the receiving end of theHCWM stream and are not conscious of the hazardous constituents of HCW.

This lack of awareness of workers is very often a source of accidents causing woundsand infection. Moreover, the inappropriate collection, storage, and HCW disposal, resultin an extraordinary mixing of HCW with other solid non-toxic wastes (or less toxic ones),which can cause environmental degradation. In these circumstances HCW becomes animminent occupational health hazard within the health sector. In this regard includingHCWM in pre-service training curricula in all health training institution for all cadres isimperative. Further organising and conducting in-service training is a prerequisite toimproving occupation health and safety in the health facilities.

1.4.3 IEC And Advocacy On Community Involvement In HCWM

In general, the public's knowledge of risks linked with the handling of HCW is very weak,particularly: (i) the scavengers looking for useful objects, (ii) children playing on thelandfill or looking for toys, (iii) population using recycled objects, (iv) populationperforming or receiving home based health care, (v) people living near the landfills.Awareness campaigns targeted to such audience will facilitate a reduction in exposure toHCW.

1.4.4 Public Private Partnership

Municipalities and cities of Zomba, Blantyre Lilongwe and Mzuzu have some form ofwaste management systems for general waste .Generally these Assemblies wastemanagement systems are unable to effectively and efficiently collect, treat and disposewaste to the required standards. No private companies are involved in solid wastecollection in Malawi at the present time. Hence there is need to explore involvement ofthe private sector in waste management. For instance, collection and transportation ofwaste including HCW, there is non-existence of specialized companies/agencies in thisventure which constitutes a major constraint for waste management. This equally, posesa limitation to managing HCW in a professional manner as the management skills andfinancial resources of the private sector are not being tapped. Therefore, any proposedaction plan for HCWM should support private initiatives and develop a partnershipbetween public and private sectors with civil society. To accomplish this there is need todevelop sustainable financial resources for HCWM.

1.4.5 Improvement of HCW Collection, Treatment And DisposalHCW management inside health facilities revealed many weaknesses; despite theefforts noted in some health centres. The major constraints are: lack of planning orinternal management procedures, absence of viable data about HCW production andcharacteristics, no monitoring system or staff member designated to monitor HCWmanagement, insufficiency of secure collection materials and protective gear, mixing ofHCW with household and office waste, and inefficient treatment and final disposal. As aresult, health care workers, non-technical health facility staff, municipal landfill workers,and landfill scavengers are at serious risk of infection. Appropriate HCW facilities need

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to be put in place with accompanying equipment to safely handle treat, and dispose ofwaste in an environmentally friendly manner.

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2.0 OBJECTIVES AND STRATEGIES OF THE PLAN OF ACTION

2.1 GoalThe goal of the POA is to prevent and mitigate the environmental and health impact ofhealth care waste and protect health workers, patients and the general public from theirrisks.

2.2 Objectives

2.2.1 Institutional and Legal frame work.

Objective 1To establish health care waste management legal framework.

StrategyStrengthening HCWM legal frame work.

Objective 2To improve institutional framework for HCWM at all levels of health delivery.

StrategyStrengthening institution framework of HCWM at all levels.

2.2.2 Capacity Building And Training On HCWM.

Objective 1To improve health workers' skills in HCWM at all level of health delivery.

Strategy 1Involvement of training institution and regulatory bodies in capacity building of HCWM.Strategy 2In-service training of relevant health workers at all levels.

2.2.3 Improvement Of Health Care Waste Collection, Treatment, TransportationAnd Disposal.

Objective 1To improve the delivery of health care waste management.

Strategy 1Mobilization of supplies and equipment for HCWM at all levels.

Strategy 2Installation of appropriate infrastructure of HCW treatment & disposal in relevantinstitutions.

Strategy 3Setting up health care waste management procedures.

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2.2.4 Information, Communication, Education and advocacy for communityinvolvement in HCWM.

Objectives 1To improve Information communication and education of the community on health carewaste management

StrategyDissemination of information on health care waste management through mass media

2.2.5 Public Private Partnership.

Objective 1To promote private sector involvement in HCWM.

StrategyDevelopment of financing mechanisms to enable public private partnership for HCWMand for recycling materials.

2.2.6 Monitoring and evaluation.

Objective 1To improve compliance on the implementation of guidelines and regulations on healthcare waste management

StrategyPromotion of supportive, supervision, monitoring and evaluation of health care wastemanagement.

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3.0 PROGRAM SEQUENCING

Before such an elaborate plan is implemented, certain activities need to startimmediately, and others can be implemented over the mediumv/long term.

3.1 Immediate Activities

The following actions need to be carried out immediately:- set up a structure for coordination and follow up of the POA- planning of start-up activities- elaboration and dissemination of regulations and basic technical guidelines in

HCWM- elaboration of HCWM training program- elaboration of public awareness programmes- define HCWM procedures in health facilities, including health staff responsibilities

3.2 Short term Activities:

- training of trainers- training all the stakeholders involved in the HCWM- diffusing public awareness programmes- assessment of training program implementation- halfway appraisal

3.3 Medium/longer Term Activities:

- improvement of HCWM in health facilities- Supporting private initiatives and partnership in HCWM- Monitoring and evaluation of the HCWM plan

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HCWM Strategic Plan of Action 2003-2008 Ministry of Health and Populadon

4.0 INSTITUTIONAL ARRANGEMENTS

4.1 Improvement Of The Institutional And Legal Framework

The Ministry of Health and Population (MOHP) will be responsible for the improvementof the institutional and legal framework. These activities should be conducted in the firstyear of the programme by the Department of Preventive Health Services (DPHS) andthrough the Environmental Health Service (EHS).

4.2 Training

The training activities should be led by the DPHS / EHS of the MOHP. This structure hascompetence in HCWM and could be assisted by training institutions in this field. Atdistrict levels, management of training activities should be assigned to the District team.Specific training activities will be done in the first two years of the programme

4.3 Improvement Of Health Care Waste Collection, Treatment, And Disposal.

EHS and Health facility managers will work together to introduce improved HCWMsystems at health facilities. EHS will regulate the HCW management in health facilities,DPHS will supply health facility managers with HCWM equipment and materials, andexecution of HCWM improvement programs will be conducted by health facilitymanagers and their staff.

4.4 Public Awareness

The Health Education Unit of the MOHP will lead the activities intended to makeM thegeneral public aware about HCW. At the local level, the District team will do thesupervision. These activities will take place over a five year period, through district publicmeetings, radio and television messages, posters, etc.

4.5 Private Sector Involvement

Ministry of Health and Population through the HCWM unit will liaise with City Assemblieswho are currently operating waste management collection systems to engagecontractors on a pilot basis for collection of waste including HCW. In order to maximisethe utilisation of the contracted waste collection system, a number of health facilities willbe involved in recycling programs. Financing mechanism need to be put in place inadvance. Both the collection and recycling pilot programmes will be assessed in sixmonths in order to establish viable alternatives.

4.6 Control and Monitoring of the POA

At the local level, the control and monitoring of HCWM plan implementation should bedone by the District team which will ensure monthly monitoring, while the yearly followup will be realized by EHS/DPHS.

4.7 Evaluation And Supervision Of The POA

The evaluation of the HCWM Plan should be assigned to international/ local consultants(under supervision of EHS/DPHS), to ensure objectivity. This evaluation should be donehalfway through (at the end of the 2nd year) and at the end of the first phase program(year 5).

18

HCWM Strategic Plan of Action 2003-2008 Minishty of Health and Population

5.0 PARTNERSHIP FRAMEWORK

5.1 Potential Partners And Field Of Intervention

Delivery of essential health services and the fight against HIV/AIDS and soundenvironmental management relies on the involvement of a wide range of actors: publicand private sectors, NGOs, and civil society. So it is necessary to establish a partnershipframework to identify the roles and responsibilities of each category of actor.

Table 2: Potential field of intervention

Actors Potential field of interventionTechnical services - inform the local and national authoritiesof the State - facilitate co-ordination of HCWM plan activities(MOHP / MNREA) - supply technical expertise

- execute control and monitoring activities- train the health staff- supervise the training process, monitoring and evaluation

City Assemblies / - participate in the mobilization of populationsDistrict - ensure HCW are properly disposed in their landfillGovernments - participate in training, monitoring and evaluationPublic health - participate in training activitiesfacilities / Private - supply staff with security equipmenthealth facilities - elaborate internal plans and guidelines about HCWM

- allocate financial resources for HCWM- ensure HCW management plan is implemented

Private operators - invest in HCWM (eg, treatment, transport, disposal)- operate as sub-contractors (City Assemblies / District Govts

Health Facilities)NGOs and CBOs - inform, educate and make population aware

- participate in / offer training activitiesTraining Institution - provide health staff training

5.2 Involvement Of Private Companies In HCWM

HCW collection is a major concern for public and private health facilities. According toenvironmental regulations, health facilities must ensure sustainable management of theirwastes. However, in practice health facilities have very limited financial resources, andno public health establishment has funds to pay for collection or disposal services forwastes. For health facilities having incinerators, waste collection is less of a concern. Forprivate facilities, the major constraints are the absence of alternative solutions to theirpresent practices. Most of them can't afford appropriate equipment for treatment.

Both public and private facility managers and staff express a willingness to participate inan institutional arrangement whereby costs of treating their HCW could be shared undera common agreement. Such a public-private partnership arrangement could be put inplace on the basis of the following principles:

- selected public health facilities would be equipped with incinerators to serve adefined geographic radius;

19


- health centres equipped with incinerators would agree to accept and treat HCW fromprivate facilities and smaller health centers within their service area;

- private health facilities receiving such HCW treatment services would agree to pay acollection / treatment fee as per the terms of the cost sharing agreement.

Long-term private sector involvement in the HCWM business will depend on whethernational, district, and municipal governments are able to put in place self-sustainingsources of financing to cover investment and operating costs for this criticalenvironmental and public health service. If the financial equation is solved, then privatesector operators can be expected to identify their individual comparative advantage andexplore contractual arrangements to provide a range of services for health facilities andlandfill sites (e.g, transport, treatment, disposal).

20


6.0 COST OF THE HCWM PLAN

Solid waste management suffers from inadequate financing from the state and localcollectors. The financial resources for HCWM are symbolic in health centres: priority inrecurrent budgets is given to purchase of medicines and medical supplies, as opposedto purchase of waste storage or disposal equipment. This is the reason why majorconstraints are encountered at all stages of the HCWM cycle. Collectors are notmotivated, equipment is hardly replaced and collection is irregular. Without a regularbudget allocated to HCWM (mainly in health facilities) it is nearly impossible to improvemanagement. Without a sustainable financing mechanism for waste disposal in general,it will not be possible to attract the private sector into playing a greater role for HCWM.

In consideration of the total absence of appropriate HCWM systems in place, the cost ofimplementing this five year HCWM plan of action amounts to US$7,113,835 in total. Byarea of focus the budgets have been allocated as follows in absolute figures:-

* Institutional and legal framework US$ 86,745.22* Capacity building US$ 1,103,890.00* Improve the delivery of HCWM US$ 5,598,280.00* Public private partnership US$ 87,920.00* IEC and advocacy US$ 217,000.00* Monitoring and evaluation US$ 88,500.00

Annual budgets based on targeted activities could be obtained from the five yearstrategic Plan of Action Chapter 9.0

21


7.0 ENVIRONMENTAL AND SOCIAL CONSIDERATIONS

7.1 Measures For Reduction Of Incinerators And Landfill Negative Impacts

The operation of incinerators has negative impacts on environment and health.However, the quantities of waste to be incinerated daily by each establishment are quitesmall, so environmental and health impacts will not be significant and the harm causedwill not be big. Nevertheless, the following measures should be taken

* When installing incinerators inside health facility ground, a location should beselected that is distant from the admission rooms and health care rooms

* To minimize noise disruption and smoke discomfort during working hours of thefacility, the incinerator should be operated at night

* To reduce polluting by products from solid waste incineration, non chlorine plasticcontainers should be promoted, for example, they should be recommended asdust bin for collection

* Moreover, the promotion of the use of non-chlorine plastic containers is arecognized means of reducing the pollutant products from solid waste incineration.In this way, they should be recommended as dustbins for waste collection.

For large central disposal sites, wire fencing and locks should be installed to reinforcesecurity and to minimize the access of scavengers and children. These protectionmeasures will allow site managers to (i) control and regulate access to the landfill, (ii)identify the scavengers and (iii) make users aware of danger

7.2 Measures For Mitigating Negative Social Impact

Implementation of HCWM Plan might have negative social impacts on scavengersearning their daily living at landfills. Their income may decrease with an well-organizedmanagement of HCW, particularly when segregation is done at the source. Healthfacilities should explore developing a mechanism for giving local scavengers non-infectious reusable objects (such as empty bottles

For the populations neighboring the landfills, the risks of being driven away and resettledin other areas are minor. Generally, these populations did not come to settle around thelandfills: instead, the disposal sites have been created inside these districts.

There are cultural issues relating to disposal of anatomical wastes (amputated bodyparts, placenta, etc.), which communities may be strongly sensitive to. These culturalaspects should be taken into account in the action plan, to better ensure the populationsinvolvement in the implementation. For example: the placenta could be buried or put inseptic pits, as it is the case presently in some health facilities; generally, anatomicalwastes such as the body parts are buried inside the hospital; they can also be given tothe patients or their family if they claim for it; liquid wastes from washing of the dead aregenerally evacuated in septic pits. Generally, people don't find any harm in thesemethods.

22


8.0 LOGICAL FRAME WORK ON HEALTH CARE WASTE MANAGEMENT 2003 -2008

Strategies | Activities | Base | Target | Verifiable Means of Time frame i Cost (USD) | FundingStrategies Activlties Base Target Indicator Verification l l Agency

8.1: Institutional And Legal Framework [2.2.1]Objective 1: To establish Health care Waste management legal frame work8.1.1 1.Conduct Consensu WorkshopStrengthening consultative meeting s on reportsHCWM legal for HCWM 0 1 HCWM Nov 2003 45000.00 MOHPframe work regulation regulations

reached

2. Printing HCWM HCWM HCWM Oct03- Janregulations 0 1 regulations regulation 2004 2,723.00

printed documents

3. Review the Public Public Reviewedhealth Act 34:01 to 0 1 health act Public health Oct- Dec 18,000.00include HCWM incorporat Act 34:01 2003regulations es HCWM

4. Develop a Categories Documentscomprehensive Guideli of on technicaltechnical guidelines 0 nes technical guidelines on 2003-2004 13,000.00for HCWM 0 develo guideline HCWM.

ped on HCWMdeveloped

5. Submit finalized HCWM Public Healthdocument of HCW laws in Act withHCWM regulation Non M laws PHA 34.01 HCWMfor ministerial e adopte 2003-2004 500.00approval into laws d inunder the Public PHAhealth Act(PHA)

23


Strategies Activities Base | Target Verifiable Means of | Time frame | Cost (USD) FundingI I Indicator Verification l l I Agency

8.1: Institutional And Legal Framework [2.2.1]

Objective 2: To improve institutional framework for HCWM at all levels of health delivery

8.1.2 1. Identify Key 0 100% #of Records 2003 0 MOHPStrengthening stakeholders in HCWM stakeholderinstitution 2. Establish a HCWM HCWM Records onframework of technical committee committee membership Oct - DecHCWM at all 0 1 formed TORs & 03levels Minutes,

3. Establish an ICC ICC on Minutes, andon HCWM 0 1 HCWM list of 2003 -0

formed membership.

4. Establish HCWM Appointme Designatedunit at Health Head 0 1 nt of focal office, Work 2003 7,022.22quarters point plans

5. Establishment of % of Districtdistrict HCWM 0 27 DHCWM reports 2003 0committees committees

6. Form Health % of HC Health centreFacilities HCWM 0 585 with HC reports 2003 0committees WMC7. Designate HCWM No of Reports andofficers in Districts districts staff return

0 27 with 2003-2004 0designatedofficers

24

HCWM Strategic Plan of Action 2003-2008 MinistLy of Health and Population

Strategies | Activities | Base | Target Verifiable Meansof Timeoframe Cost undingLine I Indicator VerHication T f C Agency

_ _ _ _ _ _ _ I _ _ _ _ _ _ _ _ _ ~~~I IIIA gency8.2 Capacity Building On Health Care Waste Management [2.2.2]

Objective 1: To Improve health workers' skills In HCWM at all level of health delivery

8.2.1. 1. Hold consultative No of Minutes ofInvolvement of meetings with training Institutions meetings. Oct - Dectraining institutions and 0 3 consulted reports.& 03 27,000.00institution and regulatory bodies on consensusregulatory HCWM training documentsbodies in 2. Adapt and adopt HCWM Curriculum &capacity HCWM into training 0 1 curriculum teachers'building of institutions' curricula curdeveloped guide 2003 27,000.00HCWM. and teachers guides documents

3. Orient tutors in No of tutors Orientation 2003 &training institutions 0 36 oriented reports 2005 13,500.00on HCWM curriculum4. Printing HCWM No of Paymentcurriculum for all HCWM vouchers,health training 0 50 curricula records. 2003 1,250.00institutions copies

printed

5. Evaluate pre- % of Pre-serviceservice training of graduating annualHCWM annually 0 8 HW passed evaluation 2003-2008 10,640.00

aptitude reportstests onHCWM

25


Strategies Activities |Base| Target Verifiable Means of Time frame Cost (USD) I Funding____________I ___~Line Indicator Verification I Agency

8.2 Capacity Building On Health Care Waste Management [2.2.2]

8.2.2 In-service 1. Adapt and adopt Modul Training HCWMtraining of HCWM modules 0 e modules in modules 2003 13,500.00relevant health adopt HCWMworkers and edauxiliary 2. Identify and # health Reports onworkers categorize health workers workers

workers for in-service 0 11000 identified. requiring 2003 0training in HCWM Categories training by

of health district andworkers cadres

3. Identify and train # trainers Reports listtrainers for in-service 4 150 identified of trainers of 2003 & 13,500.00training of health HCWM. 2005 .workers4. Training of health # health Trainingworkers on HCWM 59 10550 workers reports on 2003-2008 990,000.00

trained on HCWMHCWM

5. Monitor training of # monitor- Quarterlyin-service quarterly. 0 10 ing monitoring 2003-2005 5,000.00

sessions reports onconducted HCWM

6. Evaluate In-service # evalua- Annualtraining of health 0 5 tions con- evaluation 2003-2005 2,500.00workers annually ducted reports

26


Strategies Activities Base Target Verifiable | Means of | Time frame Cost (USD) | FundingI - I I I Indicator | Verfication l l Agency

8.3 Improvement of HCW collection, treatment and disposal[2.2.3]

Objective 1: To improve the delivery of health care waste management.

8.3.1. Mobiliza- 1. Identification of No and Document ontion of supplies appropriate supplies type of standard listand equipment and equipment for 30% 100% supplies & of medical 2003 0

HCWM by level of equipment supplies &health delivery identified equipment.

2. Procurement of %of hosp Procurementsupplies and 100% adequately documents 2003-2008 632,500.00equipment for HCWM stockedin hospitals

3. Procurement of % of HC Distributionsupplies and 100% adequately list 2003-2008 3,213,625equipment for HCWM stockedin health centres4. Distribution of No of HF Deliverysupplies & equipment 25% 100% with notes; 2003-2008 39,500.00in all health facilities. adequate Inventory /

logistics stock cards

5. Submission of Annual AnnualHCWM requirements budget budgetand budgets to ICC 0 4 submitted documents 2003-2008 1,250.00on HCWM to ICC on on HCWM

HCWM

27


Strategies | Activities | Base I Target Verifiable Means of Time frame Cost (USD) FundingI I l Indicator I Verification l l Agency


6. Supply Personal % of HW Records onProtective Equipment issued supplies of(PPE) to workers with PPE -2008 825,000.00engaged in handling, 20% 100% adequate Stock cardstreatment & disposal PPEof HCW

8.3.2. 1. Hold technical HCWM Minutes &Installation of meeting on selection 0 6 facilities recommendat 2003-2008 3,000.00appropriate of appropriate HCWM Options ionsInfrastructure facilities selectedof HCW 2. Conduct an No of sites Report ontreatment & appraisal for sites identified selected sitedisposal In requiring construction by facility for HCWMrelevant and installation of 0 4 infrastructure 2003-2007 5,320.00Institutions appropriate HCWM

treatment anddisposal facilities.3. Ordering and Orders RequisitionProcurement of submitted documentsmaterials for HCWM 0 100% 2003-2007 1,210.00treatment & disposalfacilities

4.Tendering for Tenders Tenderconstruction of 0 4 submitted documents 2003-2007 2,400.00HCWM facilities. on HCWM

28


Strategies Activities Base nTarget dVeriable Meansof Timeframe Cost (USD) FundingII| | . | lndicator | Verification l l }Agency


5. Selection of No. of Report oncontractors for 0 4 contractor selected 2003 2005 0installation and s selected contractorsconstruction

6. Construction and No of Commissioniinstallation of HCWM refuse ng Contracttreatment and 100 585 bays documents 2003-2004 20,475.00disposal facilities in constructeHealth facilities d(waste pits, batch % of HF State ofburners, and with Placenta pitsIncinerators) ? 100% functional 2004-2006 105,000.00

placentapits

%of HF Pit latrines

50% 100% with 2004-2005 135,000.00adequate20420 '150.0latrines

No/% of Districtbatch reports/

50 585 burners commissionin 2003-2007 468,000.00constructe g documentsd

No of Corfimissioni2 4 incinerator ng 2005-2006 80,000.00

s installed documents

29


Strategies | Activities | Base I Target Verfiable Means of Time frame Cost (USD) Fundingl | Indicator Verification I l Agency


7. Maintenance of °/ % of Districttreatment and 25% treatment Maintenancedisposal facilities for 0 per & disposal reports. 2005-2008 25,000.00central hospitals annu facilitiesctam maintained

8.3.3 Setting up 1. Standardize waste No of std Doc. Onhealth facility flows for various 0 waste Standardised 2003 6,000.00waste levels of HF flows by HCW flowsmanagement level of HF by level of HFprocedures 2. Develop/ update % of HCWM plans

HCWM plans for 0 585 facilities Documents 2003-2008 0each facility with Plans

3. Set up a register for %of HF Report/all off-site HCW 0 585 with records on 2003 0disposal register sanctions l

4 Conduct ElAs for % of DH EIA reportsmajor HF's HCW in 0 22 ElAs done 2003-2004 33,000.00District Hospitals(DH)

30


Strategy Activities Base | Target Veriiable Means of Time frame Cost (USD) 1 FundingIl __ I Indicator Verification I l | Agency

8.4 Information, Education Communication and Advocacy for Community Involvement in HCWM[2.2.4]Objective 1: To improve information communication and education of the community on HCWM8.4.1. 1. Hold press 0 11 No of press Reports andDissemination conferences on conference press releases 2003-2008 2,200.00of Information HCWM s held in print newson HCWM mediathrough mass 2. Issue press 0 3 per No of press Print newsmedia releases on HCWM yr releases media 2003-2008 4,500.00

issued3. Insert radio jingles 0 4 per No of Jingles heardon HCWM yr jingles on the radio. 2003-2008 774.00

released

4. Develop posters on 0 2000 No of Posters onHCWM poste posters HCWM 2003-2008 38,000.00

rs developed

5. Develop leaflets 0 5000 No of HCWM 2003-2008 34,000.00and flyers on HCWM leaflet leaflets leaflets

6. Advocate for 0 75% %of HBC Reports 2003-2008 7,500.00HCWM in HBCs reached ._.

6. Develop messages 0 22 No & type Printedon HCWM. of messages on 2003-2008 946.00

message HCWMdeveloped

31

HCWM Strategic Plan of Action 2003-2008 Minustiy of Health and Population

Strategy Activities Base Target Verifiable Means of Time frame Cost (USD) FundingIndicator Verification Agency

8.5 Promotion of private sector involvement in HCWM [2.2.5]Objective 1: To promote public private partnership in HCWM.

8.5.1. 1. Advocate for Number of Records &Promotion of private sector private reportsprivate sector involvement in HCWM 0 7 firms 2003-2008 10,500.00involvement in involved inHCWM HCWM

2. Define financing Mechanis Recordsmechanism for private 0 1 m 2003-2004 4,500.00sector contracts identified

3. Contract out HCW No of Contracttreatment & disposal Central agreementin Central hospitals 0 4 Hospital documents 2004-2008 182,000.00

contractedout HCWM

4. Conduct feasibility Potential Report ofstudies on potential 0 2 recyclable feasibility 2003-2004 20,000.00waste recyclable material study.materials identified.

32


Strategy Activities Base | Target 1 Verifiable Means of |Time frame Cost (USO) | FundinglI _ Indicator J Verification l l | Agency

8.6. Monitoring And Evaluation [2.2.6.]Objective 1: To improve compliance on the Implementation of guidelines and regulations on health care wastemanagement

8.6.1 1. Develop Checklists checklistsPromotion of supervisory checklist 0 1 developed 2003-2004 4,500.00supportive on HCWMsupervision , 2. Conduct supportive No of Supervisionmonitoring and supervision on supportive report.evaluation of HCWM in all health 0 135 visits 2003-2008 27,000.00HCWM facilities by district conducted

level

3. Conduct monitoring No. of Monitoringof HCWM activities in 0 15 montoring reportsthe district by HCWM monitexercises 2003-2008 7,500.00unit

4. Conduct mid-term #Evaluatio mid & end ,and end program 0 2 n evaluation 2005 & 20,000.00evaluate conducted reports 2008

33

HCWM Strategic Plan of Action 2003-2008 Mimstry of Health and Population

9.0 FIVE YEAR STRATEGIC PLAN OF ACTION FOR HEALTH CARE WASTE MANAGEMENT 2003 -2008

Unitary measure Quantityperyear jAnnualbudgets per activity_l_lActivity Unit ~~~Unit I 1 Activity |Unit I coSt|1 2 1 3 | 4 | 5 1 Year 1 Year 2 Year3 Year 4 Year 5 Total

9.1.0 Institution and Legal Framework.

9.1.1 Strengthening HCWM legal framework.

1 Conduct consultative Sessio $meeting for HCWM n 9,000.00 4 1 0 0 0 36,000.00 9,000.00 0.00 0.00 0.00 45,000.00

2 regulation &

2 Print regulations for copy 3.89 700 0 0 0 0 2,723.00 0.00 0.00 0.00 0.00 2,723.003 Review the Public health half

Act 34:01 to include sessio 4,500.00 1 3 0 0 0 4,500.00 13,500.00 0.00 0.00 0.00 18,0$00.00HCWM regulations n _ _ __ _ __ _

4 Develop a comprehensive half Stechnical guidelines for sessio 4,500.00 2 1 0 0 0 9,000.00 4,500.00 0.00 0.00 0.00 13,500.00

_ HCWM n 1350000

5 Submit finalised documentof HCWM regulation for $ministerial approval into ceornem 500.00 0 1 0 0 0 l°.00 500.00 0.00 0.00 0.00 500.00laws under the Public Yf:health Act

Subtotal 52,223.00 27,500.00 0.00 0.00 0.00 79,7300

9.1.2 Strengthening Institutional Framework Of HCWM At All Levels.1 Identify key stakeholders in Na 0.00 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 $

HCWM 2 Establish an ICC on Commi 0.00 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 $

__ _ H C W M ttee __ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

3 Establish HCWM unit at Office $Health Hq equipme 7,022.22 1 0 0 0 0 7,022.22 0.00 0.00 0.00 0.00 7,022.22

34


Unitary measure | _Quantityperyear Annualbudgets per activi t

Activity Unit Unit 1 2 3 4 5 Yearl Year 2 Year3 Year 4 Year 5 Total_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ~c o st$ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

4 Establishnent of district Na 0.00 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 $HCWM commnittees

5 Form Health Centre WCM Na 0.00comniittees 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 $

6 Designate HCWM officers Na 0.00in Districts 0 0 0 0 0 0.00 0.00 0.00 0.00 0.00 $

Subtotal= $ -S$ $ $ $7,022.22 0.00 0.00 0.00 0.00 7,022.22

$ $ $ $ *$ '$-_____ Subtotal 9.1.1 and 9.1.2 = 59,245.22 27,500.00 0.00 0.00 0.00 86,745.22

35

HCWM Strategic Plan of Action 2003-2008 Ministly of Health and Population

jUnitary measure I_Quantity per year Annual budgets per activity= Activity j Unit 1| 2U 3s 4 p Year 1 Year 2 | Year3 Year 4 Year5 Total

9.2.0 Capacity Building and Training on HCWM

9.2.1 Involvement Of Training Ins itution And Regulaory Bodies In Capacity ilding On HCWM1 Hold consultative

meetings with training Sessio 3institutions and n g,ooo.oo 3 0 0 0 0 27,000.00 0.00 0.00 0.00 0.00 27,000.00regulatory bodies onHCWM training _ _

2 Adapt and adoptHCWM into training Sessio $institutions' curriculum n 9000.00 3 0 0 0 0 27,000.00 0.00 0.00 0.00 0.00 27,000.00and teachers guides

3 Orient trainers in Halftraining institutions on sessio 4,500.00 2 0 1 0 0 9,000.00 0.00 4,500.00 0.00 0.00 $HCWM curriculum n 13,500.00

4 Printing HCWMcurriculum for training Copies 25.00 50 0 0 0 0 1,250.00 0.00 0.00 0.00 0.00 1,25$0.00institutions

5training visit 1,330.00 4 1 1 1 1 5,320.00 1,330.00 1,330.00 1 ,330.00 1,330.00 10,640.00Subtotal= $ $ $ $ $ $

1 69,570.00 1,330.00 5,830.00 1,330.00 1,330.00 79,390.009.2.2 In-Service Training Of Relevant Health Worker And Auxiliary Staff On HCWM

1 Adapt and adopt 1/2 4,500.00 _ I I $

~HCWM modules sessio 3 0 0 0 0 13,500.00 0.00 0.00 0.00 0.00 13,500.00

36


Unitary measure 3__uantity per year - Annual budgets per activityActivity Unit Unit 1 2 3 4 5 Year 1 Year 2 Year3 Year 4 Year 5 Total

2 Identify and categorieshealth workers for in- Numbe o.oo 1100 0 0 0 0 0.00 0.00 0.00 0.00 0.00 $service training in r 0

IHCWM I I3 Identify and train

trainers for in-service Numbe 90.00 100 0 50 0 0 9,000.00 0.00 4,500.00 0.00 0.00 $training of health r 13,500.00workers

4 Training of health Numbe 90.00 3000 6000 100 500 500 270,000.00 540,000.00 90,000.00 45,000.00 45,000.00 $workers on HCWM r I 0 1990,000.00

5 Monitor training of in- 500.00 2 2 2 2 2 100000 100000 100000 1 00000 100 $service quarterly. round ,. ,. ,. 10 .00 5,000.00

6 Evaluate In-servicetraining of health round 500.00 1 1 1 1 1 500.00 500.00 500.00 500.00 500.00 2,500.00workers annually

, _ ~ ~~ ~~$ S $ ",$ $ S____ Subtotal = 294,000.00 541,500.00 96,000.00 46,500.00 46,500.00 1,024,500.00

____ Subtotal 9.2.1 and 9.2.2 = 363,570.00 542,830.00 101,830.00 47,830.00 47,830.00 1,103,890.00

37

Original Page Missing

Page Number missing = 38



HCWM Strategic Plan of Action 2003-2008 Mmiistry of Health and Population

| Unitary measure Quantity per year I Annual budgets per ctivityActi Unit Unit cost 1 21 3 4 5 Year 1 | Year 2 | Year3 Year4 Yearl Total

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ~~$ 2 _ _ _ _ _

9.3.0 Improvement Of HCW Collection, Treatment, Transportation And Disposal In All Health Facilities

construction _

6 Construction and Refuse 35.00 285 300 0 0 0 9,975.00 10,500.00 0.00 0.00 0.00 20,475.00installation of HCWM bay 20____ 475______ 00__

treatment and disposal Batch 800.00 85 150 200 150 0 68,000.00 120,000.00 160,000.00 120,000.00 0.00 468 0$000facilities in Health burner _ ,facilities (waste pits, No of $batch burners, and placent 350.00 0 100 100 100 0 0.00 35,000.00 35,000.00 35,000.00 0.00 105,000.00Incinerators) a pits __ _ $_I_I

Pitlatri 450.00 0 150 150 0 0 0.00 67,500.00 67,500.00 0.00 0.00 135,000.00ne 135_00_ $ 0

No. of $inciner 20,000.00 0 2 1 1 0 0.00 40,000.00 20,000.00 20,000.00 0.00 80,000.00

ator _

Maintenance of

treatment and disposal round 5,000.00 0 0 1 1 3 0.00 0.00 5,000.00 5,000.00 15,000.00 $facilities at central 25,000.00Hospitals $ $ $ $ $ S

Subtotal= 81,125.00 275,760.00 290,260.00 182,760.00 15,500.00 845,405.009.3.3 Setting up health facility waste management procedures

1 Standardize waste flows 1/3 $ $ $ $ $ $for various levels of HF sessio 3,000.00 2 0 0 0 0 6,000.00 000.00 000.00 000.00 000.00 6,000.00

n _

2 Develop/ update HCWM Na 0.00 585 585 585 585 585 $ $ $ $ $ $___plans for each facility 000.00 000.00 000.00- 000.00 000.00 000.003 Set up a register for all Na 0.00 585 585 585 585 585 000.00- $ $ 000.00 000.00 000.00off-site H OW disposal I I_I______0-1 I 000.00 I ___ ___ _ __ _ _ I_04

40

HCWM Strategic Plan of Action 2003-2008 Ministuy of Health and Population

|_Unitarymeasure uantityperyear I Annual budgets per activity_l_ lActivity |Unit |Unitcost 3 4 | 5 Year 1 j Year 2 Year3 [ Year 4 Year 5 Total

9.3.0 Improvement Of HCW Collection, Treatment, Transportation And Disposal In All Health Facilities

4 Conduct EIAs for major Round 1,0.11 7 7 $ $ $ $ $ $HF's HCW in District i dp 1tp 500 22 0 l l 33,000.00 000.00- 000.00 000.00 000.00 33,000.00Hospitals I..I...J....___________

P ~~~~~ ~~ ~~~~~$ S S S S Subtotal = 39,000.00 000.00 000.00 000.00 000.00 39,000.00

Subtotal 9.3.1 and 9.3.2 and 9.3.3 = 1,6,0.01,2117,135.0 $$Subtotal 9.3.1___________ an_.32an_.33=1,068,500.00 0 1,231,635.00 1,124,135.00 956,875.00 5,598,280.00

41


|____ |____________ mUnitary easure Quantity per year Annual budgets per ctivtyActivity Unit Unit I 13 4 Year Year 2 Year3 Year 4 Year 5 Total

__cost$ _I _ II9.4.0 Information, Communication, Education and advocacy on community involvement in HCWM

9.4.1 Dissemination of information on HCWM through mass_media1 Hold press conferences Numbe 200.00 1 3 3 3 1 $ $ $ $ $ $

on HCWM r 200.00 600.00 600.00 600.00 200.00 2,200.002 Issue press releases on $ S

HCWMsu pesrlasonAnnual 900.00 1 1 1 1 1 $ $ $ $ $HCWM Annuai 900.00 1 1 1 1 1 900.00 900.00 900.00 900.00 900.00 4,500.003 Insert HCWM jingles numbe 43.00 2 4 4 4 4 $ $ $ $ $ $

on radio r 86.00 172.00 172.00 172.00 172.00 774.00

4 Develop posters on 1200 300 200 1000 100 $ $ $ $ $ $HCWM Copies 2.00 0 0 0 0 24,000.00 6,000.00 4,000.00 2,000.00 2,000.00 38,000.00

5 Develop leaflets and 1000 300 200 1000 100 $ $ $ $ $ $flyers on HCWM Copies 2.00 0 0 0 1 0 20,000.00 6,000.00 4,000.00 2,000.00 2,000.00 34,000.00

6 Advocate for HCWM 1/ $ $ $ $ $ $sessio 1,500.00 1 1 1 1 1 1,500.00 1,500.00 1,500.00 1,500.00 1,500.00 7,500.00

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ n _ _ _ _ I_ I__ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

7 Develop messages on numbe 43.00 6 6 4 4 2 $ $ $ $ $ $HCWM. r 258.00 258.00 172.00 172.00 86.00 946.00

_ S ~ ~ ~ $ $ $ $ $Subtotal = 46,944.00 15,430.00 11,344.00 7,344.00 6,858.00 87,920.00

42


_ jUnitary measure Quantity per year Annual budgets per activity

Activity Unit J Unit 2 ii 3 | 4 |5 Year 1 Year 2 Year3 [ Year 4 Year 5 Total

9.5.0 Public Private Partnership

9.5.1 Promotion of business opportunities in HCWM

1 Advocate for private bnefing

sector involvement in 1/4 1500 1 2 2 1 1 $$$$$$seHCWM sessn 1,500.00 3,000.00 3,000.00 1,500.00 1,500.00 10,500.00

2 Define financingmechanism for private 1/4 10 3 00 0 0 $ $0.0 $000$ $ $sector contracts o session 1500 3 0 0 0 0 4,500.00 $ 000.00 $000.00 000.00 000.00 4,500.00

HCWM I I_I3 Contract out HCW

treatinent &disposal annual 13,000 1 2 3 4 4 $ $ $ $ $ $services for central 13,000.00 26,000.00 39,000.00 52,000.00 52,000.00 182,000.00hospitals

4 Conduct feasibilitystudies on potential study 1 0,000 1 1 0 0 0 $ $ $ $ $ $waste recyclable 10,000.00 10,000.00 000.00 000.00 000.00 20,000.00

_____ materials __ S S S $ S$

_____ Subtotal = 29,000.00 39,000.00 42,000.00 53,500.00 53,500.00 217,000.00

43


[ |Unitary measure | Quantty per year Annual budgets per activity

Activity |Unit Unit 1 2J3j 4YYear 2 Year3 Year|4 Year 5 Total

9.6.0 Monitoring and Evaluation

9.6.1 Continuously monitor and evaluate HCWM activities at all levels1 Develop supervisory 1/4 $ $ $ $

checklist on HCWM sessio 1,500.00 1 1 0 0 1 1,500.00 1,500.00 $ 000.00 $ 0000.0 1,500.00 4,500.00

2 Conduct supportivesupervision on HCWM round 200.00 54 54 54 54 54 $ $ $ $ $ $in all health facilities trip 10,800.00 10,800.00 10,800.00 10,800.00 10,800.00 54,000.00by district level

3 Conduct monitoring ofHCWM activities in round 500.00 4 4 4 4 4 $ $ $ $ $ $the district by HCWM trip 2,000.00 2,000.00 2,000.00 2,000.00 2,000.00 10,000.00unit

4 Conduct mid-term and $ $ $ $ $end program Study 10,000.00 0 0 1 0 1 00.00 000.0 10,000.00 $ 000.00 10,000.00 20,000.00evaluation on HCWM I__III___ _ _

$ $ S $ $ $__ Subtotal =$14,300.00 $14,300.00 $22,800.00 $12,800.00 $24,300.00 88,500.00

44


Annex 1.

A.1 Roles And Responsibilities

The national strategy for the implementation of injection safety relies on the involvement of all-public and private sectors, NGOs, associations and commissions, national coalition of donoragencies, regulatory bodies and training institutions. So it is necessary to establish a partnershipframework to determine the roles and responsibilities of each category of actors.

A.1.1 Ministry of Health and PopulationIts duties shall include:

* Taking leadership in co-ordinating activities of HCWM, both to the district and nationalcoalition

* Establishing HCWM Unit (HCWMU) to co-ordinate HCW management in departments ofthe MOHP including IMCI, EPI, RHU and family planning, infection prevention, bloodtransfusion services, department of clinical services, preventive health, health care supportservices, essential laboratory services, TB control programme and CMS. The HCWMUshall also develop a data base for injection safety

* Taking leadership in co-ordinating budgetary allocation on HCWM in all programmeswhere HCWM will be implemented

* Co-ordinating implementation of the policy and future evaluation of the policy accordancewith NHP through HCWMU

* Taking leadership in locating financial resources in collaboration with donors* Enforcing law and regulation in HCWM

A.1.2 National HCWM Coalition in ICC.

It shall be composed representatives from stakeholders involved in HCW activities. Its duties shallinclude:

* Evaluating Health care Waste Management*0 Locating and mobilising financial resources for HCWM and its research* Reviewing the policy in collaboration with the MOHP* Guiding collaboration of HCWM unit in MOHP with other stakeholders* Receiving reports from HCWU on HCW* Developing curriculum for HCWM at all levels in collaboration with relevant stakeholders* Review indicators for monitoring impact* Approving technologies in HCWM

A.13 District HCWM Committee.

The DHMT shall work act as the District HCW management committee. Its duties shall include:* Allocation of financial and human resources to HCWM* Budget for HCWM annually* Ordering HCWM equipment from CMS and distribution to health facilities.* Supervising of injection safety practices in the district including CHAM and the private

health facilities.* Establishing an HCWM information and reporting system* Collecting all information on HCWM including HCW related injuries and contamination

reported from health facilities to create a district database.* Establishing disciplining system for the district to those that perpetuate misconduct or

failing to implement HCWM standards or guidelines

45

HCWM Strategic Plan of Action 2003-2008 Mimstry of Health and Population

A.1.4 Health centres HCWM Committee.The HCMT shall work as the Health centre HCWM committee. Its duties shall be:Budgeting for HCWM.

* Mobilising financial resources at local level through income generating activities like userfee.

* Mobilising the local community and community based organisation to support HCWM.* Collaborating with local community in developing information system for feedback from

the community.* Promoting the role of the community in HCWM.* Locating human resource to HCWM.* Establishing auditing system for HCWM.* Ordering HCWM equipment.* Observing injection safety principles in accordance with the infection control practices.* Integrating health care waste management with injection safety.* Recording all injuries and contamination due to HCW exposure/ contact.* Establishing HCW information and reporting system* Establishing disciplining system for misconduct in HCWM.* Establishing data base for HCWM* Training all auxiliary staff in HCWM before starting their work

A.1.5 District, Town and City AssembliesIt duties shall be:

* Recording any presence of infectious waste and sharps from health care facilities and thecommunity, which finds its way to the municipal disposal site or landfills.

* Identifying the source of the waste containing infectious waste* Reporting presence infectious wastes and sharps to District HCWM Committee and nearest

public health facility.* - Encouraging public awareness in HCWM in the district.

A.1.6 MLG, CHAM and Private and Company Health FacilitiesTheir duties shall be:

* Collaborating with the HCWMU through their district HCWM committees to ensureimplementation of HCWM in their health facilities as above.

* Authorising HCWM research to be carried out in their health facility which might not beinformed to them in advance to avoid bias

* Providing financial support for HCWM

A.1.7 Ministry of Water Development and MNREATheir duties shall be:

* Monitoring environmental impact of HCW pollution* Recording all HCW pollution* Reporting HCW pollution HCWMU or National HCWM Coalition* Participating in public sensitisation of HCWM* Defining norms associated HCW pollution to environmental degradation in collaboration

with Malawi Bureau of Standards

A.1.8 Regulatory Bodies (MCM, NMCM, MPMPB, MBS)Their duties shall be:

* Collaborating with the HCWMU and National HCWM Coalition* Incorporating HCWM in their routine inspections of health facilities* Facilitating curriculum development in HCWM for health institutions in Malawi* Enforcing law and regulation in HCWM practices

HCWM Strategic Plan of Action 2003-2008 Ministuy of Health and Population

A.1.9 Health Training Institutions (COM, KCN, MCHS, CHAM Institutions)Their duties shall be

* Developing HCWM curriculum in collaboration with National HCWM Coalition andregulatory bodies

* Incorporating HCWM curriculum in their curricula* Assisting in development of curriculum for in-service and public awareness* Assisting in development of IEC materials for HCWM* Training their student in HCWM* Assisting in in-service training and community awareness.* Carrying out research in HCWM

A.1.10 Non-Governmental OrganisationsIts duties shall be:

* Mobilising financial resources to HCWM* Carrying out in-service training and public awareness training* Harmonising and validating HCWM procedure

A.1.11 Composition and responsibilities of the HCW Management teamThe HCWM team shall comprise the following persons:

* The DirectortDHO or his/her Deputy, who shall be the Chairman;* The Head of the administration* The Heads of all hospital departments;* The Matron of the hospital;* The DEHO* Any other person that the Director/DHO may designate

47


Annex 2.0 Treatment Systems and Technologies

A..2.1 SOLID WASTES TREATMENT

HCW treatment systems should be efficient, environmentally sound, and permit access controls, soas to protect persons from voluntary or accidental exposition to waste during the treatment process.Technology choices should de made according to the following criteria:- Performance and efficiency of treatment- Environmental viability.- Easiness and simplicity in the settling, the operating-and care.- The spare parts should be available, easy to get.- Costs of investments and operating.- Social acceptability

In addition to this, the waste treatment system should be close to the waste generating point.

a. Microwave disinfection

This method is used to disinfect bio-medical waste in stationary or mobile plants. The waste isheated by means of microwave energy. This method needs high investment and operating costs.

b. Autoclave sterilization

This type of treatment is used in health facilities (medical analysis laboratories) for the sterilizationof reusable medical equipment. In this process, a dry heat sterilizer is used and heat of 180°C isgenerated for 30 minutes or longer, for activating vegetative microorganisms and most bacterialspores. This process is able to handle only limited quantities of waste and therefore is commonlyused only for highly infectious waste such as microbial cultures from clinical or researchlaboratories. Autoclaving is environmentally sound, requires fairly high investment and moderateoperating costs, and ensures good disinfection efficiency under appropriate operating conditions.However, it cannot be used for all type of waste and generates contaminated wastewater. Inaddition, operation requires qualified technicians and its shredders are subject to frequentbreakdown.

c. Incineration

Waste incineration is a thermal treatment, which aims at destroying organic waste parts byoxidation. Various types of equipment are in use:

* Pyrolitic incinerator: This has a treatment capacity ranging from 500 to 3,000 kg wastes daily,at a combustion temperature of 12000 or 16000 C; its initial cost is very expensive. It also needshighly qualified staff . The remnants of wastes are sent to landfill disposal sites.

• Pyrolitic incinerator (modem incinerator): its treatment capacity is from 200 to 10,000 kg/daily,with a combustion temperature ranging from 800 to 900° C; its requirements in terms ofinvestment and care taking are somewhat high; it needs qualified staff; the remnants of wastesare sent to the landfill disposal sites.

* Incinerator with combustion room (artisanal construction, with local materials): Its investmentand care taking costs are relatively low; it can work effectively, even with low-qualificationstaff.

Incineration provides very high disinfection efficiency and drastic reduction of weight and volumeof waste. It is relatively low in cost and does not need qualified staff for operating. But it generatessignificant pollutant emissions.

d. Chemical disinfection


Chemical disinfection, frequently used in health facilities to destroy microorganisms on medicalequipment, floors and walls, is now being extended to the treatment of biomedical wastes.Chemicals are put in the waste to destroy or inactivate the pathogens. This treatment usually ismore efficient as in disinfection than in sterilization. Chemical disinfection is most suitable fortreating liquid waste such as blood, urine, stools or hospital sewage. Solid (and even highlyhazardous) biomedical wastes, including microbiological cultures, sharps, etc., may also bedisinfected chemically. Chemical products such as hypo-chlorine and other acids are used todestroy pathogens, before wastes are burned or transported to disposal sites. The most frequentchemical disinfectants are:

• Chlorine - which is a universal disinfectant, very active against micro-organisms. In case ofpossible HIV/AIDS infectious materials, concentration of 5 g/liter (5000ppm) of chlorine isrecommended.

* Formaldehyde - which is an active gas against all micro-organisms except at low temperature(<20°C); the relative humidity must be near 7 %. It is also sold in the form of gas dissolved inwater at concentrations of 370 g / liters. This disinfecting product is recommended for Hepatitisand Ebola virus (but not for HIV/AIDS). The risk associated with formaldehyde is that it cancause cancer.

The drawback of this system is that the disinfected wastes are still there and other methods of finalelimination must be devised. This method gives highly efficient disinfection in good operatingconditions, and some chemical disinfectants are relatively inexpensive. But it requires highlyqualified technicians for operating the process.

e. Burial in municipal landfills

This practice consists in disposing of HCW directly in municipal landfills. In fact, this is not atreatment system: the wastes are stored with household wastes. This system requires very lowinvestments, but it presents huge health and environmental risks, in view of scavenging practices atpublic landfills. However, landfilling is better than leaving hazardous wastes accumulated athospitals or other publicly accessible places. More suitable treatment methods should immediatelybe envisaged.

f. Burial inside health facilities

Burial at the origin of HCW production - the health facility - is another form of elimination, mainlyused where there is no treatment system or means of waste transportation to public landfills. Therisk in this case is that the destruction of infected wastes is not sure, according to the burial place.Also, there is always the risk of digging out wastes, most of all, the sharp objects.

g. Open air burning

When done in open air, the burning of HCW constitutes a factor of pollution and harm to theenvironment. Since HCW is generally burned in a hole, the destruction is never complete: often thequantity of unburned residue constitutes 70 % of the original wastes. This encourages children andscavengers to look for toys and reusable objects.

h. Encapsulation

This method consists of disposing of wastes by filling metal or plastic containers /4 full with wastematerials and topping the container up with plastic foam, bituminous sand, cement mortar or claymaterial. The process is cheap, safe and very appropriate for health centres that cannot envisageother methods to treat sharps, chemical and pharmaceutical waste. Encapsulation is notrecommended for non-sharps infectious waste. The main advantage is to prevent the risk ofscavengers getting access to these wastes in landfills and to reduce mobilization of toxicsubstances.

49


i. Comparative analysis of solid HCW treatment systems

Table I demonstrates the advantages and drawbacks of each treatment system, along with its fitnessin the economic and socio-cultural context of Malawi.

Table 3: Comparative analysis of solid HCW treatment systems

System Technical Investmen Operating Easiness/ Availabilit Environ- SocialFeasibility t Cost Cost simplicity y of spare mental acceptanc

________ __ parts Viability eAutoclave Very Fairly high Average Very Not Ecological, Very good

efficient qualified available but gener-butcannot staff locally ates con-be used for taminatedall types of wastewaterwaste

Microwave Very Very high Very high Very Not Very Very goodirradiation efficient qualified available ecological

staff locallyPyrolyse Very Very high Average Qualified Possible Very Very good

efficient staff ecologicalPyrolitic Very Fairly high Average Limited Possible Little Very goodincinerator efficient skills pollution(modemincinerator)

Local Fairly Weak Weak Limited Available Polluting Very goodmaterial efficient skillsincineratorChemical Fairly Weak Weak Qualified Available Polluting Fairlydisinfectio efficient staff goodnBurial in Inefficient Weak Weak Qualified Available Very Badmunicipal staff pollutingpublic and riskylandfillsBurial inside Inefficient Weak Weak Limited Available Polluting Badhealth skills and riskyfacilitiesIncineration Inefficient Weak Weak Limited Available Polluting Very badat open air I_skills and riskyEncapsulatio Very effi- Weak Weak Limited available Non Goodn cient for skills polluting

sharps,drugs butnot recom-mended fornon-sharps


j. Recommendations

The comparative analysis, based oh the above mentioned economic and technical criteria, leads tothe following recommendations:

* Modem incinerators in Central / national / and district hospitals, because of its fairly low costand operating skills requirements;

* Local incinerators (built with local material) in health centres and urban health posts, becauseof its very low cost and small quantities of HCW produced in these facilities;

* Pit latrine in rural health posts, because of very low HCW production.

Inadequate incineration, or incineration of non- incinerable (halogenated plastic, radioactive waste,reactive chemical waste, silver salts or radiographic waste, mercury or cadmium, heavy metals,etc.) waste can release pollutants into the air. The incineration of materials containing chlorine cangenerate dioxins and furans, which are classified as possible human carcinogens and can have otheradverse effects. Incineration of heavy metals or materials with high metal contents (in particular:lead, mercury and cadmium) can increase the spread of heavy metals in the environment. Dioxins,furans and metals are persistent and remain in the environment. Materials containing chlorine ormetal should therefore not be incinerated.

To ensure that inappropriate materials are not incinerated, the waste incineration system must bebased on a strategy of segregation at source, to reduce as much as possible the infectious wastestream and to prevent the contamination of other wastes (papers, plastic objects, etc.). All types ofwastes must not be incinerated, mainly the non-incinerable ones mentioned above. Wastesegregation will allow the non-contaminated, non-infectious and non-incinerable wastes to bedisposed at municipal landfills. Only the contaminated wastes (needles, sharp objects, blood stainedcottons, etc.) are reserved for incineration. The latter don't produce (or produce very little) toxicelements. In addition, this system of treatment allows a complete melting of needles, which are themain vectors of accidental transmission of HIV/AIDS.

Modem incinerators, with special emission-treating equipment, are able to work at 800-1000 °C,and can ensure that no dioxins and furans, or only insignificant quantities are produced. Smallermodels, built with local materials and able to operate at these high temperatures are currently beingfield-tested and implemented in some countries.

In the health centres, the quantities of HCW produced are insignificant. If waste segregation isperformed well, the quantities to be incinerated will be reduced and negative impacts on theenvironment will be insignificant. In addition, promotion of the use of non-chlorine plasticcontainers can reduce polluting by-products in solid waste incineration.

Although incineration has its critics, it is difficult to choose another system for developingcountries such as Malawi, given the economic and technical conditions. The proposal is not toincinerate all solid urban waste (household wastes, industrial wastes, etc.), but only selectedcontaminated health care wastes. Appropriate incinerator technology is supported by the WHOelsewhere in Africa. For example, during vaccination campaigns against tuberculosis in Togo andBenin, the WHO has supported, since 2001, a program to produce craft incinerators (made of localmaterials, cement with clay), in order to destroy the syringe needles used in the vaccinationprogram. WHO organized a workshop in Bamako in 2001 to train some African technicians in thebuilding of these types of incinerators. These models can reach very high temperatures (800 °C)able to get the needles and sharp objects melted (the model is shown in annex xx).

Presently, there are no environmentally sound options at low-cost for safe disposal of infectiouswastes. Incineration of wastes has been widely practiced, but alternatives, which may be preferableunder certain circumstances, are becoming available, such as autoclaving, chemical treatment andmicrowaving. Landfilling, when safely practiced, may also be a viable solution for part of thealready segregated wastes.


system for liquid wastes, along with its suitability in the economic and socio-culturalcontext of Malawi.

Table 5: Comparative analysis of liquid waste treatment systems

System of Technical Technical investment Recommendationtreatment Characteristics Efficiency and for Malawi

Operating_________ Cost

Decanting and - Mud draining Medium Fairly high Recommended indigesting - very weak area (buried) central and districtbasin hospitalsSeptic pits - Mud draining Medium Very low Recommended in

- very weak area (buried) health centersActivated mud - sifting Very high Very high Not recommendedsystem - mud draining (very expensive)

- ventilation- fairly important area

Biological - sifting High Very high Not recommendeddisk, bacterial - mud draining (very expensive)field - fairly important area

Physic and - sifting Very High Very high Recommended forchemical - chemical products central or generaltreatment - fairly important area hospitals only

Chemical - use of chemical High Medium Recommendeddisinfection products only

- little area is necessary- No investments ininfrastructure

Disinfection is clearly the most efficient way to deal with liquid infectious wastes. That iswhy this option should be favored among the other interventions, because the HCWMplan is focused especially on HIV/AIDS related waste management. Consequently, acombined system (disinfection then storage in septic pits) is recommended for theprovincial hospitals, district hospitals and health centres, which don't produce much liquidwaste. For the central and general hospitals, a physic and chemical treatment, comprisinga disinfection system, is recommended. The implementation of this option requires afeasibility study.

A.2.3 Choice Of Landfill Sites

In big cities such as Lilongwe and Blantyre, incineration residues, which are considered ashousehold waste, can be disposed in the public municipal landfill, if specific burial areasare prepared, mainly to receive sharp objects not melted during the process. These typesof waste hurt scavengers and street children even though they are sterilized duringincineration. At District and local level, the remaining wastes after burning can be buriedinside health centers, away from patient treatment areas

A.2.4 Decision Tree Scenario

Five scenarios have been developed to describe the context within which health carefacilities operate and must find solutions for the safe management of their wastes. The






scenarios mainly distinguish between the population density -of the area, the proximity tomodern waste treatment facilities, and whether facilities are located in urban, peri-urbanor rural environments. Five decision trees corresponding to each scenario are presentedto show treatment choices and disposal options:

* Scenario 1 (Annex 4.1 ): Urban area with access to a modem waste treatment facility orlocated reasonable distance of a larger health-care facility with treatment facility

* Scenario 2 (Annex 4.2 ): Urban area without access to modem waste treatment facility

* Scenario 3 (Annex 4.3 ): Peri-urban area

* Scenario 4 (Annex 4.4 ): Rural area without access to modem waste treatment or disposalfacility

* Scenario 5 (Annex 4.5 ): Rural area with access to modern waste treatment orlocated reasonable distance of a larger health-care facility with treatmentfacility.


Annex 3: Training and Public Awareness Strategy

A3.1 OBJECTIVE

Correct attitudes for effective HCWM result from knowledge and awareness regarding the potentialrisk of healthcare and administrative procedures for handling the waste. Apart from a generalunderstanding of the requirements of waste management, each category of actors (doctors, nurses,caretakers, ward attendants, ground workers, administrative staff, etc.) working within the healthfacility has to acquire his or her own individual waste management skills. Staff cannot be assumedto have the theoretical knowledge and practical skills, but must be taught and trained. For thetraining to be successful and to lead to changed behaviour, participants must become aware of therisks linked to HCWM.

A3.2 TARGET GROUPS

In health facilities, two target groups may be distinguished:

- Principal group: (i) Management and administrative staff; (ii) Medical and laboratory staff;(iii) ward attendants, caretakers, ground workers and other support staff;

- Secondary group: Patients and visitors.

i) Management and administrative staff

It is the task of the management to build up the awareness of waste management in each type ofhealth facility. However, often the management itself is not totally aware of all the risks resultingfrom HCW, and in many cases does not know about appropriate waste management technologiesand procedures. Some guidance is needed before the management staff of health facilities will beable to install a proper waste management structure and procedures.

ii) Medical and laboratory staff

Due to their professional training, doctors, nurses and the other medical staff have the broadestknowledge about health risks resulting from HCW. They, in turn, should create awareness amongthe other members of health facility staff. Although, they may be aware of the health risks, doctors,nurses and other medical staff also need training in proper waste management and handlingtechnologies and procedures.

iii) Ward attendants, ground workers, caretakers and other support staff

Ward attendants, ground workers, caretakers, cleaners, kitchen and laundry personnel constitutethe group of people having the greatest daily contact with HCW and the least knowledge abouthealth risks or waste management practices. Therefore, they need extensive training and regularsupervision to ensure the desired improvement in waste management practices actually occurs.

iv) Patients and visitors

Due to the permanent fluctuation of patients and visitors, it is virtually impossible to teach thisgroup of people systematically about the principles of HCWM. One possibility may be to offeradvice on basic HCWM subjects during the waiting periods. Patients and visitors should be madeaware of the proper use of waste containers to dispose of their waste. Attentive hospital staff mightguide patients and visitors from time to time regarding their waste management practices. Relevantposters may often provide the public with additional information.


v) Waste Management Operators

The waste operators have a daily and direct contact with HCW because they are mainly responsiblefor waste handling. For this reason, they need to be informed on risks and advised about infectionprevention and security protection.

vi) Waste Transportation Staff

Waste transportation staff (mainly off-site transportation) need to be trained because HCW shouldbe collected in specific containers and specific vehicles. In addition, procedures for HCW handling(loading and unloading) need to be known because of the special characteristics of HCW, andbecause handling and transport require specific protection equipment to prevent infection by HCW.

vii) Treatment Systems Operators '

HCW treatment systems require specific capacities. That is why the operators in charge need to betrained in order to master the operating process, to know health and security related to the operatingsystem (mainly the procedures in emergency cases), to learn how to care for the equipment.

viii) Disposal Managers

The staff (municipal staff) who manage landfills disposal need to be informed about health andsecurity linked to HCW. The must be aware of the necessity of protection equipment and personalhygiene and they must control scavenging activities and recycling of used instruments inside thesespecific sites.

A33 TRAINING STRATEGY

The training program aims to operationalize the HCWM plan by: promoting the emergence ofexperts and professionals in HCWM; raising the sense of responsibility of people involved withHCWM; and safeguarding health and security of health staff and waste handlers. The trainingstrategy will be articulated around the following principles:

- Training trainers: this involves training the senior officer in health centres (doctors, EHO, andtechnical services' supervising staff in City Assemblies).The training sessions will be held inevery health district, (5 trainers per district and LCH, for 22 districts, during 5 days, nearly 600person/day);

- Training health care staffs in health centres (medical staff, nurses), by the already trained seniorstaff member. These training sessions will be held District by District and will be performed bythe already trained key staff ( 40 participants for each district and LCH, during 3 days, nearly3000 person/days);

- Training HCWM supporting staffs in health centres (ward attendants, ground workers,cleaners). These training sessions will be held in health centres and will be performed byalready trained key staff (3000 person/days, with 3 agents during 2 days, for nearly 500 healthfacilities).

The training modules will deal with risks in the handling of HCW : sustainable managementprocess (collection, storage, transportation, treatment, disposal) ; good behaviors and practices;caring for installations; protection measures. The training of medical and paramedical staff remainsa priority if the program is to have a major impact on HCWM. The recommended content of thesetraining modules is presented below:


Training module for waste management operators- Information on the risks; advice about health and security- Basic knowledge about procedures of wastes handling, including the management of

risks.- The use of protection and security equipment.

Training module for waste transportation staff- Risks linked with waste transportation;- Procedures for waste handling: loading and unloading;- Equipment such as vehicles for waste transportation;- Protection equipment.

Training module for treatment systems operators- treatment and operating process guidelines;- health and security related to the operating system;- procedures in emergency cases and help;- technical procedures;- caring for equipment.- control of waste production;- watching over the process and the residues.

Training module for disposal managers- Information about health and security- Control of scavenging activities and recycling of used instruments;- Protection equipment and personal hygiene;

- Secure procedures for the management of wastes at the disposal site;- Measures concerning emergency cases and help.

Training modules for HF staff

Administrative staff- Information on the risks- Advice about health and security- Basic knowledge about procedures of HCWM waste collection, storage, transportation,

treatment and final disposal including the management of risks.- The use of protection and security equipment- Health care waste management guidelines- Financial resources to be allocated to HCWM.

Doctors, clinicians, nurses, midwives, etc.- Information on the risks; advice about health and security- Basic knowledge about procedures of HCWM waste collection, storage, transportation,

treatment and final disposal including the management of risks.- The use of protection and security equipment (protective clothes)- Strategies to control and ensure that used disposable equipment/materials are placed in

appropriate disposal and collection facilities and to ensure that all patients are safefrom injury or hazards resulting from HCW

- HCW segregation at source- How to orient the staff on the guidelines for waste management- Good practices on HCWM

Cleaners, ward attendants, grounds attendants, other personnel in touch with waste, etc.- Information on the risks; advice about health and security- Basic knowledge about procedures of HCWM waste collection, storage, transportation,

treatment and final disposal including the management of risks.- The collection and transportation of HCW containers


- The use of protection and security equipment (protective clothes)- Good practices on HCWM

A.3.4 Population Awareness StrategyThe awareness raising strategy will aim at the general public and scavengers. They must beinformed about dangers in HCW handling. This objective can be achieved through information andawareness campaigns on local radio (120 messages, 2 message per month, durant 5 years) andtelevision (30 messages, 6 messages per year, during 5 years), but mostly, by animation sessions inpopular districts, organized by NGOs and CBOs active in health and environment management(nearly 110 animations, 5 per district x 22 districts). These actions can be reinforced by educationcampaigns (1000 posters, 20 unit for 500 health facilities) in health facilities in other highlyfrequented places.

Another concern is to ensure that HCW from home care'are well-managed. In fact, advances inmedicine now allow monitoring family health and treating some sickness at home. Such activitieshave the effect of introducing infectious wastes closer to households. These health care wastesinclude: used needles, syringes and lancets, medicine unused or outdated, broken thermometers,etc. They must also be managed at home where health care is practiced, to avoid their minglingwith household wastes and increasing hazardous risks. For example, it is noticed that razor bladesare widely used at home (scarification, etc.) and they can be sources of infection if they are not wellmanaged. For this reason, it is necessary to elaborate information and awareness programs (radio ortelevised) towards the health agents (professionals, traditional, and family members) who exercisein the home. The targeted actors must be advised to have specific containers for needles, sharpobjects (box, empty bottles, etc.) and other HCW (cotton, gloves, bandages, etc.) and not to mix theHCW with the general household or office wastes.

Used needles, syringes, lancets and other sharps may be safely disposed with other home solidwastes, provided that special care is taken while packaging them. The safe packaging of thesewastes may be done very simply at home: one can use rigid plastic bottles (with a tight fitting lid),such as empty laundry detergent bottle; and one must not put sharp objects in any container to berecycled or returned to a store; needles and syringes don't need to be recapped. The rigid bottle willminimize possible needle pricks and when they are full, the lid should be tightly fixed and thebottle placed with other solid waste for disposal.

Unused and outdated medicines stored at home are considerable risks for children and carelesspeople. These medicines may be safely disposed by throwing them into a flushing toilet. Athorough cleansing of empty medicine containers with warm water should then be done. After that,close the lid tightly and dispose with other home solid waste. Medicines should be out of reach ofchildren who should not play with unclean empty medicine containers.

Contaminated bandages, pads, gloves, etc., may be double bagged in standard plastic waste bagsand securely fastened. This material may then be combined with other household waste fordisposal.

Condoms are not considered as Health Care Waste (they are protective materials against HIV/AIDSinfection). It is possible, in the programs for public awareness raising, to draw people's attention tothe necessity of managing these wastes well: condoms should not be dropped anywhere; after use,they should be disposed of by throwing them into flushing toilets, burying them safely, or double-bagging them in standard plastic waste bags (securely fastened) for combination with otherhousehold waste disposal.

Health agents (both formal and informal) who exercise at home must have collection containers,which they should carry to the nearest health centre for treatment and disposal. They should alsohave sterilizing products in order to sterilize all the HCW before disposal. The needles must beburied if there is place for this inside the house; if not, they must be put into bottles or other closedboxes, then evacuated to the public landfill (or health care facility). Other HCW (cotton, gloves,

59


bandages, etc.) could be disposed in the public landfill after sterilization. Gloves should be torn toprevent people from re-using them and risking infection.

Table 6: Topics of training and public awareness guide (Health Staff)

Training subject Cate ory of tr et rupA B C D

Basic knowledge about HCW X_____

Waste categories X X XHazardous potential of certain waste categories X X X XTransmission of nosocomial (hospital acquired) infection X XHealth risk for health care personnel X X X

Proper behavior of waste generatorsEnvironmentally sound handling of residues X X X XWaste avoidance and reduction possibilities X X XIdentification of waste caiegories X X _

Separation of waste categories X XKnowledge about appropriate waste containers X X X

Proper handling of wasteAdequate waste removal frequency X XSafe transport containers and procedures X X XRecycling and re-use of waste components X XSafe storage of waste X XCleaning and maintenance of collection, transportation and storage X Xfacilities ..Cleaning and maintenance of sanitation facilities, drains and piping X X XHandling of infectious laundry X XHandling of chemical and radioactive waste, outdated drugs X X XMaintenance of septic tanks and other sewage treatment facilities X XMaintenance and operation of incinerator for infectious waste X XMaintenance and operation of waste pit and landfill site X X ____

Safety regulation in waste management, protective clothing X X XEmergency regulations in waste management X X X

Establishment of a waste management systemEstablishment and implementation of a waste management plan XSampling of waste quantities, monitoring and data collection X XMonitoring and supervision of waste management practices X X XCost monitoring of waste management XEstablishment of a chain of responsibilities X X XSet-up of occupational safety and emergency regulations X X XInteraction with City assemblies or private sector waste handling XstructuresPublic relation and interaction with local community X

A Management and administrative staffB : Medical and laboratory staffC : Ward attendants, caretakers, ground workers and other support staff;D : Patients and visitors


Table 7: Topics of training and public awareness guide (Non-Health Staff)

Training subject Cate o of tarGt upE F G H

Basic knowledge about HCWWaste categories X X X XHazardous potential of certain waste categories X X X XTransmission of nosocomial (hospital acquired) infection X X X XHealth risk for health care personnel X X X X

Proper behavior of waste generatorsEnvironmentally sound handling of residues X X X XWaste avoidance and reduction possibilities X X X XIdentification of waste categories X X X XSeparation of waste categories X X X XKnowledge about appropriate waste containers X X X X

Proper handling of wasteAdequate waste removal frequency X XSafe transport containers and procedures X XRecycling and re-use of waste components X X X XSafe storage of waste X X X XCleaning and maintenance of collection, transportation and storage X X X XfacilitiesCleaning and maintenance of sanitation facilities, drains and piping XHandling of infectious laundry X XHandling of chemical and radioactive waste, outdated drugs X XMaintenance of septic tanks and other sewage treatrment facilities XMaintenance and operation of incinerator for infectious waste X XMaintenance and operation of waste pit and landfill site X X XSafety regulation in waste management, protective clothing X X X XEmergency regulations in waste management X X X X

Establishment of a waste management system =_= -Establishment and implementation of a waste management plan XSampling of waste quantities, monitoring and data collection XMonitoring and supervision of waste management practices X X X XCost monitoring of waste management XEstablishment of a chain of responsibilities X X X XSet-up of occupational safety and emergency regulations XInteraction with City assemblies or private sector waste handling X Xstructures _ _Public relation and interaction with local community X X

E : Waste management operatorsF : Waste transportation staffG Treatment systems operatorsH : Disposal managers

61


Annen 4 Decision Trees

Annen 4.1 Urban area with access to a modern waste treatment acIility

Waste lMinimization

Segregation

Sharps, Infectious Non- Non-Infectious WAunicipalin sharps boxes Sharps in waste stream

Bags/Containers

Contact waste treatment facilities or large health-care facilitiesand explorea The use of a treatment facility authorized to treat healthcare

wastes (prefer alternative to incineration)D Facility requirements for disposal of health care wastesD Organization of waste transport

Sufficient fund Inform managers on risks relatedfor off-site no to wastes and obtain budget fortreatment in the > future. In the meantime proceedtreatment facility as in scenarios 2 or 3 (annexes

\s /4.2 and 4.3)

ves

no Inoran Recycling \

practices In the community / es

Check number of injectionsSafe transpo~ation against number of safety boxes

g afe transportation}\vilable/ aiabe no > D'sinfect with leach

l (r,ol<~~~~~~~~f rliera ionV^- yes neF+tr jrOha/

Transport for off- 4 L_> site treatment at the

modern facilityThese solutions should only beused during a limited tim, and

LX better arrangements should besought.


Annex 4.2: Urban Area Without Access To Modern Waste Treatment Facility.

MODERN WASTE TREATMENT FACILITY

|Waste|lMinirnization l

F Segregation

+

Sharps, in Infectious non-sharps Non-infectious Municipalsharps boxes in bags/containers waste stream

Explore waste treatment facilities in the area

Waste incinerator (ifmodern facility l1modern facility ~Controlled landfillavailable (see availablescenario 1 or A4.1)

no f al ral no/ Recycling Recycling

practices in practicesna the ~~~~~~~in the

yes yes

Check number of injections against numberof safety boxes (scenario 1 or annex 4.1)

Disinfect syringes and needleswith bleach/destroy or remove

needles with cutter or othermethods

Syringes without needles Needlesand nonsharps

> 1 | IE ~~~~~~~~~~Encap'sulateneedles

Make managers and authorities aware of risks, and These solutions should only be usedlobby for more funds to prevent disease as a direct during a limited time, and betterconsequence of mismanaged health care waste anrangements should be sought

63






Annex 4.5: Rural Area With Access To Modern Waste Treatment

WasteMinimi7ntin|

ISegregation I

SeparateOn-site | biodegradable

Sharps, in | Infectious Non- Non-Infectious ncine use yes organic materialsharps boxes | sharps in ~ < for infectious waste - and use non-

l bags/containers \ / organic part ascombustible

qr ; ~~~~~~~~~~~~no

Municipal/ Possibility of off-site \ waste stream

/ treatment\no < * Reliable facility recognized

\ by authorities/

\transportation available*/

|yes

Informal norecycling incommunity

yesCheck number ofinjections against numberof safety boxes

Safeye d transportation yes *

travailable / Transport to off-sitetreatment facility

4,no

See on-s4ite Either a central waste treatment facility, or contact largertreatment on health-care facilities to explore arrangement for transferringannex 44 waste to their site

health-care facilities to explore arrangement for transferringwaste to their site


Annex 5: Model of "WHO" incinerator made with local materials

Some technical characteristics Efficient model of local incinerator (WHO-Togo)

- Materials: red sand (laterite), clay, whitecement

- Bricks of cooked sand- Galvanized metal sheet Chimney

Structure:- 0.6m x lmx 1.5m- Height of chimney 5 to 6m- Opening <<A >> for lighting and ashes

recuperation: 40cmx30cm- metallic gate (Galvanized metal sheet

galvanized) for opening << A >>- metallic grate for burning the waste- opening << B >> for the introduction of

waste: 40 cm x30cm- mobile lid for shutting opening << B >>- Concrete paving stone (2m x 2m)

Face view Profile view

Chimney - 0

Chimney _ / Opening <<B >>

StructureOpeninQ B >> - / / ___

Structure-

Openi

Grillr

Paving stone

67


Annex 5 Calculation of Unit Cost for Activities included in the POA

Calculation of Unit Costs1.1 Cost of training , orienting or briefing one participant per day

Workshops and training sessionsItem No. of people days rate/dayPerdiem participants 30 5 1300 195000.00Perdiem support staff 20 5 1300 130000.00Accommodation 30 5 4500 675000.00Stationary II 10000.00Hall refreshments,Proiector, PA system 150000.00Fuel for approx. 30 cars 80000.00

MK 1240000.00Cost of one session of 30 participants for 5 days $ 13,777.78Cost of one person per days $ 91.85

Say $ 100.00

1.2 Office Equipment cost Unit cost Number FrequencyComputer 300,000 1 1 300000.00Printers 45,000 1 1 45000.00Fax 12,000 1 1 12000.00Stationary+ pens 500 50 1 25000.00

MK 382000.00I $ 4,244.44

1.3 Cost of a round trip Unit cost Number Frequency | _-

Fuel 200 66 1 13200DSA for driver 1300 1 5.00 6500DSA for supervisor 1300 1 5 6500Accommodation 4500 1 | 4 18000

I______ _______ T_________ _______ IM K I 44200$ 491.11

Estimated distance 1400 Km per trip/round/visit Say $ 500.00

1.4 Personal protective eq lpment costOverall $ 12.50 $ 2.00 $ 25.00Dustcoat $ 15.00 $ 1.00 $ 15.00Gumboots $ 20.00 $ 2.00 $ 40.00Heavy duty gloves $ 10.00 $ 2.00 $ 20.00Masks $ 2.00 $ 3.00 $ 6.00

________ _____ _ I I__ __ $ 106.001Complete PPE kit for one worker Say $ 110.00


1.5 Cost of a study Unit cost Number DaysFuel 66 400 1 26400Principal Investigator 4500 1 6 27000fee__ _ _ _ _ _ _

Assistants fee 2500 4 5 50000DSA for study team 1300 5 5 32500Accommodation 5000 5 5 125000Stationary + printing 15000 1 1 15000Drivers 1300 2 6 15600Half session ( 551,000 1 1 551000debrfefing) e

MK 842500$ $ 9,361.11

Cost of a five days single study Say $ 10,000.00

1.6 Cost of HCWM Service from private sectorcost of one ton trp of waste collection liumpsum MK 7500

l 1 1 83.33333333Cost of 3 days collection per wk for Central hospitals $ 13,000.00

1.7 HCWM Collection & disposal Unit cost No/yr/HFEquipmentDustbins number 1000 2 2000Waste bags number 35 500 17500Labels slips 25 1000 25000Paddle bins number 450 2 900Wheel burrows number 3000 2 6000Trolleys number 4500 3 13500Mops number 40 208 8320Rakes number 250 3 750Picks number 400 3 1200Shovels number 350 6 2100Paraffin litres 45 260 11700

MK 88970$ 988.56

Say $ 1,000.00

69


Annex 6 Distribution of Health Facilities by type & Ownership

Distribution of Health Facilities by type and ownership (source JICA 2003)MOHP MOHP

Type CHAM LG MOHP /CHAM /LG TotalCentral Hospital _ 4 4Clinic 6 1 7Dispensary 6 6 46 4 62District Hospital 22 22Health Centre 105 11 230 1 50 397Health Post 2 3 5Hospital 23 2 1 25Maternity 1 12 2 15Maternity Clinic 1 1Mental Hospital 1 1 2Rehabilitation Centre 1 1 2Rural Hospital 18 18 1 37Urban Health Centre 5 1 6Total 163 32 333 1 56 585

'7A