Kingdom of Lesotho ADDENDUM NO. 2 Of VOLUME 1 - ICWMP INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) January 2016 THIS AMENDMENT modifies, and is made part of, the above-referenced document (attached as Appendix I to this document). Except as modified by this Amendment, all other conditions and procedures of the respective document will remain applicable. The amendment will be applicable during COVID-19 disease outbreak for control and management of the infections and waste generated by COVID-19 facilities including vaccination facilities, and will be used together with the Infection Control and Waste Management Plan (ICWMP), 2016, together with its Standard Operating Procedures (SOP). COVID-19 Emergency Preparedness and Response Project (P173939) Additional Financing (P176307) Infection Control and Waste Management Plan (ICWMP) July 2020 Updated May 2021 This Infection Control and Waste Management Plan (ICWMP) for COVID-19 Outbreak� is developed and published to improve on the Lesotho INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP), VOLUME 1, dated January 2016. This (Version 2, April 2021) is the updated version of the Addendum 1 (July 2020) to the ICWMP 2016. For comments or enquiries please contact the below-mentioned: Mrs. Boopane Ntai Project Coordinator Lesotho COVID-19 Emergency Preparedness and Response Project Ministry of Health P.O. Box 514 Maseru 100 Lesotho Email: mathabo.ntai@gov.ls OR Mr. Lepekola Lepekola Environmental and Social Specialist Lesotho COVID-19 Emergency Preparedness and Response Project Ministry of Health P.O. Box 514 Maseru 100 Lesotho Email: lepekola.lepekola@gov.ls This report is also available from Physical Address The Project Coordinator Ministry of Health Head-Quarter 3rd Floor Maseru Contents 1. Introduction .................................................................................................................................... 1 1.1. Project context and components ............................................................................................. 1 1.2. Healthcare Facility Design Requirements .............................................................................. 4 1.2.1. General Design and Safety Requirements ...................................................................... 5 1.2.2. Water, Sanitation and Hygiene (WASH) requirements .................................................. 5 1.2.3. Heating, ventilation and air conditioning (HVAC) requirements ................................... 6 1.2.4. Laboratory requirements ............................................................................................... 7 1.2.5. Quarantine / Isolation Rooms at Health Care Facilities ................................................. 9 1.2.6. Incinerator requirements ............................................................................................. 10 1.3. Storage, distribution, waste management and infection prevention during COVID-19 Vaccine deployment ......................................................................................................................... 13 2. Infection Control and Waste Management ................................................................................... 15 2.1. Overview of infection control and waste management in the HCF...................................... 16 2.1.1. Categorisation of HCW in Lesotho................................................................................ 16 2.1.2. COVID-19 Waste Categorisation................................................................................... 17 2.1.3. Current Healthcare waste management system in Lesotho ........................................ 19 2.2. Healthcare Waste Management Procedure and Measures .................................................... 20 2.2.1. General measures for Waste Management at Healthcare Facilities (including vaccine facilities) 21 2.2.2. Some Best Practices for Disposal of Hazardous Waste ................................................ 22 2.2.3. Plans for COVID-19 Waste Management ..................................................................... 25 3. Emergency Preparedness and Response ....................................................................................... 31 4. Infection Prevention and Control Procedures ............................................................................... 33 4.1. Establishment of a COVID-19 management system and coordination mechanism ............. 33 4.1.1. Education for effective prevention............................................................................... 33 4.1.2. Strengthening management of employees, visitors, and related personnel ............... 33 4.1.3. Social distancing ........................................................................................................... 34 4.1.4. Actions following detection of suspected patients ...................................................... 34 4.2. PPE procedure ...................................................................................................................... 34 4.3. Hygiene Procedures .............................................................................................................. 35 4.3.1. Hand hygiene procedure .............................................................................................. 35 4.3.2. Respiratory hygiene ...................................................................................................... 35 4.3.3. Hygiene and environmental management ................................................................... 36 4.4. Occupational health .............................................................................................................. 36 4.5. Community health ................................................................................................................ 37 4.6. Mortuary Arrangements (Handling of dead bodies)............................................................. 39 5. Institutional Arrangement and Responsibilities, Training and Capacity Building, Public Awareness, and Engagement of Private Sector .................................................................................... 40 5.1. Institutional Arrangement and Responsibilities ................................................................... 40 5.2. Training and Capacity building ............................................................................................ 43 5.3. Public Awareness ................................................................................................................. 44 5.4. Strategy for private sector involvement and partnership ...................................................... 44 6. Monitoring and Reporting ............................................................................................................ 45 Annex 1: Detailed Guidelines for Medical Waste Emergency Collection and Transportation System46 Annex 2: Guidelines for Patients Pending Hospitalization .................................................................. 49 Annex 3: COVID-19 Medical Waste Collection Request Form .......................................................... 50 Annex 4: Personal Information Protection Agreement template .......................................................... 51 Annex 5: Daily Collection and Disposal of Medical Waste from Self Isolated Individuals template . 52 Annex 6: Healthcare Facility COVID-19 Waste Management and Disposal Manual ......................... 53 Annex 7: Residential Waste Management and Disposal Manual for Self Quarantined Individuals .... 54 Annex 8: WHO COVID-19 Case definitions ....................................................................................... 55 Appendix I: Infection Control and Waste Management (ICWMP) 2016............................................. 56 1. INTRODUCTION .......................................................................................................................... 1 1.1 BACKGROUND ..................................................................................................................... 1 1.2 PROJECT DESIGN CONSIDERATIONS ............................................................................. 3 1.3 PROJECT STRUCTURE ........................................................................................................ 3 1.3.1 COMPONENT 1: .................................................................................................................. 3 1.3.2 COMPONENT 2: .................................................................................................................. 4 1.3.3 COMPONENT 3: .................................................................................................................. 5 2. BASELINE DATA ......................................................................................................................... 6 2.1 INTRODUCTION ................................................................................................................... 6 2.2 GENERAL LESOTHO GEO-PHYSICAL CONDITIONS .................................................... 6 2.2.1 Location, Size, and Extent ................................................................................................... 6 2.3 BASELINE DATA AND BACKGROUND OF HEALTH CHALLENGES ......................... 8 2.4 THE STRUCTURE OF THE HEALTH CARE SYSTEM .................................................... 8 2.5 HEALTH CARE DELIVERY SYSTEM ................................................................................ 9 2.6 THE HEALTH SECTOR REFORM PROCESS .................................................................. 11 2.7 WASTE MANAGEMENT IN LESOTHO ............................................................................ 11 2.7.1 Categorisation of HCW in Lesotho .................................................................................... 12 2.7.2 Overview of the present HCWM System in Lesotho ........................................................ 12 2.8 HANDLING AND TREATMENT OF HCW ....................................................................... 14 2.9 LEVEL OF AWARENESS OF GOOD HCWM PRACTICES ............................................ 14 2.10 THE CERTIFICATION SYSTEM ..................................................................................... 15 2.11 THE LESOTHO QUALITY ASSURANCE SYSTEM ...................................................... 16 2.12 INFORMATION SYSTEM AND LICENSING ................................................................. 16 3. CONTEXT OF THE HCWM PLAN ........................................................................................... 17 3.1 INTRODUCTION ................................................................................................................. 17 3.2 THE POLICY FRAMEWORK ............................................................................................. 17 3.2.1 Poverty Reduction Strategy (PRS). .................................................................................... 17 3.2.2 National Health Policy (2011) ........................................................................................... 18 3.2.3 Lesotho National Environmental Policy (1998) ................................................................ 18 3.2.4 Healthcare Waste Management Policy (2010) ................................................................. 19 3.2.5 National Tuberculosis Programme: NTP Policy and Manual ............................................... 19 3.2.6 Lesotho Science and Technology Policy 2006-2011 (2006)................................................. 19 3.2.7 ICT Policy for Lesotho - 4 March 2005 .............................................................................. 20 3.2.8 National Health Sector Strategic Plan - 2012 - 2017 ........................................................ 21 3.2.9 Infection Prevention and Control Policies & Guidelines (2006) ....................................... 21 3.2.10 Consolidated Lesotho National Health Care Waste Management Plan .......................... 22 3.2.11 National Implementation Plan for the Stockholm Convention ....................................... 22 3.2.12 Health Telecommunications Technical Assistance Project.............................................. 23 3.2.13 The Health Services Decentralisation Strategic Plan (2009)............................................ 23 3.2.14 Human Resources Development Strategic Plan 2005–2025 (2004) ................................ 24 3.3 LEGAL FRAMEWORK ....................................................................................................... 24 3.3.1 Constitution of Lesotho .................................................................................................... 24 3.3.2 The Environment Act No 10 of 2008 ................................................................................ 24 3.3.3 The Public Health Order No. 12 of 1970 ........................................................................... 25 3.3.4 The Water Act 2008 - Water and Sewage Authority – (WASA) ........................................ 26 3.3.5 Local Government Act 1997. ............................................................................................ 26 3.3.6 The Labour Code Order 1992 - Ministry of Employment and Labour .............................. 27 3.3.7 The Hazardous and Non-Hazardous Waste Management Act, 2008 ............................... 27 3.4 REGULATIONS .................................................................................................................... 27 3.5 INTERNATIONAL CONVENTIONS AND TREATIES .................................................... 28 3.5.1 The Basel Convention ....................................................................................................... 28 3.5.2 Stockholm Convention on Persistent Organic Pollutants ................................................. 29 3.5.3 The convention of biological diversity .............................................................................. 29 3.5.4 The convention concerning the protection of world and natural heritage. ..................... 29 3.5.5 African convention on conservation of nature and natural resources............................. 29 3.5.6 Summative comment on legislation for HCWM ............................................................... 30 3.6 INSTITUTIONAL FRAMEWORK ...................................................................................... 30 3.6.1 Department of Environment ............................................................................................ 30 3.6.2 Ministry of Health (MoH) .................................................................................................. 30 3.6.3 Ministry of Labour and Employment (MOLE) ................................................................... 31 3.6.4 Participating Ministries ..................................................................................................... 31 3.7 PRIVATE SECTOR PARTICIPATION ............................................................................... 31 3.8 FINANCIAL RESOURCES ALLOCATION ....................................................................... 32 4. DESCRIPTION OF THE ICWMP PROJECT ............................................................................. 33 4.0 INTRODUCTION ................................................................................................................. 33 4.1 THE ICWMP GOAL.............................................................................................................. 33 4.2 THE ICWMP OBJECTIVES ................................................................................................ 33 4.3 THE ICWMP STRATEGIC OBJECTIVES ......................................................................... 33 5. ASSESSMENT OF HCWM IN THE COUNTRY ...................................................................... 35 5.0 INTRODUCTION ................................................................................................................. 35 5.1 THE ASSESSMENT PROCESS .......................................................................................... 35 5.2 THE RAPID ASSESSMENT OF THE INSTITUTIONS ..................................................... 35 5.3 SELECTION OF HEALTH CARE FACILITIES ................................................................ 36 5.4 BASELINE INFORMATION OF THE SELECTED FACILITIES ..................................... 36 5.4.1 General observations ........................................................................................................ 36 5.5 SUMMARY OF THE ANALYSIS ....................................................................................... 38 5.6 GENERAL RECOMMENDATIONS ................................................................................... 40 6. TRAINING NEEDS ASSESSMENT .......................................................................................... 41 6.0 INTRODUCTION ................................................................................................................. 41 6.1 TRAINING NEEDS FOR HEALTH CARE STAFF............................................................ 41 6.2 TRAINING NEEDS - GENERAL PUBLIC/NON HEALTH CARE STAFF..................... 43 6.3 TRAINING STRATEGY ...................................................................................................... 45 6.4 PUBLIC AWARENESS STRATEGY .................................................................................. 46 7. THE INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) .................. 48 7.1 MAJOR OBJECTIVES OF THE ICWMP............................................................................ 48 7.2 THE ICWMP ACTION PLAN ............................................................................................. 54 7.3 SUMMARY OF COSTS ....................................................................................................... 63 8. BUDGET FOR THE ICWMP ...................................................................................................... 64 8.1 INTRODUCTION .................................................................................................................. 64 8.2 ESTIMATED COST OF IMPLEMENTING THE ICWMP ................................................ 64 8.3 MOH CONTRIBUTION TO THE IMPLEMENTATION OF THE ICWMP ...................... 65 8.4 CONTRIBUTION FROM IDA PROJECT ........................................................................... 66 8.5 CONTRIBUTIONS FROM OTHER SOURCES/PARTNERS ............................................ 66 8.6 PROJECT FUNDING SUMMARY...................................................................................... 66 9. ICWMP IMPLEMENTATION MODALITIES .......................................................................... 67 9.1 INSTITUTIONAL FRAMEWORK ...................................................................................... 67 9.2 RESPONSIBILITIES ............................................................................................................ 67 9.3 INSTITUTIONAL ARRANGEMENTS FOR ICWM IMPLEMENTATION ..................... 69 9.4 IMPLEMENTATION TIMEFRAME ................................................................................... 71 9.5 POTENTIAL PARTNERS AND FIELD OF INTERVENTION ......................................... 72 9.6 INVOLVEMENT OF PRIVATE COMPANIES IN ICWM................................................. 73 10. HANDLING HEALTH CARE WASTE STREAMS .................................................................. 74 10.1 RECOMMENDED SYSTEM FOR HANDLING WASTE................................................ 74 10.2 SUMMARY OF THE WASTE HANDLING SYSTEM ...................................................... 78 11. DETERMINATION OF TREATMENT SYSTEMS AND TECHNOLOGIES .......................... 81 11.1 INTRODUCTION ................................................................................................................ 81 11.2 SOLID WASTES TREATMENT ........................................................................................ 81 11.2.1 Comparative analysis of solid HCW treatment systems ................................................ 83 11.2.2 Recommendations for Solid Wastes Treatment ............................................................ 85 11.3 LIQUID WASTES TREATMENT ..................................................................................... 89 12. DETERMINATION OF DISPOSAL SITES ............................................................................... 90 12.1 CHOICE OF LANDFILL SITES ......................................................................................... 90 12.2 DECISION TREE SCENARIOS ......................................................................................... 90 13. THE MONITORING PLAN ........................................................................................................ 91 13.1 PRINCIPLE AND OBJECTIVE .......................................................................................... 91 13.2 METHODOLOGY ............................................................................................................... 91 13.3 MEASURABLE INDICATORS .......................................................................................... 92 14. REFERENCES ............................................................................................................................. 93 ABBREVIATIONS AND ACRONYMS COVID Corona Virus Disease DHMT District Health Management Team EHD Environmental Health Department EHS Environment, Health and Safety EPR Emergency Preparedness and Response ESC Environmental and Social Committee ESIA Environment and Social Impacts Assessment GDP Gross Domestic Product GIIP Guidelines and Good International Industrial Practice GoL Government of Lesotho HAI Hospital Associated Infections HCF Health Care Facility. HCGW Health Care General Waste HCRW Healthcare Risk Waste HCW Health Care Waste HCWM Health Care Waste Management HCWMP Health Care Waste Management Plan HEPA High efficiency particulate air HVAC Heating, Ventilation and Air Conditioning systems IBRD International Bank for Reconstruction and Development. ICU Intensive Care Unit ICWM Infection Control and Waste Management ICWMP Infection Control and Waste Management Plan IDA International Development Association IT Information Technology LEC Lesotho Electricity Company MoH Ministry of Health MPA Multiphase Programmatic Approach MTEC Ministry of Tourism, Environment, and Culture NHWMP National Healthcare Waste Management Plan OHS Occupational Health and Safety PCR Polymerase Chain Reaction PPE Personal Protective Equipment SOPs Standard Operating Procedures SPRP Strategic Preparedness and Response Program TB Tuberculosis UN United Nations UPS Uninterrupted Power System UV Ultraviolet WASCO Water and Sewerage Company WASH Water, Sanitation, and Health WB World Bank WHO World Health Organization WWTP Wastewater Treatment Plant 1. Introduction 1.1. Project context and components The outbreak of the coronavirus disease (COVID-19) has been spreading rapidly across the world since December 2019, following the diagnosis of the initial cases in Wuhan, China. On March 11, 2020, the World Health Organization (WHO) declared it a global pandemic. Lesotho has been also severely affected due to the pandemic – with 10,831 positive cases recorded, and 326 deaths as of May 31, 2021.1 In order to respond to this global pandemic, the Government of Lesotho (GoL) has been implementing the Lesotho COVID-19 Emergency Preparedness and Response Project (EPRP) – the Parent Project (PP) - with World Bank (WB) financial support. The PP (P173939) was prepared and approved in May 2020 and became effective on May 27, 2020 with an amount of US$ 7.5 million. The recent PP Implementation progress review conducted in November 2020 has found the current ‘Progress Towards Achievement of the PDO’, and ‘Overall Implementation Progress’ as “satisfactory� for the PP. The Lesotho COVID-19 PP comprises of two main components: Component 1: This component has been supporting the government to enhance disease surveillance, improve sample collection and transportation, and ensure rapid laboratory confirmed diagnoses to promptly detect all potential COVID-19 cases and to carry out contact tracing to quickly contain COVID-19. The focus has been on: (i) screening travelers at all nine ports of entry (Maseru airport and cross-border areas, including when the current restrictions are lifted) as well as priority communities and targeted health facilities; (ii) diagnosing cases by setting up designated testing and laboratory sites, including inter alia through development of ‘minilabs’ using available GeneXpert machines, other PCR technologies and SARS-CoV-2 testing cartridges; (iii) carrying out contact tracing to minimize risk of transmission; (iv) conducting risk assessments to identify hot spot areas of transmission, including maps that can help visualize transmission; (v) providing on-time data and information for guiding decision- making and response and mitigation activities; (vi) referring cases for quarantining and/or treatment as needed, community and village health workers to strengthen surveillance efforts; and (viii) strengthening health management information system, DHIS2, specifically the COVID-19 module of DHIS2 that has been developed for this purpose to facilitate recording and on-time virtual sharing of information on COVID-19 patients. Component 2: This component has been supporting program coordination, management and monitoring, operational support and logistics, and project management. This includes support for the COVID-19 Incident Management System Coordination Structure; operational reviews 1 Lesotho - COVID-19 Overview - Johns Hopkins (jhu.edu) 1 to assess implementation progress and adjust operational plans; and provide logistical support. The project has been supporting in technical assistance, conducting representative rapid phone surveys targeting health workers and the general population as part of monitoring and evaluation, and operating costs. Further to GoL request to the WB in January 2021 for additional resources to expand the COVID-19 response with the objective to provide additional financing as well as technical assistance to the Ministry of Health (MOH)/GoL to adequately plan and roll out the vaccines for COVID-19, the proposed Additional Financing (AF) Project (P176307) will be a total envelope of US$25.5 million. It will be financed by the World Bank International Development Association (IDA) (US$22 million) and the Health Emergency Preparedness and Response Trust Fund (HEPRTF) (US$3.5 million). The AF is envisaged to provide essential resources to enable an expansion of a sustained and comprehensive pandemic response that will appropriately include also the vaccination program in Lesotho. The changes proposed for the AF entail expanding the scope of activities in the PP, and adjusting its overall design. An increase in scope and cost will be required to support: (i) vaccine, PPEs, medical supplies; (ii) upgrading the cold chain for the vaccines; (iii) strengthening service delivery to ensure effective vaccine deployment; (iv) rehabilitation of some health facilities to establish ICUs; (v) establishing two mini oxygen plants; and (vi) monitoring, tracking of vaccine use and recording of any adverse reactions to vaccination. The AF is also required to extend the testing, PPE, and sustained communications and promotions around the national vaccine introduction (NVI) plan, inter alia. The content of the components and the Results Framework of the parent project are adjusted to reflect the new activities proposed under the AF and the expanded scope. The implementation arrangements will be adjusted to implement the AF, including through strengthening the PIU and introducing a steering committee. New requirements to be tracked for all COVID-19 operations approved in FY21 will apply to this AF, namely: gender tag, citizen engagement framework, and climate and disaster screening requirements and climate co-benefit commitments. Given uncertainties related to the availability of vaccines globally and their efficacy against new variants of the virus, the closing date will be extended by two years from June 30, 2022 to June 30, 2024. The project covers mainly, the following health facilities: Mafeteng Hospital, Motebang Hospital, Berea Hospital, Machabeng Hospital, Mokhotlong Hospital, and Lesotho National TB Reference Laboratory (NTRL). The EPRP-AF components are detailed below. 2 Component 1: Emergency COVID-19 Response (Total of US$29.675 million) including US$6.675 million IDA under the parent project, US$19.5 million IDA AF and US$3.5 million HEPR TF). Sub-component 1.1: Vaccine procurement (US$14 million IDA AF). Support for vaccines will be added as part of the containment and mitigation measures to prevent the spread of SARS-CoV-2 and COVID-19 deaths under Component 1. This sub-component will also cover associated costs (freight and insurance, clearing and transportation, handling charges) as well as medical supplies needed for administration (e.g. needles, syringes, alcohol prep pads). Sub-component 1.2: Strengthen systems for vaccine deployment (US$5.5 million IDA AF). The AF will support investments to bring the immunization system capacity to the level required to successfully deliver COVID-19 vaccines at scale. The AF is geared to assist the GoL, working closely with the WHO, the UNICEF and other Development Partners (DPs), to overcome bottlenecks as identified in the country’s COVID-19 vaccine readiness assessment. Envisioned support includes distribution and administration of vaccines and strengthening the immunization supply chain system, including: (a) procurement and distribution of ancillary supply kits that may include COVID-19 vaccination record cards for each vaccine recipient and PPE for vaccinators; (b) supporting the administration of vaccines including training health workers in vaccine distribution, administration, and climate disaster response, micro-planning activities for rollout, development of contingency plans to maintain vaccination campaigns during climate shocks, and outreach sessions to reach specific target groups as well as people living in remote areas (e.g., operating costs, vehicles); (c) strengthening the supply chain and logistics systems including financing climate friendly cold-chain equipment to comply with the cold-chain requirements of different vaccines and the construction of the Maseru district vaccine store; (d) undertaking relevant traceability activities to ensure capabilities for the system to track and trace from production to the target population; (e) strengthening post- vaccination vigilance and monitoring system(s) to identify any adverse reactions on people and undertake corrective measures immediately; (f) conducting focused group discussions at community level targeting different stakeholders to gather information and adapt immunization rollout; (g) developing and distributing risk communication products for COVID-19 vaccination, including communication on the risks and response to climate shocks; and (h) ensuring adequate medical waste management. Sub-component 1.3: Strengthen systems for the COVID-19 response (Total of US$10.175 million IDA including US$6.675 million IDA under the parent project and US$3.5 million HEPR TF AF). In line with the National COVID-19 Preparedness and Response Plan and the original activities under Component 1 in the parent project, sub-component 1.3 will also continue supporting the overall government response to COVID-19. This includes: (a) enhancing disease surveillance, improving sample collection and ensuring rapid diagnoses to promptly detect all potential COVID-19 cases and carry out contact tracing to quickly contain COVID-19; (b) strengthening critical clinical care capacity, including enhancing isolation and treatment capacity for infected patients in the country; and (c) reinforcing public health 3 measures such as social distancing, personal hygiene promotion, risk communication and community engagement (RCCE) using local language and traditional channels to communicate the risks associated with COVID-19. The AF will cover new activities to: (a) increase capacity for case management such as through refurbishment of two intensive care units (ICUs) with minor civil works, supervision and mentoring visits, training of ICU staff, increased availability of oxygen through procurement of equipment and supplies and establishment of two mini-plants, and procurement of medical supplies including PPE; (b) increase testing capacity such as through expansion of the polymerase chain reaction (PCR) laboratory within the National Reference Laboratory (NRL); enhanced and decentralized testing capacity using multiple modalities (such as using the existing PCR instrument used for human immunodeficiency virus (HIV)/tuberculosis testing (GeneXpert) as well as procuring WHO- approved antigen test kits that can be scaled up rapidly in the community through mobile testing centers at low cost); (c) strengthen surveillance capacity; and (d) strengthen COVID- 19 data reporting and management across the board, including support for COVID-19 vaccination specific M&E and surveillance strengthening, which will apply to COVID-19 as well as other climate-induced, vaccine preventable diseases. Component 2: Project Implementation and Monitoring and Evaluation (Total US$3.325 million including US$0.825 million IDA under the parent project and US$2.5 million IDA AF). As under the parent project, Component 2 will continue supporting the coordination and management of project activities, including procurement of goods and their distribution across health facilities, technical assistance, rapid surveys as part of the project M&E, and operating costs. This will include a client feedback survey through digital health solutions to gather iterative feedback on project implementation, especially of immunization activities. The capacity of the PIU will also further be enhanced. Eligibility Criteria for Exclusion of Subprojects have been determined, and documented in the project’s Environmental and Social Commitment Plan (ESCP). The excluded main activities under the project include: (a) activities that may cause long term, permanent and/or irreversible adverse impacts; (b) activities that have high probability of causing serious adverse effects to human health and/or the environment not related to treatment of COVID19 cases; (c) activities that may have significant adverse social impacts and may give rise to significant social conflict; (d) activities that may affect lands or rights of vulnerable minorities/communities; and (e) activities that may involve permanent involuntary resettlement, among others as detailed under section 2 of the ESMF. 1.2. Healthcare Facility Design Requirements A clean environment plays an important role in the prevention of hospital associated infections (HAI). Many factors, including the design of patient care areas, operating rooms, vaccination area/room, air quality, water supply, sanitation, and hygiene, etc. can significantly influence the transmission of HAI. 4 1.2.1. General Design and Safety Requirements In response to COVID-19 disease outbreak, the general requirements for design of Healthcare facilities for hospitalization of COVID-19 patients, vaccination, etc. should ensure: a) Adequate safe water supply; b) Appropriate cleaning practices; c) Adequate floor space for beds (at least two meters apart); d) Adequate handwashing facilities; e) Adequate ventilation for isolation rooms and high-risk areas like operation theatres, transplant units, intensive care areas, etc.; f) Adequate isolation facilities for airborne, droplet, contact isolation and protective environment; g) Regulation of traffic flow to minimize exposure of high-risk patients and facilitate patient transport; h) Measures to prevent exposure of patients to fungal spores during renovations; and i) Appropriate waste management facilities and practices. 1.2.2. Water, Sanitation and Hygiene (WASH) requirements The health care facility should provide safe water. Several measures can improve water safety, starting with protecting the source water; treating water at the point of distribution, collection or consumption; and ensuring that treated water is safely stored in regularly cleaned and covered containers. Conventional, centralized water treatment methods that utilize filtration and disinfection should inactivate the COVID-19 virus. For effective centralized disinfection, there should be a residual concentration of free chlorine of ≥0.5 mg/L after at least 30 minutes of contact time at pH < 8.0. 10 A chlorine residual should be maintained throughout the distribution system. In situations where centralized water treatment and safe piped water supplies may not be available, a number of household water treatment technologies may be used to effectively remove and destroy viruses such as boiling or using high performing ultrafiltration or Nano membrane filters, solar irradiation and, in non-turbid waters, Ultraviolet (UV) irradiation and appropriately dosed free chlorine. If the facility uses water storage tanks, they should be cleaned regularly and the quality of water should be sampled periodically to check for bacterial contamination. In addition to effective water treatment, water utility managers can adopt several other preventive measures, as part of a broader water-safety planning approach. These measures include: 5 a) Ensuring adequate stocks of chemical additives and consumable reagents for water- quality testing, b) Ensuring that critical spare parts, fuel and contractors can still be accessed and that there are contingency plans for staff and training to maintain the required supply of safe drinking water. In addition to the existing WASH facilities (such as toilets, portable water supply, etc.) at the healthcare facility, low-cost WASH facilities such as hand washing stations (e.g., tippy taps, soap dispensers, etc.) should be erected through-out the hospital (Outside the buildings, and at the entrance of the hospital) for the patients who came for services at the hospitals to have access to them, in order to promote regular hand washing practice, as per WHO requirements. People with suspected or confirmed COVID-19 disease should be provided with their own flush toilet or latrine. Where this is not possible, patients sharing the same ward should have access to toilets that are not used by patients in other wards. Each toilet cubicle should have a door that closes, to separate it from the patient’s room. Flush toilets should operate properly and have functioning drain traps. When possible, the toilet should be flushed with the lid down to prevent droplet splatter and aerosol clouds. If it is not possible to provide separate toilets for COVID-19 patients, then the toilets they share with other non-COVID-19 patients should be cleaned and disinfected at least twice daily by a trained cleaner wearing PPE (impermeable gown, of if not available, an apron, heavy-duty gloves, boots, mask and googles or a face shield). Health-care staff should have toilet facilities that are separate from those used by all patients. 1.2.3. Heating, ventilation and air conditioning (HVAC) requirements Ventilation systems should be designed and maintained to minimize microbial contamination. The air conditioning filters should be cleaned periodically and fans that can spread airborne pathogens should be avoided in high-risk areas. High-risk areas such as operating rooms, critical care units and transplant units require special ventilation systems. Filtration systems (air handling units) designed to provide clean air should have high efficiency particulate air (HEPA) filters in high-risk areas. Unidirectional laminar airflow systems should be available in appropriate areas in the hospital construction. Ultra clean air is valuable in some types of cardiac surgery/neurosurgery/implant surgery theatres and transplant units. For the operating room, the critical parameters for air quality include: a) Frequent maintenance/validation of efficacy of filters (in accordance with manufacturer’s requirements); b) Pressure gradient across the filter bed and in the operation theatre; c) Air changes per hour (minimum 15 air changes per hour); d) General areas should be well ventilated if they are not air-conditioned. 6 It should be noted that faulty plumbing and a poorly designed air ventilation system were among the contributing factors for the spread of the aerosolized SARS-CoV-1 coronavirus in a high-rise apartment building in Hong Kong Special Administrative Region in 2003.2 Similar concerns have been raised about the spread of the COVID-19 virus from faulty toilets in high- rise apartment buildings.3 1.2.4. Laboratory requirements The EPRP mostly uses the existing laboratories with established standards that meet the Biosafety Level III (BSL III) design requirements. This is suitable for work involving agents that pose moderate hazards (COVID-19) to personnel and the environment. It entails that: • the laboratory personnel have specific training in handling pathogenic agents and are supervised by scientists competent in handling infectious agents and associated procedures; • access to the laboratory is restricted when work is being conducted; and • all procedures in which infectious aerosols or splashes may be created are conducted in BSCs or other physical containment equipment, inter alia. The following standard design, special practices, safety equipment, and facility requirements shall be adhered to: It is essential to ensure that medical health laboratories adhere to appropriate biosafety practices. Any testing for the presence of the virus responsible for COVID-19 or of clinical specimens from patients meeting the suspected case definition should be performed in appropriately equipped laboratories, by staff trained in the relevant technical and safety procedures. WHO and national guidelines on laboratory biosafety should be followed in all circumstances 4 . The following shall be the minimum requirements for the beneficial laboratories under the Project (as provisioned in the WHO Laboratory Biosafety Manual and WHO interim guidance for laboratory biosafety related to 2019 nCoV): • Ample space and a designated hand-washing basin must be provided, with appropriate restriction of access, 2 Yu IT, Li Y, Wong TW, Tam W, Chan AT, Lee JH, et al. Evidence of airborne transmission of the severe acute respiratory syndrome virus. N Engl J Med. 2004;350(17):1731-9. doi: 10.1056/NEJMoa032867. 3 Regan H. How can the coronavirus spread through bathroom pipes? Experts are investigating in Hong Kong. CNN. 12 February 2020. (https://edition.cnn.com/2020/02/12/asia/hong-kongcoronavirus-pipes-intl-hnk/index.html, accessed 22 April 2020). 4 Laboratory biosafety manual, 3rd ed. Geneva: World Health Organization; 2004 (https://www.who.int/csr/resources/publications/biosafety/Biosafety7.pdf?ua=1 , accessed 31 March 2021). 7 • Doors must be properly labelled, and laboratory walls, floors, and furniture must be smooth, easy to clean, impermeable to liquids and resistant to the chemicals and disinfectants normally used in the laboratory, • Laboratory ventilation, where provided (including heating/cooling systems and especially fans/local cooling split-system air-conditioning units - specifically when retrofitted) should ensure airflows do not compromise safe working. Consideration must be made for resultant airflow speeds and directions, and turbulent airflows should be avoided; this applies also to natural ventilation, • Laboratory space and facilities must be adequate and appropriate for safe handling and storage of infectious and other hazardous materials, such as chemicals and solvents, • Facilities for eating and drinking must be provided outside the laboratory, and first- aid facilities must be accessible, • Appropriate methods for decontamination of waste, for example disinfectants and autoclaves, must be available and close to the laboratory, • The management of waste must be considered in the laboratory design. Safety systems must cover fire, electrical emergencies, and emergency/incident response facilities, based on risk assessment, • There must be a reliable and adequate electricity supply and lighting to permit safe exit, • Emergency situations must be considered in the design of the existing labs, as indicated in the local risk assessment, and should include the geographical/meteorological context, • Laboratory furniture must be capable of supporting anticipated loads and uses: o Open spaces between benches, cabinets, and equipment should be accessible for cleaning. o Bench tops must be impervious to water and resistant to heat, organic solvents, acids, alkalis, and other chemicals. o Chairs used in laboratory work must be covered with a non-porous material that can be easily cleaned and decontaminated with appropriate disinfectant. o Ample space must be provided for the safe conduct of laboratory work and for cleaning and maintenance. • Safety systems should cover fire, electrical faults, emergency shower and eyewash facilities with First-aid areas or rooms suitably equipped and readily accessible should be made available. In-depth design requirement for the laboratories is elaborated in WHO Laboratory Biosafety Manual and WHO interim guidance for laboratory biosafety related to 2019 nCoV. 8 1.2.5. Quarantine / Isolation Rooms at Health Care Facilities When an isolation room is being incorporated into an existing facility, it is rarely possible to create the ideal room. Physical and financial factors often constrain the construction. It is critical to create a room that is fit for its purpose; therefore, the design intent of this section should be adhered to as closely as possible in line with the WHO guidelines on COVID-19. When converting existing accommodation into such rooms, the easiest and least expensive option is to adapt existing single rooms with ensuite facilities. It is recommended that a quarantine facility should be of: • at least 3 SQM of space per person for personal space at a quarantine site exclusive of space required for eating, recreation, offices or ancillary services. • an isolated ensuite rooms with wash room facilities, • a dormitory set-up with a maximum of 5 - 10 beds per room or zone separated from one another by a curtain or wall with each bed separated by a minimum of 1metre from all sides. The following requirements should be met in any conversion: • furnishing and fittings: a) clinical hand wash basin with non-touch, fixed temperature mixer tap; b) wall-mounted soap dispensers; c) disinfectant hand rub dispensers; d) disposable towel holders; e) glove dispensers; f) storage for clean personal protective equipment; g) clean waste bins. observation window in corridor wall with integral privacy blinds; • Adequate ventilation either natural or mechanical. • The door is kept closed at all times (preferably with a patient observation window so that the patient can be seen without the need to open the door). • Hand washing station with running water and soap and alcohol-based hand rub. These should be placed near the point of care, at the entrance and exit of the isolation room. • Should preferably have toilet and bathroom so the patient does not leave the room. In case the room does not have one, a dedicated toilet and bathroom should be identified. • Patient bedside locker or table for placing items • Easy to clean surfaces (no carpets, preferably no curtains) • Space for provision of PPE at the entrance to the room for HCWs • A designated team of HCWs, to care for known or suspected COVID-19 patients. These HCWs care only for these patients during their shift. 9 • Keep a roster of all staff working in the isolation areas including visitors, for possible outbreak investigation and contact tracing. • investigate the use of a pressure stabilizer above the room door; and • Provision of two-way intercommunication system between the patient’s room and the nurses’ station. 1.2.6. Incinerator requirements5 Proper design and operation of incinerators should achieve desired temperatures, waste residence times inside the furnace, and other conditions necessary to destroy pathogens, minimize emissions, avoid clinker formation and slagging of the ash (in the primary chamber), avoid refractory damage destruction, and minimize fuel consumption. Good combustion practice (GCP) elements also should be followed to control dioxin and furan emissions. Technology to be selected should be based on available supporting infrastructure and resources (reliable sources of power, fuel, etc.), total amount of medical waste generated by the HCF, and would consider the need for temporal storage due to the peak waste generated due to COVID-19 in comparison to average monthly medical waste generated. The design consideration of the incinerator should fulfil the following criteria: Primary combustion • The primary combustion chamber shall be accepted as the primary combustion zone and shall be equipped with a burner/s burning gas or low sulphur liquid fuel. • The minimum combustion temperature of the primary chamber shall not be less than 8500 C. Secondary combustion • The secondary combustion chamber shall be accepted as the secondary combustion zone and shall be fitted with a burner/s burning gas or low sulphur liquid fuel with capacity to reach 1,100o C. • The residence time in the secondary chamber shall not be less than two seconds. Additional Specifications include: The incinerators should incorporate air control parts to mitigate air pollution and have an additional specification for hot water system to generate hot water as part of resource use efficiency. The incinerator should be housed in a controlled shed free of rodents, adequate ventilation with sanitary facilities including toilet, cloak room and wash area, and 5 077to112.pdf (who.int), accessed on March 31, 2021 10 The incinerator facility should have appropriate fire suppression equipment including fire extinguishers, sand bucket and fire blanket, and equipped First Aid Kit and health and safety manual. Chimney Design Requirements: The chimney shall have a minimum height of nine (9) meters above ground level and clear the highest point of the building by not less than six (6) meters for flat roofs or 3 meters for pitched roofs. The topography and height of adjacent buildings (i.e., closer than 5 meters chimney height) shall be taken into account. The Stack Height computation design for Incinerator Chimney as per the GIIP have been detailed in WBG General EHS Guidelines for Environmental Air Emissions and Ambient Air Quality and WHO Treatment and disposal technologies for health-care waste. Site selection design criteria of incinerators should consider: i) direction of the prevailing winds should be away from the populated areas (patient wards, residential areas) or where food is grown; ii) There should be no public passage within the immediate proximity of the incinerator, iii) location should be secure and free from risk of vandalism, iv) the location should permit construction of the incinerator housing, store waste awaiting final treatment and an ash pit. The above design is in line with the WBG guidelines and according to GIIP. Other essential facility within the incinerator are the ash pit and waste storage area which should be constructed adjacent to the incinerator. Ash pit–where ash and other residues from the incineration process are disposed of. It is considered the final disposal point of healthcare wastes. It should be located in the immediate proximity of the incinerator to ensure convenient transfer of ash. The ash pit should be 1.5 m above water table and its wall lined to prevent contamination of underground water as well as positioned to prevent the risk of flooding. It should also be covered and secured with a lock to prevent access to unauthorized persons and avoid accidents. Storage area–Adequate storage space should be provided for safety boxes and waste bags awaiting incineration. The storage capacity should be adequate and take consideration of peak waste generated due to increased patient intake as a result of COVID-19 related cases in comparison to the average monthly medical waste generation. The area should be secured to prevent unauthorized access and covered to keep the safety boxes dry. Storage should also be provided for tools, records, personal protective equipment and fuel (both kerosene and firewood). Though it is possible to incinerate soft waste, the below items SHOULD NOT be incinerated: • Pressurized gas containers (aerosol cans) • Large amounts of reactive chemical waste • Silver salts and photographic or radiographic wastes • Plastic containing polyvinyl chloride (blood bags, IV tubing or disposable syringes) 11 • Waste with high mercury or cadmium content, such as broken thermometers, used batteries and lead-lined wooden panels • Ampoules or vials, as molten glass will cause the grate to block up and vials can explode. • Bottles of chemicals and reagents due to risk of explosion and formation of toxic gases. • Needles due to the risk of needle stick injury from the metal ash. • Expired drugs. • Kitchen waste as this is wet, does not burn and will lower the efficiency. Solid wastes that should not be incinerated will be appropriately packaged, transported to and disposed of in Government recognized landfill. Landfill is acceptable also if it is properly designed to accept Health care waste. A landfill area should not be confused with damping sites, as they should be regulated and well protected. The major design components of a landfill that should be carefully considered are sub-base, liner, leachate management system, gas management system, final cap, and stormwater management, and monitoring is an important task during landfill construction/operation and after closure. No open dumping sites should be used for high risk waste. Open air burning is not recommended because it is dangerous, unsightly and the wind will scatter the waste. If open burning must be done, burn in a small, designated area, transport waste to the site just before burning and remain with the fire until it is out. However, open burning should be avoided, as much as possible, unless there are no other feasible options, and as strong justification and mitigation measures should be provided. Burying waste: Only contaminated and hazardous waste needs to be buried. In healthcare facilities with limited resources, safe burial of wastes on or near the facility may be the only option available for waste disposal. If burying wastes of under-resourced HCF, is the only option, a strong justification, more specific definition of site selection criteria, responsibility and mitigation measures should be presented. To limit health risks and environmental pollution, following basic rules should be followed: • Access to the disposal site should be restricted. • The burial site should be lined with a material of low permeability (e.g., clay), if available. • Select a site at least 50 meters away from any water source to prevent contamination of the water table. • The site should have proper drainage, be located downhill from any wells, free of standing water and not in an area that encounters flooding. Large quantities (over 1 kg) of chemical (liquid) wastes should not be buried at the same time; burial should be spread over several days. Safe on-site burial is practical for only limited periods of time (1-2 years), and for relatively small quantities of waste. 12 1.3. Storage, distribution, waste management and infection prevention during COVID-19 Vaccine deployment The vaccine will be stored at the national level in Maseru, and distributed to the districts once vaccines become available for the identified priority groups. There is 14670m3 net available of vaccine storage of +20C to +80C at the national level, and no -200C or -700C storage space. The maximum shipment size that could be received, captured (in m3) is 8670m3. Delivery of these shipment size can be undertaken within 24 weeks’ intervals. The total contingency cold chain storage capacity available is 5128m3 of the +20C to +80C temperature. There is no contingency storage for the -200C and -800C storage. There is no contingency storage capacity available for ancillary items. An application for accessing additional vaccines through the African Union (AU) Advanced Procurement Commitment (APC) facility has been made. Lesotho has been allocated doses between three manufactures, and the Pfizer vaccine is among the vaccine products allocated. The country has been allocated an indicative amount of 27 457 doses of the Pfizer vaccine. It is in this regard that the country will be procuring ultra-cold chain for the national level under the AF Project allocated to the country for COVID-19 vaccine introduction preparatory work. Proper vaccine storage and handling are important factors in preventing and eradicating many common vaccine preventable diseases. Yet, many cases, storage and handling errors do happen, resulting in revaccination of many patients and significant financial loss due to wasted vaccines. Failure to store and handle vaccines properly can reduce vaccine potency, resulting in inadequate immune responses in patients and poor protection against disease. Patients can lose confidence in vaccines and providers if they require revaccination because the vaccines they received may have been compromised. It is important for the facility to have proper storage and monitoring equipment that is set up correctly, maintained appropriately, and repaired as needed. This equipment protects patients from inadvertently receiving compromised vaccine and the facility against costs of revaccinating patients, replacing expensive vaccines, vaccine wastage, and losing patients confidence in the process. Measures to prevent percutaneous injuries associated with the use and disposal of needles and other sharp instruments must be taken. This also includes the protective equipment that will be used by vaccinators during each COVID-19 immunization session. The routine practice is to collect, at regular intervals, biohazard waste, such as protective clothing for incineration at the district level. All needles and sharps are disposed using a 3-bin system. These bins are also collected for incineration at regular intervals. Due to the infectious nature of the COVID-19 virus, and in order to accommodate additional volume of wastage due to the new vaccine introduction, all biohazard and immunization waste will have to be collected after every session for incineration at the district level. To minimize the risks to the health workers themselves and communities, the vaccination team will continue practicing on-site waste 13 segregation and implementing reverse logistics, where healthcare waste is taken back to the facility to be disposed of properly. 14 2. Infection Control and Waste Management The principal objectives of the EPRP Infection Control and Waste Management Plan are to prevent and/or control the spread of the virus while preventing and/or mitigating the other adverse effects of medical waste on human health and the environment. The waste generated during the implementation of the EPRP activities must be managed in a safe manner to prevent the spread of infection and reduce the exposure of health workers, patients and the public to the risks from medical waste. The plan includes advocacy for good practices in medical waste management and is to be used by health, sanitary and cleaning workers who manage medical waste at the HCFs engaged in the Project activities. All the health facilities and health services supported through the World Bank financing are to have appropriate procedures and capacities in place ensuring effective and efficient infection control and waste management mechanisms. With the coronavirus disease (COVID-19) pandemic continuing to spread and its impacts upon human health and the economy intensifying day-by-day, there is urgent need to treat waste management including medical, household and other infectious waste, as an urgent and essential public service in order to minimize possible secondary impacts upon public health and the environment. COVID-19 outbreak is associated with the generation of many types of infectious wastes, including infected masks, gloves and other protective equipment, together with a higher volume of general waste of the same nature. Unsound management of this waste could cause unforeseen “knock-on� effects on human health and the environment. The safe handling, treatment and final disposal of this waste is therefore a vital element in an effective emergency response. Effective management of biomedical and health-care waste associated with COVID-19 requires appropriate identification, segregation, collection, storage, treatment, transportation and disposal, as well as important associated standard precautions including hand hygiene, cleaning and disinfection, personal protection and training. Improper disposal of the infectious health care waste may result in masks, gloves, syringes and needles being scavenged and reused thus leading to spread of diseases. Even after the formulation of policies and laws on health care waste management, many health care establishments in Kenya still is lagging behind the enforcement of legislation for handling, and disposal of health care waste. Furthermore, improper treatment or disposal of HCW such as open-air burning constitute to a significant source of pollution to the environment through the release of substances such as dioxins, furans or mercury coupled with the virus persistence for days in the environment deposited; this calls for the formulation of this Infection Control and Waste Management Plan in relation to COVID-19 pandemic 15 The safe and sustainable management of medical waste is a public health imperative and a responsibility of the authorities/entities working in the health sector. Improper management of medical waste poses a significant risk to patients, health-care workers, the community and the environment. This problem, however, can be solved with the mobilization of the appropriate resources, leading to a substantive reduction of disease burden and corresponding savings in health expenditures. The effective management of medical waste is an integral part of the Lesotho national health- care legislations and those of the WB. Under the EPRP, a holistic approach to medical waste management has been adapted, including a clear delineation of responsibilities, and approaches for waste minimization and segregation, the development and adoption of safe and environmentally-sound technologies, and capacity building activities. Medical waste refers to the entirety of waste generated by health care and medical research facilities and laboratories. Though only 10-25% of medical waste is considered hazardous, posing various health and environmental risks, it is essential that a comprehensive plan be developed to prevent and mitigate these risks and adverse impacts due to the Project activities. Best practices for safely managing health-care waste should be followed in COVID-19 treatment units, which includes assigning responsibility and sufficient human and material resources to segregate and dispose of waste safely. There is no evidence yet that direct, unprotected human contact during the handling of health-care waste has resulted in the transmission of the COVID-19 virus. All health-care waste is considered to be infectious (infectious, sharps and pathological waste) which is produced during patient care, including those with confirmed COVID-19 infection, and vaccination. It should be collected safely in clearly marked lined containers and sharp safe boxes. This waste should be treated, preferably on-site, and then safely disposed. It is also critical to fix the site where and how this waste will be treated and safely disposed if it is transported off-site.6 2.1. Overview of infection control and waste management in the HCF 2.1.1. Categorisation of HCW in Lesotho Health Care Waste (HCW) is usually divided into the two main categories: Health Care General Waste (HCGW) and Health Care Risk Waste (HCRW). HCGW consists of the general household (domestic) waste and much of this waste can be recycled. Health Care Risk Waste (HCRW) is the more hazardous part of the waste generated from health care facilities and comprises: infectious waste; sharps; anatomical; pharmaceutical; chemical; and radioactive waste. 6 https://www.who.int/publications/i/item/water-sanitation-hygiene-and-waste-management-for-the-covid-19virus-interim-guidance 16 The need for correct segregation is determined by the different treatment methodologies required for the safe and environmentally friendly treatment and disposal of the different waste streams. In Lesotho, the Hazardous (Health care) Waste Management Regulations of 2012 defines HCRW as waste that is hazardous or which is capable of producing disease, injury or pollution and includes the following: a) Infectious waste; b) Pathological waste; c) Sharp’s waste; d) Pharmaceutical waste; and e) Genotoxic waste; In Health Care Facilities in Lesotho, the following categories of waste are observed: a) Healthcare general waste: This comprises of the normal ‘household’ waste and is mainly waste coming out of a healthcare facility that has not come into contact with patients, such as plastic bags, boxes, paper, food waste etc. A large portion of this waste can be recycled. b) Infectious waste: All waste that is likely to contain pathogens (in sufficient concentration to cause diseases to a potential host). These include blood bags, urine, body secretions, etc. c) Pathological (anatomical) waste is waste that comprises of body parts and blood and includes placentas. d) Pharmaceutical waste: These include expired medication, unused pharmaceutical products, drugs, vaccines, etc. e) Chemical waste: These consist of chemicals that are generated during disinfecting procedures or cleaning processes. f) Sharps: These consist of all items that can cause cuts for puncture wounds, such as needles, syringes, scalpel blades and slides; g) Highly infectious waste: This group consists of waste from laboratories, in microbial cultures, and stocks with viable biological agents, etc. h) Radioactive waste: Includes liquids, gases and solids that spontaneously emit radiation. 2.1.2. COVID-19 Waste Categorisation In addition to categories of Health Care Waste (HCW), already described above; waste from all COVID-19 facilities, including self-quarantine individuals, and vaccine facilities, here in after, referred to as COVID-19 Medical Waste can be categorised as follows: a) Waste from COVID-19 Healthcare, Isolation and Quarantine Facilities o These may comprise of all Health Care General Waste (HCGW) and Health Care Risk Waste (HCRW), which include health care general waste, infectious waste, 17 pathological (anatomical) waste, pharmaceutical waste, chemical waste, sharps, highly infectious waste, and radioactive waste, as described in section 2.1.1 above. o All these forms of waste generated by confirmed patients admitted to all type of COVID-19 Facilities are treated as COVID-19 Medical Waste, should be disinfected and sealed; and then disinfected again and stored in a designated storage area to be processed on the same day. o All general waste generated in all type of COVID-19 Facilities in no association with confirmed patients (e.g., wastes generated by administrative personnel, etc.) are treated as general medical waste. They are disinfected and sealed, then disinfected again and stored in a designated storage area to be processed on the same day. b) Waste from Self Isolation or Quarantine Individuals o These comprise of the normal ‘household’ waste that has not come into contact with patients, such as plastic bags, boxes, paper, food waste etc. Under normal situations (without COVID-19 disease outbreak), a large portion of these waste can be recycled. o In case a confirmed patient is holding at home before being transported to COVID-19 Healthcare Facilities, the waste generated will be disposed as COVID-19 medical waste via a local Healthcare facility. o In case a spike in confirmed cases forces a large number of confirmed patients to be quarantined at home and their waste cannot be processed via a local Healthcare Facilities, management of local Healthcare Facilities may form a separate emergency waste collection, transportation, and processing system to dispose of such waste materials (refer to Annex 1 for a detailed guidelines for medical waste emergency collection and transportation system), in consultation with the Environmental Health Department (EHD) of MoH or District Health Management Team (DHMT). c) Waste from Vaccine facilities o These comprise of the disposable materials used during vaccination, including needles and other sharp instruments o The personal protective equipment (PPE), including surgical mask, surgical gloves, etc., that will be used by the medical and non-medical personnel (including the vaccinators) engaged during each COVID-19 immunization session or vaccination activities. o General waste from people coming for vaccination, health /vaccination workers and others, such as food packages. d) Waste from rehabilitation/construction facilities The waste generated from the civil works (ICU rehabilitation, activities pertinent to the construction of the prefab structures, storage room and installation of mini oxygen plants) will mostly include the muck/spoil produced at sites. Also, the packaging materials and any used PPEs as may be disposed by the contractor teams are the other wastes. 18 2.1.3. Current Healthcare waste management system in Lesotho The 3-bin concept is used to cater for the general Infectious waste (for example, intravenous lines/bags, gloves, dressings, gauze, swabs, urine and blood bags, sump tubes, sanitary napkins) as well as placentas, body parts, isolation waste and pre-treated highly infectious laboratory waste. No differentiation is made between the laboratory waste, isolation waste and pathological / anatomical waste. Sharps are placed into sharps containers and healthcare general waste into black liners. Elements of the existing waste management system in Lesotho include: a) The 3-bin system introduced into all the HCFs and placed at all generation points comprises of the following: o one container with a red liner for the infectious waste, o one yellow container or “sharps container� for the sharps and o one container with a black liner for the general waste. b) The black and red/yellow liners should be sealed prior to transportation to a temporary storage area. c) All the Health Care Waste (HCW) should be collected in rigid two-wheeled containers (120 to 240 litres) with a lid. d) These wheeled containers are to be used for transportation of waste directly to the treatment area for the infectious waste and to the temporary central storage area for the general waste. e) Infectious waste should be sent for treatment every 24 hours or at least every 48 hours in the case of unforeseen delays. f) Every HCF should have ‘storage’ at least in the form of 4-wheeled 1.1m3 “euro bins� or skips with lids that can easily be carried by a truck or tractor to the final disposal site. g) Central storage areas should not store infectious waste or sharps; only the ash and general waste must be collected there and emptied at least once a week. h) All waste handlers at all levels, cleaners, porters, gardeners and incinerator operators must wear appropriate protective clothing. i) Designated personnel in each unit must be made responsible for monitoring the HCWM System and ensuring that all bags are sealed when full or before removal. They must also supervise the removal to the temporary storage or treatment areas. All Healthcare facilities must have access to a functional waste treatment facility e.g., an incinerator and the ash disposed of appropriately together with the health care general waste. Lesotho has also specified minimum requirements for the management of Health Care Risk Waste (HCRW) starting from the generation point to the final disposal. The regulations are 19 to be applied throughout the country, with variations allowed for facilities that are classified as rural or inaccessible. These are summarised in table 2-1 below. Table 2 – 1 Legal requirement for collection, treatment and disposal of HCW Urban Peri-urban Rural Infectious waste incinerated on Infectious waste As the quantities do not site every 24 hours or at least incinerated on site every warrant an incinerator at the every 48 hours 24 hours or at least every HCFs, sharps containers must 48 hours be securely stored for transport by a hospital vehicle or the flying doctor service to a central hospital on a monthly basis Collected by the local authority For HCFs generally Infectious waste can be for final disposal at an accessible by vehicles but buried in a secure, restricted, established sanitary landfill where there is no local well-lined and ventilated authority refuse removal “septic tank� type pit where service, can be collected biodegradation can occur. by a private contractor and taken to a landfill once every two weeks 2.2. Healthcare Waste Management Procedure and Measures As highlighted by WHO recommendations7, the first step in medical waste management is to minimize the waste. To this end, a standardized assessment tool should be developed to identify gaps in the management process, including occupational health issues. Though all staff are responsible for managing waste, to ensure optimal waste management, it is recommended to establish a facility-based Waste Management Committee and designate a single waste management supervisor. The supervisor should coordinate the medical waste management system and be supported by the health facility management. In addition, the roles and responsibilities of key personnel engaged in waste management activities should be defined during all phases (i.e., generation, segregation, transportation and final disposal, either through an incinerator or landfill, depending on nature and quantity of waste.). Following sections provide further details in this regard. 7 9789241548564_eng.pdf;jsessionid=8A6195716901485CBF8E9F6E0A9F7661 (who.int) 20 2.2.1. General measures for Waste Management at Healthcare Facilities (including vaccine facilities) a) Waste minimization, reuse and recycling: The Contractor engaged for the minor construction/rehabilitation works (civil works) and HCF should consider practices and procedures to minimize waste generation, without sacrificing patient hygiene and safety considerations. b) Delivery and storage of specimen, samples, reagents, pharmaceuticals, vaccine, and medical supplies: HCF should adopt practice and procedures to minimize risks associated with delivering, receiving and storage of hazardous medical goods. c) Waste segregation, packaging, color coding and labeling: The Contractor and HCF should strictly conduct waste segregation at the point of generation. Internationally adopted method for packaging, color coding and labeling the wastes should be followed. d) Onsite collection and transport: The Contractor and HCF should adopt practices and procedures to timely remove properly packaged and labelled wastes using designated trolleys/carts and routes. Disinfection of pertaining tools and spaces should be routinely conducted. Hygiene and safety of involved supporting medical workers such as cleaners should be ensured. e) Waste storage: The engaged Contractor for construction works, waste management and HCF should have multiple waste storage areas designed for different types of wastes. Their functions and sizes are determined at design stage. Proper maintenance and disinfection of the storage areas should be carried out. Existing reports suggest that during the COVID-19 outbreak, infectious wastes should be removed from HCF’s storage area for disposal within 24 hours. f) Onsite waste treatment and disposal (e.g. an incinerator): Some HCFs may have their own waste incineration facilities installed onsite, or use local hospital incineration facility. Due diligence of an existing incinerator should be conducted to examine its technical adequacy, process capacity, performance record, and operator’s capacity. In case any gaps are discovered, corrective measures should be recommended. The Contractor can use the HCF system of waste disposal if possible or should have its own waste disposal management system established with due permission from the authorities as may be required. For new HCF financed by the project, waste disposal facilities should be integrated into the overall design and Environment and Social Impacts Assessment (ESIA) and management plans developed. Good design, operational practices and internationally adopted Generation standards for healthcare waste incinerators can be found in pertaining to Environment, Health and Safety (EHS) Guidelines and Good International Industrial Practice (GIIP). g) Transportation and disposal at offsite waste management facilities: Not all HCF has adequate or well-performed incinerator onsite, hence waste maybe exported from one Healthcare facility to another with incineration facility. Not all healthcare wastes are 21 suitable for incineration. An onsite incinerator produces residuals after incineration. Hence offsite waste disposal facilities provided by Local government authority or the private sector may be needed. These offsite waste management facilities may include incinerators, hazardous wastes landfill. In the same vein, due diligence of such external waste management facilities should be conducted to examine its technical adequacy, process capacity, performance record, and operator’s capacity. In case any gaps are discovered, corrective measures should be recommended and agreed with the government or the private sector operators. h) Wastewater treatment: HCF wastewater is related to hazardous waste management practices. Proper waste segregation and handling as discussed above should be conducted to minimize entry of solid waste into the wastewater stream. In case wastewater is discharged into Local sewer sewerage system, the Contractor engaged and HCF should ensure that wastewater effluent comply with all applicable permits and standards, and the local wastewater treatment plant (WWTP) is capable of handling the type of effluent discharged. In cases where local sewage system is not in place, HCF should build and properly operate onsite primary and secondary wastewater treatment works, including disinfection. Residuals of the onsite wastewater treatment works, such as sludge, should be properly disposed of as well. There’re also cases where HCF wastewater is transported by trucks to a local wastewater treatment plant for treatment. Requirements on safe transportation, due diligence of WWTP in terms of its capacity and performance should be conducted. 2.2.2. Some Best Practices for Disposal of Hazardous Waste Chemical Waste Chemical waste includes residues of chemicals in their packaging, outdated or decomposed chemicals, or chemicals that are no longer required. Small quantities of chemical waste are generally collected in containers with infectious waste, and are incinerated, encapsulated or buried. Large quantities should not be collected with infectious waste. Because there is no safe and inexpensive method for their disposal, the preferred treatment options might be incineration at a high temperature for the disposal of chemical waste, and if this is not possible, returning the chemical waste to the original supplier. Also, the chemical waste of different types should never be mixed. Chemical waste should not be disposed of in sewer systems. Because either method is expensive and may be impractical, it is important to keep chemical waste to a minimum. Disposal of Used Chemical Containers should be done by rinse glass containers thoroughly with water. Glass containers may be washed with soap, rinsed and reused. For plastic containers that contained toxic substances such as glutaraldehyde (e.g., formaldehyde), rinse 22 three times with water and dispose of by burning, encapsulating or burying. These containers should not be reused for other purposes. Disposal of Pharmaceutical Waste (Small quantities), including drugs or medicine waste should be conducted by placing it in containers with infectious waste and disposed of in the same way - either incinerated, encapsulated or safely buried. It should be noted, however, that temperatures reached in a single-chamber drum or brick incinerator may be insufficient to totally destroy the pharmaceuticals; therefore, they can remain hazardous. Small quantities of pharmaceutical waste, such as outdated drugs (except cytotoxic and antibiotics), may be discharged into the sewer but should not be discharged into natural waters (rivers, lakes, etc.). Disposal of Large amounts of pharmaceutical waste may be conducted by the following methods: • Cytotoxic and antibiotics may be incinerated with the residues then going to the landfill. An incinerator, like those used in making cement, that is capable of reaching a combustion temperature of at least 800°C should be used adhering to the WHO recommendations. • When incineration is not available, these pharmaceuticals should be encapsulated. • Water-soluble, relatively mild pharmaceutical mixtures, such as vitamin solutions, cough syrups, intravenous solutions, eye drops, etc., may be diluted with large amounts of water and then discharged to sewers (where sewerage systems exist). • If all else fails, return pharmaceutical waste to the original supplier if possible. Mercury spill handling and management: Mercury usually becomes a waste because of instrument breakage and cannot be treated by techniques described here. Mercury should be collected in a special container and shipped to a recycler. Using electronic devices for measuring temperature and blood pressure is the most effective way to eliminate mercury from the waste streams. While dealing with a mercury spill the engaged personnel should be ready with the following items, which can be put together in all the wards in advance and labeled as MERCURY CONTAINMENT KIT. This would ensure the availability of the following items the moment the spill occurs. • Nitrile gloves or at least two pairs of latex gloves (Mercury can pass through single pair of latex gloves). • Face mask. • Protection for the eyes • Scotch Tape • 10 cc syringe 23 • Covered plastic/ glass container with water • Posters depicting the process of mercury spill containment PRECAUTION: Mercury- based instruments should never be used in a carpeted area. Once a mercury spill occur, appropriate steps should be followed: • Mercury should not be touched with bare hands, as mercury is absorbed quickly through the skin. • all jewelry should be removed when dealing with mercury, as mercury combines with gold, silver and other metals. • the area around the spill should be cleared and spread of mercury should be contained. • all the protective gears should be used. • all the small droplets of mercury should be gathered with the help of two hard cardboard sheets and then using a syringe to suck the bigger droplets of mercury. The contents of the syringe should be poured into a plastic/ glass container with 5 to 10 ml of water. The scotch tape, if used, should be put in the plastic/ glass container whereas the used syringe should be kept back in the kit, upside down. 24 2.2.3. Plans for COVID-19 Waste Management 2.2.3.1. Plans to ensure health and safety measures for waste workers There is a need to ensure the health and safety precautions of waste workers as they are one of the most important sanitary barriers to keep health facilities and people safe from several diseases, including COVID-19. Current scientific research has not provided evidence that waste management is a vector for the transmission of SARS-CoV2 virus, but considering waste workers are everyday on duty to ensure safe and healthy working environment, the following measures should be considered as follows: a) Strict adherence to enhanced hygiene norms, including frequent change and cleaning of PPE and professional clothing; replacing professional gloves in the event of breakage or any incident of potential contamination; sanitizing regularly facilities, vehicle cabins and other equipment. An important measure here is to make sure that where masks are usually worn, the workers are removing masks and gloves without getting in contact with them. This means using correct techniques for putting the mask on and taking it off. b) Adaptation (as much as possible and considering the particularities of the waste collection systems) of the behavior in order to avoid contamination between workers in teams like strict respect of the distance between people (>1m), limiting as few as possible workers in the same area (storage rooms, changing rooms) and all precautionary measures helping at preserving health of workers in safe occupational conditions. c) Direct contact (without gloves) with bins or bags should be avoided in any case. d) Uniforms should be daily changed or cleaned - cleaning of work clothes and shoes is minimizing the possibility of dispersing the virus and limiting its transmission. e) If possible, put a disposable set of gloves, on a daily basis, in direct contact with workers’ skin, before wearing usual work gloves. f) Make sure that there are disinfectants and hand sanitizers available in each and every vehicle. g) Frequent hand-washing and increased cleaning in workers’ facilities is a must. h) Drivers and collectors should avoid contact with residents and employees from serviced COVID-19 facilities. i) Sanitize and disinfect the driver's cab of vehicles destined for the collection of health facility waste after each work cycle, paying particular attention to hard surfaces which can represent a site of greater persistence of the virus. The vacuum cleaner must be used only after adequate disinfection. The use of disinfectants (e.g., at least 70% v / v alcohol) in a spray pack is recommended. j) Social distancing practices should be applied at all times, including, at meeting rooms as well as at changing rooms. 25 2.2.3.2. Plans for Safe Disposal of COVID-19 Medical Waste from Intensive Care Unit Facilities a) Generation o The waste is immediately inserted into a container designated for COVID-19 Medical Waste at the site of waste Generation (and minimize movement of the waste within the Healthcare facility). The Container is then sealed (double seal with designated bag plus designated container: Refer to Annex 6 for designed medical waste containers and PPE). o The waste is disinfected before being put in the waste container and after sealing the container. In case supply of designated container made with synthetic resin is disrupted, designated container made with corrugated cardboard may be used to dispose of personal protective equipment (masks, protective suit, etc.) used by medical staff or waste disposal workers, as such equipment will not cause the designated bag to rip or leak. o Food waste from confirmed patients is also treated as COVID-19 medical waste to be disposed of in a designated container. In case the entire Healthcare Facility is quarantined (cohort quarantined) and food waste cannot be disposed of in designated medical waste containers, such waste is disinfected and collectively incinerated (at public incinerators or commercial waste incinerators operated by the respective local governments or private facilities, where possible). o Bed sheets, pillow cases, blankets, and other linens that can be washed are cleaned in washing machines with disinfectant or detergent in warm water cycle (as per the WHO guidelines) before reuse. b) Storage o In principle, waste is disposed from hospitals on the same day it was generated as to minimize the storage time in hospitals, however; o When such waste is stored in hospitals, it is stored separately from other waste materials in a designated storage warehouse. o Organic tissues must be stored in a designated refrigerated facility (4℃ or colder), and quarantined waste that do not decay must be refrigerated in principle when possible. o Storage warehouses must be disinfected every day. Warehouses must block the view of medical waste from outside, and entry must be controlled. c) Collection Transportation o Waste is sealed inside dedicated containers. In transportation, waste should not pass- through temporary holding locations, and should be directly sent to medical waste incineration facilities to be incinerated. o While transporting in sealed, cargo boxes the waste must maintain a temperature of 4℃ or less. Cargo boxes must be disinfected with chemical agents after every use. 26 d) Incineration o Waste is put into incinerators as soon as they arrive at the incineration facility, while sealed inside designated container. o Status of waste disposal and final processing are monitored on a regular basis by Environmental Health department. 2.2.3.3. Plans for Safe Disposal of COVID-19 Medical Waste from Isolation Facilities All waste (including food waste) generated by confirmed patients are treated as COVID-19 medical waste. Such waste is (1) disinfected and sealed before Generation, (2) regularly disinfected, and (3) all incinerated for disposal every day. All COVID-19 facilities providing living and medical support (i.e. isolation centers, quarantine centers or healthcare facilities, either private or government owned), are considered to be facilities generating COVID-19 medical waste. a) Generation o All Waste materials generated are disinfected, sealed and put into designated bags and designated synthetic resin containers, seal them, and put in a secure place. b) Collection and Transportation o Waste management workers collect the waste on a designated time every day. The waste is disinfected and stored in separately designated (temporary) storage locations. Such storage locations must block the view of medical waste from outside (in a separate space, temporary cargo container, etc.). Entry to such locations must be controlled, and must be chemically disinfected at least once a day. c) Transportation and Disposal o Designated collection and transportation companies transport the stored waste to a designated disposal facility on the same day to be incinerated. o Residential waste materials generated by the operation and support functions of Healthcare Facility, without coming into contact with confirmed patients, are strictly treated as general COVID-19 medical waste and are incinerated. o As in the case with COVID-19 medical waste in Healthcare Facilities, materials treated as general medical waste are all disinfected, sealed and incinerated on the same day it was generated. However, they are contained in designated corrugated cardboard containers rather than designated synthetic resin containers. o Healthcare Facility Management designate companies to exclusively collect and dispose of the COVID-19 medical waste. Such companies check the volume of generated and processed waste materials and report the figures to the Healthcare facilities and Department of Environment. 27 2.2.3.4. Plans for Safe Disposal of COVID-19 Medical Waste from Quarantine Facilities All COVID-19 quarantine facilities providing living and medical support, are considered to be facilities generating COVID-19 medical waste. Quarantined individuals are provided with designated bags and disinfectant for free. a) Generation o Waste is disinfected and sealed inside designated medical waste bags, then put inside standard garbage bags to be stored. o Individuals are advised to refrain from generating waste, with generations of waste taking place in extremely exceptional circumstances. Quarantined individuals must disinfect their own waste (including food waste), put it in designated medical waste bags and apply seal. b) Collection and Disposal o Waste management workers collect the waste on a designated time every day. The waste is disinfected and stored in separately designated (temporary) storage locations. Such storage locations must block the view of medical waste from outside (in a separate space, temporary cargo container, etc.). Entry to such locations must be controlled, and must be chemically disinfected at least once a day. c) Transportation and Disposal o Designated collection and transportation companies transport the stored waste to a designated disposal facility on the same day to be incinerated. 2.2.3.5. Plans for Safe Disposal of COVID-19 Medical Waste from Suspected COVID- 19 Patients Who Are Self Quarantined Due to Lack of Government Quarantine Facilities a) Generation o Self-quarantined patients disinfect ALL of their own waste, seal and put them inside designated medical waste bags, then put inside standard garbage bags until the patient is transported to a government quarantine facility. o For individuals whose self-quarantine was released (tested negative), waste materials stored in designated medical waste bags are put into standard garbage bags and disposed as residential waste materials to be incinerated (see Annex 2 for guidelines for patients pending hospitalization). b) Collection and Disposal 28 o When the patient is transported to COVID-19 hospital, the waste is safely transported to a public clinic. Then, the public clinic contains the waste inside designated synthetic resin containers sends them to the company contracted to collect, transport, and process medical waste to be incinerated on the same day. o In case of inevitable circumstances such as excessive waste volume and the waste cannot be disposed of on the same day, the waste is processed via local Health Centre. c) Emergency Collection o In case Healthcare facilities cannot dispose of the waste materials specified above, management of the district Healthcare facilities may configure and implement a separate emergency waste collection, transportation, and processing system (refer to Annex 1 for detailed guidelines for medical waste emergency collection and transportation system). 2.2.3.6. Plans for Safe Disposal of COVID-19 Medical Waste Generated by Individuals Exhibiting COVID-19 Symptoms During Self Quarantine a) Generation o All generated waste is disinfected and sealed inside designated medical waste bags, then put inside standard garbage bags to be stored in a secure place (see Annex 2 for guidelines for patients pending hospitalization). b) Collection and Disposal o After safely transporting the waste to a local Healthcare facility, the Healthcare facility contains the waste inside designated synthetic resin containers and sends them to the company contracted to collect, transport, and process medical waste to be incinerated on the same day. o In case of inevitable circumstances such as excessive waste volume and the waste cannot be disposed of on the same day, the waste is processed via district Healthcare facility. o For individuals whose self-quarantine was released (tested negative), waste materials stored in designated medical waste bags are put into standard garbage bags and disposed as residential waste materials to be incinerated. 2.2.3.7. Plans for Safe Disposal of COVID-19 Medical Waste from Locations Visited by Confirmed Patients Areas exposed to patients are appropriately disinfected as per WHO guidelines and blocked off until the next day. o Generated waste materials are double-sealed in standard garbage bags and disinfected before sending off for incineration in public Hospital incinerators. 29 o Protection suits, masks, etc. generated during disinfection process are treated as COVID- 19 medical waste. o Waste generated by preventive disinfection of public facilities are double sealed, disinfected, and incinerated in public Healthcare facility incinerators. 2.2.3.8. Plans for Safe Disposal of COVID-19 Medical Waste from Vaccination Facilities All COVID-19 vaccination facilities are considered to be facilities generating COVID-19 medical waste. These include disposable surgical masks, gloves, needles, food packages, etc. a) Generation o Waste from health workers is disinfected and sealed inside designated medical waste storage. o Individuals are advised to refrain from generating waste, with generations of waste taking place in extremely exceptional circumstances. Vaccine recipients must put the waste in designated medical waste bins. b) Collection and Disposal o Waste management workers collect the waste at designated time (s) every day. The waste is disinfected and stored in separately designated (temporary) storage locations. Such storage locations must block the view of medical waste from outside (in a separate space, temporary cargo container, etc.). Entry to such locations must be controlled, and must be chemically disinfected at least once a day. c) Transportation and Disposal Designated collection and transportation companies transport the stored waste to a designated disposal facility on the same day to be incinerated. 30 3. Emergency Preparedness and Response The potential threats associated with both COVID-19 and other non-COVID - 19 risks that could affect Health Care Facility operations (including risks to workers, patients, communities and on operation of waste treatment and disposal options) should be documented, avoided, minimized or mitigated in line with the requirements of the GoL and WB ESS4. Emergency incidents/accidents occurring in a HCF may include spillage, occupational exposure to infectious materials or radiation, accidental releases of infectious or hazardous substances to the environment, medical equipment failure, failure of solid waste and wastewater treatment facilities, failure of water supply systems, fire, criminal act. These emergency events are likely to seriously affect medical workers, communities, the HCF’s operation and the environment. In case of any of the above incident/accident occurring, resulting in serious distraction/destruction of the Health Care Facility or delivery of its services, the event should be immediately reported to the Healthcare Facility Management. The following emergency numbers (in Table 3-1) below, may also be used to report the event to the external emergency service providers. In addition to the existing Healthcare Facility emergency response procedures - such as emergency reporting lines, identified emergency assembly point, automatic alarms, shutoff systems, etc.- minor events such as blood spillage, chemical spillage, etc. that can be addressed by health workers on duty, will be addressed using the current Lesotho Infection Control and Waste Management Plan (ICWMP) and its Standard Operating Produces (SOP), 2016. Table 3-1: Emergency numbers Incident Emergency number Area coverage Fire +266 223 17 163 All districts Electricity +266 521 00 000 All districts Water and Sewage +266 223 13 943 All districts Environment Impacts and +266 80022020 All districts Pollutions Criminal act (police + 266 58881024 All districts emergency) Ambulance and Hospital +266 223 12 501 Botha-Bothe +266 224 00 305 Leribe +266 227 00 208 Mafeteng +266 227 85 210 Mohale’s Hoek +266 223 12 501 Maseru +266 229 20 213 Mokhotlong 31 Incident Emergency number Area coverage +266 229 50 208 Qacha’s Nek +266 227 50 231 Quthing +266 229 00 211 Thaba Tseka +266 225 00 272 Berea 32 4. Infection Prevention and Control Procedures Health care workers and related personnel, including vaccinators, should follow infection prevention and control procedures for effective prevention and control of COVID-19. 4.1. Establishment of a COVID-19 management system and coordination mechanism Facilities should establish an implementation action plans for COVID-19 preparedness and response, which include strategies on effective management of their employees, visitors, etc. Facilities should designate specific persons responsible for COVID-19 infection control to ensure accountability in disease prevention and mitigation efforts. 4.1.1. Education for effective prevention - Facilities should provide their employees, visitors, and related personnel with information about COVID-19 and conduct training sessions on proper hand washing, social distancing, cough etiquette, etc. - Notify facility users that their access to the facilities can be limited if they have a fever or respiratory symptoms with visual displays of such notification in common areas. - Promote respiratory and cough etiquette by: o Educating HCF staff, patients, and visitors on the importance of containing respiratory droplet/aerosol and secretions to prevent the transmission of infectious disease. o Post visual signage informing that patients and family members with respiratory symptoms should use respiratory hygiene/cough etiquette. 4.1.2. Strengthening management of employees, visitors, and related personnel - Facilities must conduct temperature checks at entry points and within the office. o It is recommended to conduct temperature checks and respiratory symptom screening of employees and related personnel twice a day. o Conduct temperature checks for facility users and visitors as they enter the facilities. o Maintain a record of visitors and users with their personal details, contact information, temperature check results, etc. - Do not permit employees or visitors with fever or respiratory symptoms to work or use the HCF. - Workers with a fever or respiratory symptoms will remain at home and refrain from making contact with others, while monitoring their health for the next few days. - Actively provide managerial notice that workers are required to stay home if they develop a fever or respiratory symptoms. - If there is a suspected COVID-19 patient, provide an isolation area within the facilities with well-ventilated doors that can be closed and restrict access to this area to those who wear protective equipment such as medical facial masks. 33 4.1.3. Social distancing - Avoid physical contact including handshakes, etc. with other employees and visitors of the HCF. - Improve the working environment by taking measures to keep an adequate distance between workers. - Utilize alternative work and lunch hours to promote flexible work schedules and to prevent mass gathering of personnel. - Temporarily suspend the operation of public spaces such as indoor lounges and rest areas. - Postpone and/or cancel unnecessary mass gatherings, small-group events, etc. 4.1.4. Actions following detection of suspected patients - Facilities managers should immediately report the local public health centre/facilities if a suspected patient is identified. - The suspected patient should wear a mask and stay in a separated space until the patient is transferred to a screening post. The suspected patient should be placed under self- quarantine until the test results are confirmed. - After the suspected patient is transferred to the screening post, disinfect the area that the patient remained. 4.2. PPE procedure The PPE to wear will depends on the type of isolation precautions; therefore, several PPE procedures are possible. Keep in mind the steps of removing the PPE (from more contaminated to less), this will guide the step of putting on the PPE. Personal Protective Equipment Procedures HCWs must select the appropriate PPE after having assessed the risk of contact with body fluid. Wear PPE in a logical order, to be able to take off from the most contaminated item to the less contaminated item. Gloves - Putting on: Carefully put on disposable gloves; When wearing long sleeves gown, gloves cover the write of the gown. - Taking off: Outside part of gloves if contaminated; Grasp outside of glove with opposite gloved hand; peel off; Hold removed glove in gloved hand or discharge in waste container; Slide fingers of un-gloved hand under remaining glove at wrist; Peel glove off; Discard gloves in waste container. Gown 34 - Putting on: Fully cover torso from neck to knees, arms to end of wrists, and wrap around the back; Fasten in back of neck and waist - Taking off: Gown front and sleeves are contaminated; Unfasten ties; Pull away from neck and shoulders, touching inside of gown; Turn gown inside out; Fold or roll into a bundle and discard. Surgical Mask - Putting on: Secure ties or elastic bands at middle of head and neck; Fit flexible band to nose bridge; Fit snug to face and below chin - Taking off: Front of the mask is contaminated; Grasp ties of elastics and take off; Discard in waste container Eye’s protection (Goggles, face shield, safety glasses) - Putting on: Place item over eyes and face and adjust to fit. - Taking off: Front of the eye protection is contaminated; Take off, by handling the head band, elastics; Place in designated receptacle for reprocessing or in waste container for single use. 4.3. Hygiene Procedures 4.3.1. Hand hygiene procedure HCFs staff, care givers, and vaccinators should perform hand hygiene, when arriving at work/HCFs and before leaving work/HCFs, as well as before eating and after using the toilet/ latrine. Additionally, for anyone who is providing care to patients, the “Five moments for hand hygiene� must be respected. Routine Hand Hygiene Hand hygiene must be performed before and after every episode of patient contact. - Before touching a patient - Before a procedure - After a procedure or body substance exposure risk - After touching a patient - After touching patient’s surroundings Note: Hand hygiene MUST also be performed after taking off PPE. 4.3.2. Respiratory hygiene Respiratory hygiene and cough etiquette is a standard precaution that should be applied by all patients, visitors and HCWs to contain respiratory secretions (e.g., when coughing, sneezing, etc.) to avoid spreading respiratory infections. - Cover nose and mouth when coughing, sneezing with tissue or mask. - If no tissues are available, cough or sneeze into the inner elbow rather than hand. 35 - Do not ‘spit’ in environment. - Dispose used tissue and/or masks in the nearest bin after use. - Avoid shaking hands at all times. - Perform hand hygiene after contact with respiratory secretions. 4.3.3. Hygiene and environmental management - Facilities should place hand wash, such as hand sanitizers and liquid soaps, in sufficient quantity in restrooms and other common areas within the facilities. - Place trash bins at several locations in the facilities to allow the immediate disposal of waste used for coughing. - Increase frequency of cleaning, sanitizing, and ventilation in common areas within facilities, related transportations, etc. - Pay particular attention to enhance disinfection for areas and objects that are frequently touched by related personnel such as doorknobs, handrails, desks, tables, telephones, keyboards, etc. Disinfect entrance doors, elevators, and similar public objects on a more frequent basis. 4.4. Occupational health Any staff and visitor who is entering in the health care, isolation, or vaccination facility, or has any contact with contaminated equipment, linen, waste, dead body, etc. MUST: - Register their name and contact details in the logbook of facility for contact tracing purpose. - Follow up health status, fever and other symptoms (refer to suspect case definition in annex 8) - Take and record temperature twice daily, for the entire incubation period after the last contact - Notify to chief of unit, IPC team, focal point if any symptoms - Have a good hygiene, drink plenty of safe drinking water, and rest to avoid mistake due to overwhelmed, severe fatigue. - Provide supervision and support from chief of IU, IPC focal point and director of hospital. - Promote preventive medicine: - No pregnant women should be working in isolation room/ unit - Provide psychological support to the staff/team who work in isolation room/ unit - Prevent heat illness/ dehydration (serious risk of heat illness while wearing PPE in tropical conditions) For HCWs who are developing symptoms, - Stop work immediately or do not report to work 36 - Limit interactions with others - Exclude themselves from area - Notify the chief of unit or focal point if any fever > 38°C. and/ or other symptoms (refer to case definition in Annex 8) - Exposed persons must receive follow-up care (e.g., antiviral therapy when available), counselling and psychological support - Inform supervisor, for contact tracing and follow-up of family, friends, co-workers and other patients, who may have been exposed to the disease through close contact with the infected HCW/staff. 4.5. Community health Inappropriate handling of COVID-19 samples, vaccines, PPEs, etc. and the patients can expose local communities to infections. It could lead to adverse impacts on the environment and communities, and contribute to the spread of the disease. Therefore, relevant aspects of the GoL legislations and the WB Environmental and Social Standard (ESS4) on community health and safety should be considered, as needed, including, inter alia, measures to: proper management of the waste, minimized community exposure to disease. Also, it should be ensured that individuals or groups who, because of their particular circumstances, may be disadvantaged or vulnerable, have access to the beneficial impacts resulting from the Project and subproject activities, including vaccination. Potential community health and safety concerns and risks associated with the Project activities specific to infection control and waste management include the following: • Transport of wastes, transport of lab tests, transport of people who have tested positive with COVID-19 and movement of health workers and other staff in contact with patients with COVID-19, has the potential to spread the virus in the community (note transport of medical supplies and equipment is not expected to result in virus transmission); • Communities may have fear and apprehension on COVID-19 vaccine efficacy and safety due to the novelty and relative timeframe of development; • The proper storage conditions and transport of the vaccines are also major risks as they are needed to ensure the efficacy and safety of the vaccine. • Misinformation and disinformation on the adverse health effects of vaccines and hearsays on the conspiracy theories and underlying political agenda on the vaccines are widespread. • There is a risk of adverse health effects if the profiling and screening of candidate individuals to be vaccinated and proper data management were not observed to consider vaccine contraindications. • Crowding or influx of people in the vaccination sites as well as the violation of physical distancing are also risky. 37 The Stakeholder Engagement Plan (SEP) provides measures for stakeholder engagement at participating Health Facilities, including vaccination centres/units, to inform local communities of project activities, and to seek their feedback on potential risks and mitigation measures, including on infection control and waste management measures. The community health and safety measures that should be applied to avoid, minimize or mitigate the risks and impacts as may be imposed on the health and safety of the communities include, but are not limited, to the following: • Transport of all COVID-19 wastes and lab tests, blood samples, etc., should be collected safely in designated containers and bags, treated and then safely disposed; • Collection of samples, transport of samples and testing of the clinical specimens from patients meeting the suspect case definition should be performed in accordance with biosafety measures and WHO guidelines on Laboratory testing for coronavirus disease 2019 (COVID-19) in suspected human cases; • Transport of medical equipment/supplies is not expected to be a vector in transmitting the virus, however, workers transporting materials should be reminded to wash hands appropriately and to avoid touching their face; • To ensure the safety of the vaccines to be procured, the vaccine regulatory approval of 8 the Stringent Regulatory Authorities (SRAs) identified by the World Health Organization will be required; • Appropriate messages will be developed under the risk communication plan to address the vaccine safety concerns of the communities - including the infection control and waste management issues. • A Communications Campaign Plan will also be developed by the MoH/EHD/DOH/PIU for the COVID-19 vaccination program, including coverage on the infection control and waste management aspects. • A series of counselling - including on the infection control and waste management - should be conducted prior to the administration of the COVID-19 vaccination and other Project activities; • Coordination with the local government units as well as the uniformed personnel will be done to assist in crowd management; • Training shall be provided to medical and other staff (doctors, nurses, cleaners, lab technicians, etc.) coming in contact with patients with COVID-19 and/or their wastes, 12. World Health Organization. (June 2020). Essential medicines and health products: List of stringent regulatory authorities (SRAs). https://www.who.int/medicines/regulation/sras/en/. 38 clothes, linen or tests, on disinfection procedures when going back to their homes/communities. In extreme cases, this may involve isolating medical and other personnel involved with COVID-19 patients. • Any medical or other hospital staff (including cleaners) experiencing symptoms of COVID19 or a respiratory illness (fever + cold or cough) must remain at home/isolated from the family members and communities, and report symptoms immediately to supervisors. • Communication materials must reinforce the positive contribution of health care workers and other essential workers and their need to be supported by community members. • Widespread engagement with communities shall be ensured to disseminate information related to community health and safety – including on infection control and waste management. • MoH/PIU will ensure that the workers and local communities are informed about the Project’s GRM. MoH/PIU will review any incidents, concerns or grievances also regarding the infection control and waste management, and resolve through the Project’s grievance mechanism. 4.6. Mortuary Arrangements (Handling of dead bodies) Health Care Facilities should discourage any local practices (touching/ being in contact with the corpse) by HCW, family, friends, etc. Dead body remains should not be sprayed, washed or embalmed. PPE must be appropriately used to safely handle dead body. The PPE should include at least: - Disposable gown with long sleeves - Waterproof apron - Disposable, non-sterile gloves (over the cuffs of the gown) - Surgical mask (wear particulate mask if autopsy) - Eyes protection (preferable face-shield, or goggle) - Rubber gloves - Rubber boots Put corpse in waterproof/ impermeable body bag immediately; and transfer to the mortuary as soon as possible after death. Families of the deceased should be encouraged to bury or incinerate corpse without delay. Surveillance of staff who handle dead body (need to check and record their temperature twice a day, and notify to chief of unit, IPC team if any symptoms) 39 5. Institutional Arrangement and Responsibilities, Training and Capacity Building, Public Awareness, and Engagement of Private Sector This ICWMP directly under the responsibility of the Environmental Health Department (EHD) of MoH, the EPRP Implementing Agency. In addition, the Ministry of Health has a newly established Environmental and Social Committee (ESC), that is responsible for management of all environmental and social issues for the ministry’s activities and projects, that will work hand in hand with the EHD. The Environmental Health Department will coordinate the implementation and apply a multi-stakeholder approach to embrace all the relevant players to include Ministry of Tourism, Environment and Culture (MTEC), Local government Authorities, NGOs, and other private players. 5.1. Institutional Arrangement and Responsibilities Part of improving ICWM involves clarifying who is responsible for what functions and identifying the fields of competencies of each institutional actor involved in this process. The following roles and responsibilities are suggested: a) At the central level The MoH is responsible for the national health policy and ensures the guardianship of the health facilities. The Environmental Health Department (EHD) will take the lead in coordinating the implementation of the ICWMP because: a) it is part of its mission; b) it has competent staff in this field, c) it has decentralized services down to District level and d) it has capacity to offer Health Education Service, public information and awareness raising. The Environmental Health Department will be heavily involved in overseeing the following ICWM activities: a) Procurement of consumables (sharp containers, colour coded bin liners) b) Procurement of re-usable waste receptacles; c) Running maintenance of existing incinerators; d) Ensuring availability of land for new sites for installation of new waste treatment and disposal facilities; e) Organising /facilitating capacity building on ICWM amongst Health Care Workers; f) Providing human resources (waste handlers, incinerator attendants etc.) 40 The Environment Department of Ministry of Tourism, Environment, and Culture (MTEC) will be responsible for monitoring of the implementation of the ICWMP. It has the overall responsibility of protecting the environment and thus ultimately the activities of the Environmental Health Department of MoH must conform to the requirements of the Environmental Management regulations. It will watch over the whole chain of HCW from generation to final disposal. The Environment Department is also responsible for developing norms and standards for soil, water and air protection, mainly as they relate to the use of landfill sites that may be used for COVID-19 Medical Waste disposal after treatment by Healthcare Facilities. This function is very important as this assures an independent control and monitoring mechanism for the system to bring about safe handling of the COVID-19 Medical Waste throughout the system. b) At the District / Local Authority level The Districts and Local Authorities will need to put in place arrangements to make sure that HCW from COVID-19 facilities are not mixed with general wastes in their public landfills. The Districts and Local Authorities must ensure, either by themselves or through partnerships, that facilities capable of handling all the COVID-19 Medical Waste generated in their areas of jurisdiction are in place. They should be responsible for a centralized ICWM regime within their areas of jurisdiction. They should also give their opinion about the ICWMP activities proposed for health facilities in their jurisdiction, in case some may have negative impacts on the local population’s health. Coordination of the ICWM activities will be exercised by their respective Environmental Health Departments. The Districts and Local Authorities should design their landfills according to the norms and standards defined by the Environment Department at MTEC, in order to avoid soil, water and air pollution in case of reception of COVID-19 Medical Waste. To accomplish safe disposal of COVID-19 Medical Waste, especially the ash from incinerators, specific areas should be reserved for that purpose. In addition, local governments should enact regulations to: (i) refuse to receive mixed HCW with non-infectious wastes at local landfills; (ii) forbid uncontrolled HCW disposal; and (iii) set up strong waste management controls in their landfills (materials for covering, restriction for non-authorized public access, equipment protection, etc.). c) At the health care facility level The manager of each health care facility shall be responsible for ICWM for COVID-19 Disease outbreak in his/her establishment. The manager must ensure that a ICWM plan is prepared and then institute all the requirements of the national policy, regulations and standard operating procedures. S/he must designate the officers/teams charged with HCW segregation, collection, transportation and treatment and be overly responsible. 41 Table 4 – 1: Summary of key responsibilities for Management of waste from COVID-19 Facilities Responsible Organization Responsibilities MOH - Environmental Health o Develop ICWMP for COVID-19 Disease Department outbreak; MOH – Lesotho COVID-19 o Connect emergency waste disposal companies Emergency Prepared and Response to Healthcare Facilities; (EPR) Project Implementing Unit o Provide PPE and disinfectants to Healthcare (PIU) Facilities; MOH – Healthcare Facilities o Real-time sharing of COVID-19 infections statistics and healthcare facilities information; o Support designation of companies to dispose COVID-19 waste; o Develop and implement safety measures for waste collection, transportation, and disposal; o Provide designated waste bags and disinfectants to self-quarantined individuals; MOH – District Health Team o Build safe waste management cooperation and support system; o Oversee COVID-19 waste disposal status from all Health Facilities; o Distribute manual for safe management of COVID-19 Medical Waste to all Health Facilities; o Develop plans for disinfecting self-quarantine locations (for positively diagnosed patients) as well as locations visited by COVID-19 patients; Private Sector o Participate in Collection, treatment and disposal of HCW as when, there is a need, as per their contract agreement with MOH. MTEC - Department of Environment o Monitor Compliance for safe Disposal of All HCW; 42 The budget for implementation of the ICWMP activities has been estimated at US$14,500. Further, the costs associated with the implementation of the ICWMP arrangements, practices and measures suggested in this plan are built into the overall cost of implementing the EPRP and the regular budget of the GoL. The actual expenses may vary during the implementation of the ICWMP, and shall be accordingly taken care of as per the actual costs as may be required for effective and efficient implementation of the ICWMP. 5.2. Training and Capacity building Training and capacity building activities should be led by the EHD of the MoH. This structure has competence in ICWM and could be supported by training and higher learning institutions like the University, the Polytechnic, and other institutions, especially with Infection Control and Waste Management for COVID-19 facilities. The trainings should include among others, the World Health Organisation Guidelines on COVID-19 disease outbreak, more specifically the guidelines on Infection Control and Waste Management. At District level, management of trainings and capacity building activities should be assigned to the District Health Management Teams (DHMT). The specific training activities will be done in the first year of the programme. National Consultants will train key staff as trainers in health facilities and other institutions like the municipalities and local government authorities. The trained key staff should then train the other employees. The EHD may not have the human resources to prepare and diffuse the training courses about ICWM, for specifically with the focus on COVID-19 disease outbreak. The EHD could prepare the TORs, and do the control and supervision at national level while District Health Management Teams(DHMT) would assume the monitoring at the district and local level. In other words: a) The EHD prepares the Terms of Reference for developing the training programs, and does the control and supervision at national level; b) Health Training Institutes or National Consultants having acquired a large experience in ICWM will prepare the training courses; c) In each District, a training of trainer’s workshop will be held and will be conducted by Training institutions or national consultants, under the supervision of the DHMTs. The latter must prepare periodic reports to be sent to the central level (EHD/MoH); d) In each health care facility, the supervising staff trained in the District workshops will ensure the training of all medical staff, orderlies, cleaners, etc., under their supervision. The heads of the health establishments must supervise this work and prepare periodic evaluation reports. 43 5.3. Public Awareness The Health Education/Environmental Health Department of the MoH will lead the activities intended to increase the awareness of the general public about the risks associated with HCW, more specifically with COVID-19 Medical Waste. At local level, DHMTs will do the supervision. These activities will cover the 2 years of the program, through public animations, radio and television messages, posters, etc., and will be done as follows: a) The Health Education/Environmental Health Department of the MoH will elaborate the content of these messages, of posters and public animation; b) The televised messages will be diffused by the National Television Station; c) The radio messages will be diffused by the local radio stations, in English and Sesotho, under the supervision of Ministry of Health, Environmental Health Department. d) Private companies (printing enterprises) will make posters to be used in the Healthcare Facilities. e) Public animation sessions will be led by NGOs acting in the health and the environmental field, under the supervision of Environmental Health Department within the Ministry of Health. 5.4. Strategy for private sector involvement and partnership The elaboration of measures to involve private companies in ICWM, more specifically with the capacity to manage Waste from COVID-19 facilities will be coordinated by the MoH, in collaboration with other stakeholders. 44 6. Monitoring and Reporting HCF should establish an information management system to track and record the waste streams from the point of generation, segregation, packaging, temporary storage, transport carts/vehicles, to treatment facilities. In addition to paper based database system, the HCF is encouraged to develop an Information Technology (IT) based information management system should their technical and financial capacity allow. As discussed above, the HCF Management takes overall responsibility, leads an intra- departmental team and regularly reviews issues and performance of the infection control and waste management practices in the HCF. Internal reporting and filing systems should be in place. HCW monitoring in health facilities should be carried out regularly, in order to improve waste management and to ensure that good practices are performed after training. Measures should be adopted to ensure that problems and risks involved are identified to enhance safety and preventing the development of future problems. Supervision should be in the following areas: a) segregation, b) collection routines and labelling, c) internal treatment system, d) internal storage of HCW, e) transportation, f) worker safety measures, g) disposal at the incinerator facility, or sanitary landfill. The Quarterly and other major reports on the EPRP implementation progress - which are prepared and shared with the GoL and the Bank - will be inclusive of a dedicated section also on implementation of the ICWMP. 45 Annex 1: Detailed Guidelines for Medical Waste Emergency Collection and Transportation System 1. Purpose and Basic Directions 1.1 Purpose As infectious disease risk warning level is raised and the number of confirmed cases rapidly increase, and there are many confirmed patients who are self-quarantined and not sent to hospitals, these guidelines will be used as systems for emergency collection, transportation, and disposal of waste generated by confirmed patients who are self-quarantined. 1.2 Basic Directions Waste disposed by confirmed patients who are self-quarantined is treated as COVID-19 medical waste. In case the self-quarantined confirmed patient is quarantined at home, etc. Local Environmental Department or the Local government authority coordinates medical waste collection and transportation companies to visit and collect the waste. Waste generated by general (unconfirmed) self-quarantined individuals is treated as residential waste as specified in the “Special Waste Management Measures.� In case the self-quarantined confirmed patient is transferred to a hospital, the local Healthcare facility coordinates the COVID-19 Medical Waste to be collected and disposed by a medical waste disposal company. 2. Implementation Targets and Period 2.1 Targets In regions where number of confirmed cases spiked to force confirmed patients to be self-isolate instead of being admitted to a hospital, the director of the local Environmental Department may decide to implement an emergency collection, transportation, and disposal system for COVID-19 medical waste too difficult to process such individuals’ waste. This guideline will be implemented on such regions. 2.2 Period This guideline will be in effect from when it is implemented until the aforementioned emergency waste collection and transportation system expires. Waste generated after this guideline is implemented will be processed in accordance with “Special Waste Management Measures for COVID-19 Outbreak.� 3. Plans for Collection and Disposal of Waste Generated by Self-Isolated Individuals 3.1 Role Allocation a) Healthcare facilities Process requests for disposal of COVID-19 Medical Waste generated by self- isolated confirmed patients. o Receive phone requests for disposal of COVID-19 Medical Waste generated by self-Isolated confirmed patients. 46 o Transfer to the local Environmental department information about the received COVID-19 Medical Waste collection requests on a daily basis. b) Local government authority o Establish and operate a system for collection, transportation, and disposal of COVID-19 Medical Waste generated by self-Isolated confirmed patients. o Provide overall management of requests for collection of COVID-19 Medical Waste that are submitted to Local governments and Healthcare facilities on a daily basis. o Assign collection and transportation vehicles based on the daily requests for collection of COVID-19 medical waste. o Manage the daily collection, transportation, and disposal status of collection and transportation vehicles. o Establish a contact system with department of environment and local healthcare facilities to manage requests for collection of quarantined medical waste. c) Healthcare facilities o Promote methods of managing COVID-19 medical waste generated by self-Isolated confirmed patients. o Provide information about making phone requests for collection of COVID-19 Medical Waste (phone number for agencies, etc.). o Distribute designated medical waste containers (bags) to self-Isolated confirmed patients. 3.2 Collection and Disposal System 3.2.1 Reception of Requests to Collect COVID-19 Medical Waste Generated by Self Isolated Confirmed Patients a) Requesting body: Local Healthcare facility b) Request Method: Use phone and other methods to provide information about the requested COVID-19 Medical Waste (emitter name, waste volume, contact information, etc.). Requests must be made according to COVID-19 Medical Waste Collection Request Form (refer to Annex 3). c) Request Information Management: Healthcare facilities inform the daily COVID-19 medical waste collection request status to Environmental department via email (by 17:00, everyday) 3.2.2 Allocation of COVID-19 Medical Waste Collection and Transportation Vehicle (Organizing Department) a) Collection and transportation vehicles are allocated based on the waste location and waste volume by local government authority. b) Collection and Disposal Volume Management: Provide management of information regarding waste location, actual collection volume and processing data assigned to waste collection and transportation vehicles by local government authority. 3.3 Collection, Transportation, and Disposal of COVID-19 Medical Waste a) Supervision is done by Local Healthcare facility; 47 b) Details of the waste is detailed in the COVID-19 Medical Waste Collection Request Form (refer to Annex 3). c) Local Healthcare Facility, or designated private collector secure and provide waste collection and transportation vehicles for emergency waste collection and transportation. d) Waste collection and transportation is conducted using medical waste collection and transported vehicles. However, under inevitable circumstances such as vehicle shortage, temporary vehicles (with refrigeration capabilities) may be used for waste collection and transportation. e) Medical waste collection and transportation vehicles must display appropriate identification forms on both sides and back of the truck. f) Employees of waste collection and transportation companies or healthcare facilities must submit personal information protection agreement before participating in waste collection and transportation jobs (refer to Annex 4). g) COVID-19 Medical Waste collected and transported under emergency measure is transferred to medical waste disposal facilities on the same day of the collection. h) Data on daily collection and transportation of COVID-19 Medical Waste are sent to Department of Environment (division responsible for waste and pollutions) via internal e-mail (by 17:00). i) Data on daily collection and transportation of COVID-19 Medical Waste must be sent according to “COVID-19 Medical Waste Collection Request Form. 4. Other Administrative Items a) Daily COVID-19 Medical Waste Collection and Disposal Report o Healthcare Facilities reports their daily COVID-19 Medical Waste collection and disposal performance every day, as per this guideline (by 17:00). o Daily collection and disposal performance data are sent to the Department of Environment (Waste Management Division), District Health Team, and MOH - Environmental Health Department via internal e-mail (by 17:00, refer to the form in Annex 5). b) Financial costs o Collection, transportation, and disposal costs for operating the emergency COVID-19 Medical Waste collection and transportation system will be incurred by relevant or local Healthcare Facility. 48 Annex 2: Guidelines for Patients Pending Hospitalization Patient should fill the provided designated bags with residential waste (including food waste) generated at home (fill less than 75% of the bag capacity). Sufficiently disinfect the top part of the waste and the outside of the bags, and store the bags in a separate storage location. (Disinfecting the waste bags at least once daily is recommended.) Patient should refrain from generating the waste as much as possible. If waste must be disposed for inevitable reasons, please sufficiently disinfect the waste bags and contact the local health authorities. (Also provide information about the approximate waste volume.) When the waste collection request is submitted, local healthcare facility will notify the patient or guardian of the approximate collection time. A worker will come to patient door to collect the waste. Patient should store waste at the previously notified time of collection to waste disposal facilities. If patients pending hospitalization at home request collection of their residential waste, patient should do so by informing local healthcare facility. The local healthcare facility management should also arrange collection of medical waste generated by emergency responders and disease control personnel in relation to patients pending hospitalization. 49 Annex 3: COVID-19 Medical Waste Collection Request Form Medical Waste Generations Requester Medical Waste Transfer Records Requested District Physical Names Mobile Storage Estimated Collected Company Name of Collected date Address No. type Generations Date collecting collector amount (No. of waste (No. of Containers) container) Notes: This form is submitted to Department of Environment. The collected amount is the mass measured by the collecting company. 50 Annex 4: Personal Information Protection Agreement template Agreement In collecting and transporting medical waste related to COVID-19 infections, I agree to comply with environmental laws and emergency collection, transportation, and operating system guidelines with due diligence. I also agree not to use the personal information acquired in this process for illicit purposes. Year _____________Month______________ Day______________ Address: ___________________________ Date of Birth: ____________________________ Applicant: ____________________ (Names)___________________(Signature) 51 Annex 5: Daily Collection and Disposal of Medical Waste from Self Isolated Individuals template City/ Village No. of Collection Transportation Hospital Disposal District Collected Amount Company Incineration Amount (kg) Households (kg) Facility e.g. Masowe 1 3 50 kg ABC Pty Ltd Queen II 50 kg Maseru Hospital Daily Total - Daily Total Total - Total 52 Annex 6: Healthcare Facility COVID-19 Waste Management and Disposal Manual a) Items Required for Waste Disposal: For waste disposal, the following items are required: (1) waste disinfectant, (2) designated medical waste bag (orange bag), (3) designated medical waste container (plastic), and (4) designated medical waste container (corrugated cardboard). b) Generation Method for Waste Generated by Patients in Healthcare Facilities – COVID-19 medical waste o When disposing waste generated in quarantine rooms, first disinfect the inside of designated bags (orange bags) before putting the waste (without separating for recycle) in. When the waste is inside the bags, disinfect again and tie the bags so that the waste cannot be seen from outside. o Then, put the designated bags (orange bags) inside the provided designated medical waste container (plastic). Disinfect before closing the lid of the designated container (plastic), and seal by completely closing the lid. o Sealed designated medical waste containers should be disinfected on the outside before they are put outside in front of the quarantine room door. o Waste materials can only be collected if they are disposed with the lids completely closed on the designated medical waste containers (plastic). o Disposed waste must be collected by the center personnel every day and stored in a separate (temporary) storage location within the Healthcare facility. c) Generation Method for Waste Generated by Healthcare Facility Staff, Etc.] - General Medical Waste o Waste generated from staff work areas and lodging, as well as waste that were not directly in contact with confirmed patients (lunchbox, relief item box, etc.) are treated as general medical waste. o Such waste is put into designated medical waste bags (orange bags) without separating for recycling. Before sealing the bags, they must be disinfected. o After disinfection, the designated bags (orange bags) must be tied to prevent the contents from being seen outside. Then, the bags should be put inside designated medical waste containers (corrugated cardboard) and sealed. o The sealed designated medical waste containers (corrugated cardboard) must be disinfected on the outside before they are collected. o Disposed waste must be collected by the centre personnel every day and stored in a separate (temporary) storage location within the local Health Care Facility. d) Temporary Storage, Transportation, and Incineration Method for Waste from Healthcare Facilities o Separate (temporary) storage locations must be disinfected once daily; if required, additional disinfection may take place. o Medical waste stored in separate (temporary) storage locations must be transported and incinerated by medical waste disposal company (collection, transportation, and incineration) every day. 53 Annex 7: Residential Waste Management and Disposal Manual for Self Quarantined Individuals a. Generating Residential Waste When Asymptomatic of COVID-19 o Residential waste materials generated at home (including food waste) must be put into the provided designated bags. Use the disinfectant to sufficiently disinfect the top part of the waste and the outside of the bag before storing the waste. Disinfecting the waste bags at least once daily is recommended. o Designated bags must be filled only to 75% of the capacity to enable complete seal when tied. Used bags should be sufficiently disinfected, tied up, and stored in a separate location. Stored Bags should be disinfected at least once a day. o Patients should refrain from generating the waste materials contained inside the designated bags outside of their home. If waste contained in the designated bags must be disposed for inevitable reasons. Sufficiently disinfect the bags and put them inside standard garbage bags, and call the local Healthcare facility to request collection and disposal of the waste. o If patient have not received designated bags yet, standard garbage bags may be used in lieu. If waste needs to be disposed, bags should be put inside other standard garbage bags (double-bagging). b. Generating Residential Waste When Showing Symptoms of COVID-19 If a patient is experiencing suspected novel coronavirus symptoms, patient should immediately call the health authorities, and store residential waste in sealed double standard garbage bags (double- bagging). Waste will be collected free of charge by the health authorities and professional waste management companies to be safely disposed. c. Generating Residential Waste When Self Isolated as a Confirmed COVID-19 Patient Patient should store residential waste in designated bags in sealed double standard garbage bags (double-bagging) and store the waste bags inside the provided synthetic resin containers before a patient is sent to a hospital. Patient’s waste will be collected free of charge by the health authorities and professional waste management companies to be safely disposed. 54 Annex 8: WHO COVID-19 Case definitions CASE DEFINITIONS WHO periodically updates the Global Surveillance for human infection with coronavirus disease (COVID-19) document which includes case definitions. For easy reference, case definitions are included below. Suspect case A. A patient with acute respiratory illness (fever and at least one sign/symptom of respiratory disease (e.g., cough, shortness of breath), AND with no other aetiology that fully explains the clinical presentation AND a history of travel to or residence in a country/area or territory reporting local transmission (See situation report) of COVID-19 disease during the 14 days prior to symptom onset. OR B. A patient with any acute respiratory illness AND having been in contact with a confirmed or probable COVID19 case (see definition of contact) in the last 14 days prior to onset of symptoms; OR C. A patient with severe acute respiratory infection (fever and at least one sign/symptom of respiratory disease (e.g., cough, shortness breath) AND requiring hospitalization AND with no other aetiology that fully explains the clinical presentation. Probable case A suspect case for whom testing for COVID-19 is inconclusive. • Inconclusive being the result of the test reported by the laboratory Confirmed case A person with laboratory confirmation of COVID-19 infection, irrespective of clinical signs and symptoms. • Information regarding laboratory guidance can be found here. 55 Appendix I: Infection Control and Waste Management (ICWMP) 2016 KINGDOM OF LESOTHO MINISTRY OF HEALTH _____________________________________________ VOLUME 1 - ICWMP INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) _____________________________________________ January 2016 56 OTHER REPORTS IN THIS SERIES ________________________________ This final INFECTION CONTROL AND WASTE MANAGEMENT PLAN forms part of a series which is intended to provide complete documentation for the requirements of a holistic management of all forms of infection and types of waste from the different types of health care facilities in the country. This report contains the findings of a study conducted using the Rapid Assessment Tool developed by the WHO and the plan has been developed on the basis of the local conditions and findings. The following documents form the series: 1. Infection Control and Waste Management Plan for Lesotho Volume 1: The Action Plan - ICWMP 2. Infection Control and Waste Management Plan For Lesotho Volume 2: The Standard Operating Procedures Report no. 001 Issue no. 001 Date of issue 26/01/16 Prepared Sibekile Mtetwa Checked World Bank Checked MoH Approved THIS REPORT IS AVAILABLE FROM: The Minister of Health Attention: The Secretary of Health Ministry of Health Maseru Lesotho i TABLE OF CONTENTS TABLE OF CONTENTS ii LIST OF ANNEXES vii LIST OF FIGURES vii LIST OF TEXT TABLES viii ABBREVIATIONS AND ACRONYMS ix EXECUTIVE SUMMARY x 1. INTRODUCTION 1 1.1 BACKGROUND1 1.2 PROJECT DESIGN CONSIDERATIONS 3 1.3 PROJECT STRUCTURE 3 1.3.1 COMPONENT 1: 3 1.3.2 COMPONENT 2: 4 1.3.3 COMPONENT 3: 5 2. BASELINE DATA 6 2.1 INTRODUCTION 6 2.2 GENERAL LESOTHO GEO-PHYSICAL CONDITIONS 6 2.2.1 Location, Size, and Extent 6 2.3 BASELINE DATA AND BACKGROUND OF HEALTH CHALLENGES 8 2.4 THE STRUCTURE OF THE HEALTH CARE SYSTEM 8 2.5 HEALTH CARE DELIVERY SYSTEM 9 2.6 THE HEALTH SECTOR REFORM PROCESS 11 2.7 WASTE MANAGEMENT IN LESOTHO 11 2.7.1 Categorisation of HCW in Lesotho 12 2.7.2 Overview of the present HCWM System in Lesotho 12 2.8 HANDLING AND TREATMENT OF HCW 14 2.9 LEVEL OF AWARENESS OF GOOD HCWM PRACTICES 14 2.10 THE CERTIFICATION SYSTEM 15 2.11 THE LESOTHO QUALITY ASSURANCE SYSTEM 16 ii 2.12 INFORMATION SYSTEM AND LICENSING 16 3. CONTEXT OF THE HCWM PLAN 17 3.1 INTRODUCTION 17 3.2 THE POLICY FRAMEWORK 17 3.2.1 Poverty Reduction Strategy (PRS). 17 3.2.2 National Health Policy (2011) 18 3.2.3 Lesotho National Environmental Policy (1998) 18 3.2.4 Healthcare Waste Management Policy (2010) 19 3.2.5 National Tuberculosis Programme: NTP Policy and Manual 19 3.2.6 Lesotho Science and Technology Policy 2006-2011 (2006) 19 3.2.7 ICT Policy for Lesotho - 4 March 2005 20 3.2.8 National Health Sector Strategic Plan - 2012 - 2017 21 3.2.9 Infection Prevention and Control Policies & Guidelines (2006) 21 3.2.10 Consolidated Lesotho National Health Care Waste Management Plan 22 3.2.11 National Implementation Plan for the Stockholm Convention 22 3.2.12 Health Telecommunications Technical Assistance Project 23 3.2.13 The Health Services Decentralisation Strategic Plan (2009) 23 3.2.14 Human Resources Development Strategic Plan 2005–2025 (2004) 24 3.3 LEGAL FRAMEWORK 24 3.3.1 Constitution of Lesotho 24 3.3.2 The Environment Act No 10 of 2008 24 3.3.3 The Public Health Order No. 12 of 1970 25 3.3.4 The Water Act 2008 - Water and Sewage Authority – (WASA) 26 3.3.5 Local Government Act 1997. 26 3.3.6 The Labour Code Order 1992 - Ministry of Employment and Labour 27 3.3.7 The Hazardous and Non-Hazardous Waste Management Act, 2008 27 3.4 REGULATIONS 27 3.5 INTERNATIONAL CONVENTIONS AND TREATIES 28 3.5.1 The Basel Convention 28 3.5.2 Stockholm Convention on Persistent Organic Pollutants 29 iii 3.5.3 The convention of biological diversity 29 3.5.4 The convention concerning the protection of world and natural heritage. 29 3.5.5 African convention on conservation of nature and natural resources 29 3.5.6 Summative comment on legislation for HCWM 30 3.6 INSTITUTIONAL FRAMEWORK 30 3.6.1 Department of Environment 30 3.6.2 Ministry of Health (MoH) 30 3.6.3 Ministry of Labour and Employment (MOLE) 31 3.6.4 Participating Ministries 31 3.7 PRIVATE SECTOR PARTICIPATION 31 3.8 FINANCIAL RESOURCES ALLOCATION 32 4. DESCRIPTION OF THE ICWMP PROJECT 33 4.0 INTRODUCTION 33 4.1 THE ICWMP GOAL 33 4.2 THE ICWMP OBJECTIVES 33 4.3 THE ICWMP STRATEGIC OBJECTIVES 33 5. ASSESSMENT OF HCWM IN THE COUNTRY 35 5.0 INTRODUCTION 35 5.1 THE ASSESSMENT PROCESS 35 5.2 THE RAPID ASSESSMENT OF THE INSTITUTIONS 35 5.3 SELECTION OF HEALTH CARE FACILITIES 36 5.4 BASELINE INFORMATION OF THE SELECTED FACILITIES 36 5.4.1 General observations 36 5.5 SUMMARY OF THE ANALYSIS 38 5.6 GENERAL RECOMMENDATIONS 40 6. TRAINING NEEDS ASSESSMENT 41 6.0 INTRODUCTION 41 6.1 TRAINING NEEDS FOR HEALTH CARE STAFF 41 6.2 TRAINING NEEDS - GENERAL PUBLIC/NON HEALTH CARE STAFF 43 6.3 TRAINING STRATEGY 45 iv 6.4 PUBLIC AWARENESS STRATEGY 46 7. THE INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) 48 7.1 MAJOR OBJECTIVES OF THE ICWMP 48 7.2 THE ICWMP ACTION PLAN 54 7.3 SUMMARY OF COSTS 63 8. BUDGET FOR THE ICWMP 64 8.1 INTRODUCTION 64 8.2 ESTIMATED COST OF IMPLEMENTING THE ICWMP 64 8.3 MOH CONTRIBUTION TO THE IMPLEMENTATION OF THE ICWMP 65 8.4 CONTRIBUTION FROM IDA PROJECT 66 8.5 CONTRIBUTIONS FROM OTHER SOURCES/PARTNERS 66 8.6 PROJECT FUNDING SUMMARY 66 9. ICWMP IMPLEMENTATION MODALITIES 67 9.1 INSTITUTIONAL FRAMEWORK 67 9.2 RESPONSIBILITIES 67 9.3 INSTITUTIONAL ARRANGEMENTS FOR ICWM IMPLEMENTATION 69 9.4 IMPLEMENTATION TIMEFRAME 71 9.5 POTENTIAL PARTNERS AND FIELD OF INTERVENTION 72 9.6 INVOLVEMENT OF PRIVATE COMPANIES IN ICWM 73 10. HANDLING HEALTH CARE WASTE STREAMS 74 10.1 RECOMMENDED SYSTEM FOR HANDLING WASTE 74 10.2 SUMMARY OF THE WASTE HANDLING SYSTEM 78 11. DETERMINATION OF TREATMENT SYSTEMS AND TECHNOLOGIES 81 11.1 INTRODUCTION 81 11.2 SOLID WASTES TREATMENT 81 11.2.1 Comparative analysis of solid HCW treatment systems 83 11.2.2 Recommendations for Solid Wastes Treatment 85 11.3 LIQUID WASTES TREATMENT 89 12. DETERMINATION OF DISPOSAL SITES 90 12.1 CHOICE OF LANDFILL SITES 90 v 12.2 DECISION TREE SCENARIOS 90 13. THE MONITORING PLAN 91 13.1 PRINCIPLE AND OBJECTIVE 91 13.2 METHODOLOGY 91 13.3 MEASURABLE INDICATORS 92 14. REFERENCES 93 vi LIST OF ANNEXES ANNEX 1 NUMBER OF HEALTH FACILITIES BY CATEGORY 94 ANNEX 2 BASELINE INFORMATION OF THE SELECTED FACILITIES 95 ANNEX 3 GENERAL WASTE MANAGEMENT PRACTICES 102 ANNEX 4 MODEL OF “WHO� INCINERATOR MADE WITH LOCAL MATERIALS 113 ANNEX 5 CONCRETE LINED PIT - HOME BASED CARE WASTE DISPOSAL 114 ANNEX 6 CONCRETE LINED PIT - SHARPS AND INFECTIOUS DISPOSAL 115 ANNEX 7 HCW FACILITIES OPERATING SCENERIO 1 116 ANNEX 8 HCW FACILITIES OPERATING SCENERIO 2 117 ANNEX 9 HCW FACILITIES OPERATING SCENERIO 3 118 ANNEX 10 HCW FACILITIES OPERATING SCENERIO 4 119 ANNEX 11 HCW FACILITIES OPERATING SCENERIO 5 120 LIST OF FIGURES Figure 10-1 Temporary storage for waste .......................................................................... 76 Figure 10-2 Poor example of a centralized storage. ........................................................... 76 Figure 10-3 Example of a hazardous waste transportation vehicle. .................................. 77 Figure A.3-1 the three bin system. ................................................................................... 102 Figure A.3-2 Sharps Containers in common use ............................................................. 103 Figure A.3-3 General Waste Containers in common use................................................. 104 Figure A.3-4 Obsolete equipment piling up at a Health Facility. .................................... 105 Figure A.3-5 Temporary storage for General Waste. ...................................................... 106 Figure A.3-6 infectious waste Temporary Storage in large hospital. .............................. 107 Figure A.3-7 infectious waste temporary Storage in Sluice Room.................................. 107 Figure A.3-8 infectious waste Temporary Storage in cage next to incinerator .............. 107 Figure A.3-9 Cold room and freezer for temporary storage of anatomic waste. ............. 108 Figure A.3-10 Temporary storage for sharps containers, ................................................ 108 Figure A.3-11 Means of transporting infectious and non-infectious waste ..................... 109 Figure A.3-12 Municipal Landfill .................................................................................... 109 Figure A.3-13 Open pit burning ....................................................................................... 110 Figure A.3-14 Government Hospital incinerators ........................................................... 111 Figure A.3-15 Sharp boxes, and infectious waste ............................................................. 112 Figure A.3-16 Pit latrines at a Minor Health facility ......................................................... 112 vii LIST OF TEXT TABLES Table 2-1 Demographic and Socio-economic Statistics:................................................... 7 Table 2-2 Health Status Statistics Mortality:..................................................................... 7 Table 2-3 Health Care Providers (2006) ............................................................................ 9 Table 2-4 Distribution of HC Providers per population (2002) ........................................ 9 Table 2-5 Distribution of HCFs by Administration (2009) x .......................................... 10 Table 2-6 Distribution of HC Facilities per District (2009) ............................................. 10 Table 2-7 Legal requirements for collection, treatment and disposal of HCW ................ 14 Table 2-9 Excerpt of certification results relating directly to HCWM in hospitals. ...... 15 Table 2-10 Excerpt of certification results relating directly to HCWM in HCs. ........... 16 Table 5-1 Visited health Related Institutions .................................................................... 36 Table 5-2 Summary of issues found at institutions ........................................................... 38 Table 6-1 Topics of training and public awareness -Health Staff ..................................... 42 Table 6-2 Topics of training and public awareness guide (Non-Health Facility Staff) .... 44 Table 7-1 ICWMP ACTION PLAN - LEGAL ................................................................. 54 Table 7-2 ICWMP ACTION PLAN - INSTITUTIONAL ARRANGEMENTS .............. 55 Table 7-3 ICWMP ACTION PLAN - SITUATION ANALYSIS AND IMPROVEMENT ................................................................................................................................................. 57 Table 7-4 ICWMP ACTION PLAN - TRAINING AND GENERAL PUBLIC AWARENESS. ....................................................................................................................... 59 Table 7-5 ICWMP ACTION PLAN - PRIVATE SECTOR PARTICIPATION.............. 61 Table 7-6 ICWMP ACTION PLAN - FINANCIAL AND OPERATIONAL ISSUES .. 62 Table 7-7 Summary of costs.............................................................................................. 63 Table 8-1 Implementation costs of the ICWMP ............................................................... 64 Table 8-2 Annual costs of the ICWMP implementation ................................................... 65 Table 8-3 MHSW Contribution to the Implementation of the ICWMP ........................... 65 Table 8-4 Contribution From IDA Project ........................................................................ 66 Table 8-5 Contributions from Other Sources/Partners ...................................................... 66 Table 8-6 Project funding summary .................................................................................. 66 Table 9-1 MOH Estimated Annual Expenditure on ICWM ............................................. 68 Table 9-2 Implementation Responsibilities by Component .............................................. 70 Table 9-3 Implementation Timetable ................................................................................ 71 Table 9-4 Potential field of intervention ........................................................................... 72 Table 10-1 Categories, Labelling And Containers For Health Care Waste ...................... 75 Table 10-2 Treatment And Disposal Methods .................................................................. 77 Table 10-3 Summary on how to improve HCW handling ................................................ 79 Table 11-1 Comparative analysis of solid HCW treatment systems ................................... 84 Table 11-2 Comparative analysis of sharps treatment systems........................................... 88 Table 11-3 Comparative analysis of liquid waste treatment systems ................................. 89 Table 13-1 Implementation Plan for M&E ......................................................................... 91 viii ABBREVIATIONS AND ACRONYMS AIDS Acquired Immuno-Deficiency Syndrome CBO Community Based Organization DHMT District Health Management Team EHS Environmental Health Services EHD Environmental Health Department EONC Emergency Obstetric and Neonatal Care GAVI Global Alliance for Vaccine Initiatives GDP Gross Domestic Product HCF Health Care Facility. HCGW Health Care General Waste HCRW healthcare Risk Waste HCW Health Care Waste HCWM Health Care Waste Management HCWMP Health Care Waste Management Plan HDI Human Development Index. HepB Hepatitis B HepC Hepatitis C HIV Human Immunodeficiency Virus HSSP Health Sector Strategic Plan ICWM Infection Control and Waste Management ICWMP Infection Control and Waste Management Plan IMR Infant Mortality Rate. LG Local Government MDG Millennium Development Goals MTEC Ministry of Tourism, Environment MMR Maternal Mortality Rate. MoH Ministry of Health NEA National Environmental Agency NCDs Non-Communicable Diseases NGO Non-Governmental Organization POA Plan of Action STC Short Term Consultant SOPs Standard Operating Procedures STI Sexually Transmitted Infections WB World Bank WHO World Health Organization ix EXECUTIVE SUMMARY The Government of Lesotho has been working continuously on improving the health status of its people. Through the Ministry of Health's National TB Program is in the process of preparing for a regional TB Project with World Bank technical and financial support. The proposed project will result in more effective TB control programmes for Lesotho. A major off shot from the roll out of the improved TB control programme will be the generation of increased volumes of Health Care Waste (HCW). The proper management of all health care waste that will be generated is of prime importance, thus the development of the Health Care Waste Management Plan (HCWMP) for Lesotho. Health Care Waste (HCW) is waste generated during the course of the delivery of health care services. It is defined as the total waste stream from a healthcare facility (HCF) that includes sharps, non-sharps, blood, body parts, chemicals, pharmaceuticals, medical devices and radioactive materials. Most of it (75-90%) is similar to domestic waste. This fraction referred to as healthcare general waste (HCGW) is made of paper, plastic packaging, food preparation, etc. that haven't been in contact with patients. A smaller proportion (10-25%) is infectious/hazardous waste that requires special treatment. This fraction referred to as healthcare risk waste (HCRW) is the one which is of concern at Health Care Facilities (HCF) due to the risks that it poses both to human health and the environment. Poor management of this HCRW exposes healthcare workers, waste handlers and the community to infections, toxic effects and injuries. Exposure to HCRW can result in diseases or injury. To combat the HCW menace, the Lesotho Government developed a number of instruments to support its efforts. One of the major initial initiatives was the adoption of the Primary Health Care strategy for service provision in 1979. It then developed the National Health Policy (2012 – 2020), and then developed a Health Sector Strategic Plan (HSSP) with various facets for addressing the country’s health sector challenges of which HCWM is a part. The policy acknowledged that the health sector is under great pressure due to a number of factors: high population growth rate, increasing morbidity and mortality, insufficient financial and logistic support, deterioration of physical infrastructure, inadequacies of supplies and equipment, shortage of adequately and appropriately trained health personnel, high attrition rate as well as inadequate referral system (GoL, 2012). This pressure is resulting in high prevalence of communicable and non-communicable diseases. However, the Policy points out that most of these diseases can easily be prevented if appropriate environmental and lifestyle measures are taken, with more attention paid to development of health promotion and prevention actions than merely focusing on curative care alone. To buttress the HSSP GoL developed instruments like the National HCWM plan of 2005. This was followed by (i) the Situational Analysis (COWI) (2009); (ii) HCWM Policy (July 2010); (iii) HCWM Strategic Plan; (iv) HCWM Implementation Plan; (v) HCWM Monitoring Plan and (vi) HCWM Support Document. In August 2012, the Consolidated Lesotho National Health Care Waste Management Plan (CLNHCWMP) was developed as part of the World Bank funded Maternal and Newborn health Performance-Based Financing Project. It was a result of a synthesis of the various documents ((i) to (v) above) that had been developed as part of the updated HCWM and basically updated the National HCWM plan of 2005. The Plan provided a detailed consolidated overview of the management of healthcare waste in Lesotho. x The advent of the Tuberculosis and Health Systems Support Project has necessitated the review current instruments and the development of the Infection Control and Waste Management Plan (ICWMP) for Lesotho. The current plan brings in the holistic approach to HCWM to embrace the legal and institutional aspects and to involve all the appropriate stakeholders in the sector. The current report elaborates the current status of HCWM in Lesotho, assesses the gaps in technology and information and explores options for solutions. The resultant Infection Control and Waste Management Plan (ICWMP) sets out the requisite playing field for an effective HCWM programme, starting with a clear legal and institutional framework, appropriate technology, empowered workforce and an enlightened public. The ICWMP was developed as a result of an assessment of Health Care Waste Management (HCWM) in a sample of the Health Care Facilities of Lesotho. The Health care services are provided by three main institutions: (i) Ministry of Health (MoH) Hospitals; (ii) Private for profit Hospitals, (iii) Private non-profit Hospitals. The Health Care Facilities were divided into several categories; 1. Referral Hospitals 2. Large Hospitals 3. Health Centres 4. Private For Profit 5. Private Non-Profit (NGO) 6. MDR TB clinic (Multiple Drug resistant TB) And the other institutions which are related to them and generate similar waste are: 1. Veterinary Hospitals 2. Pharmaceuticals 3. Blood Transfusion Services 4. Local Authorities 5. Analytical Services Providers (Laboratories) The formal system of Lesotho health facilities are divided into the national (tertiary), district (secondary), and community (primary) levels. The community level includes both health posts and health centers. The district level comprises hospitals that receive patients referred from the community level and filter clinics. The national level consists of one referral and two specialized hospitals. Any patients with conditions that cannot be addressed at the national level are referred to South Africa for care, through the national referral hospital. In Lesotho, 42 percent of the health centers and 58 percent of the hospitals are government owned, 38 percent of the hospitals and 38 percent of the health centers fall under the control of the Christian Health Association of Lesotho (CHAL), and the remaining facilities are either privately owned or operated by the Lesotho Red Cross. In addition to the hospitals, filter clinics, health centers, and health posts recognized within the Government of Lesotho (GOL) system of health facilities, there is also an extensive network of private surgeries, nurse clinics and pharmacies providing care and/or medicines. In order to come up with a holistic HCWM Plan, the situation at all the health care facility categories, including the associated institutions was assessed and the desired level of operations determined. This was done by selecting a sample for each category of facility and then carrying out a rapid assessment xi of the sampled institutions using the Rapid Assessment Tool that was developed by WHO. The rapid field assessment observed the following constraints on the HCWM system: • Non formalization of HCWM in the institutions • Absence of specific operational policy about HCW; • Weak HCWM legislative regime • Absence of standard HCWM operational procedures • Inadequate budgetary resource allocations; • Limited qualified human resources; • Technological challenges in handling, treatment and disposal facilities. • Subdued and insufficient knowledge about HCW (staff and public). • Absence of private sector participation In terms of HCWM the Ministry of Health is assisted by Lesotho Millennium Development Authority (LMDA) for collection and treatment of HCW in its facilities. LMDA has sub-contracted other companies for this function. The contracted companies are expected to supplier the health facility with waste management equipment (container, liners). It collects HCW from the Health facilities for treatment at the incinerator at the hospitals. It is also mandated to maintain day to day running of the incinerator. They are again expected to collected and transport general waste from the hospital for disposal at a designated disposal site. To address these short comings, an ICWMP was then crafted. It was crafted in such a way as to initiate a process and support the national response to the shortcomings. It focuses on preventive measures, mainly the initiatives to be taken in order to reduce the health and environmental risks associated with mismanaged waste. It also focuses on the positive pro-active actions, which, in the long term, will allow a change of behaviour, sustainable ICWM, and protection of actors against risks of infection. The ICWMP is organized around the following objectives: 1. To reinforce the national legal framework for ICWM. 2. To improve the institutional framework for ICWM. 3. To assess the ICWM situation, propose options for health care facilities and improve the ICWM in health care facilities. 4. To conduct awareness campaigns for the communities and provide training for all actors involved in ICWM. 5. To support private initiatives and partnership in ICWM 6. To develop and operationalize specific financial resources to cover the costs of the management of healthcare wastes. These actions should be accompanied by complementary measures, mainly initiated by governmental programs, in terms of ICWM upgrading in health facilities. The estimated cost of implementing the ICWMP and enhancing this process of proper handling, disposal and management of medical waste is US $ 1 609 000.00. The estimated costs of implementation for the ICWMP will be covered by the MOH, the IDA project and other development partners. The IDA project will cover the cost of training and general public awareness ($300 000.00), Thus MoH will require external support from other developing partners to be able to implement the ICWMP effectively. xii The cornerstone of the management of waste is that it must be consistent from the point of generation “cradle� to the point of final disposal “grave�, following a defined waste stream which is standard and acceptable. The relative risk approach was used in determining the treatment systems and technologies to be used at each HCF. The criteria for deciding on the system are that it protects in the best way possible, healthcare workers and the community as well as minimize adverse impacts on the environment. The use of a burial pit or a small-scale incinerator, although clearly not the best solution, is much better than uncontrolled dumping. The following recommendations were drawn: • Modern pyrolitic incinerators at Referral hospitals, District hospitals, other Hospitals, and the Local Authorities, because of its fairly low cost and operating skills requirements; • Local incinerators (built with local material) in Health Centres, Private Health Centres and other Public Health Units because of its very low cost and small quantities of HCW produced in these facilities; • Stabilized concrete lined pits in Health Centres, other Public Health Units and for home based care, because of very low HCW production. The handling of the final incineration residues is also very important and it was recommended that in big cities this can be disposed of at the public municipal landfills and at District and local level, the remaining wastes can be buried within the premises or in lined pits, away from patient treatment areas. The implementation schedule of the ICWMP is over a five year period and the lead agent, the Environmental Health Department of the MoH will coordinate the implementation and apply a multi- stakeholder approach to embrace all the relevant players that include the Ministry of Environment (MTEC), Local Authorities, the Veterinary Department, NGOs, and other private players. Above all, the ICWMP emphasizes on monitoring and evaluation of the system. The monitoring of ICWM is part of the overall quality management system. To measure the efficiency of the ICWMP, as far as the reduction of infections is concerned; activities should be monitored and evaluated, in collaboration with concerned institutions: MoH, MTEC, Local Authorities, NGOs, etc. This can only be possible if it becomes mandatory to keep records of ICWM at all institutions and then maintain a reporting system of the same. xiii 1. INTRODUCTION 1.1 BACKGROUND Healthcare waste (HCW) is defined as the total waste stream from a healthcare facility (HCF) that includes sharps, non-sharps, blood, body parts, chemicals, pharmaceuticals, medical devices and radioactive materials. Most of it (75-90%) is similar to domestic waste. This fraction referred to as healthcare general waste (HCGW) is made of paper, plastic packaging, food preparation, etc. that haven't been in contact with patients. A smaller proportion (10-25%) is infectious/hazardous waste that requires special treatment. This fraction referred to as healthcare risk waste (HCRW) is the one which is of concern at Health Care Facilities (HCF) due to the risks that it poses both to human health and the environment. Poor management of this HCRW exposes healthcare workers, waste handlers and the community to infections, toxic effects and injuries. Exposure to HCRW can result in diseases or injury. Further, if these two basic categories of waste aren't segregated (separated) properly, the entire volume of HCW must be considered as being infectious according to the precautionary principle, hence the importance of setting up a safe and integrated waste management system. In 2005, the Government of Lesotho (GoL) prepared a National Health Care Waste Management Plan (NHCWMP) as part of the World Bank Health Sector Reform Project to increase access to, and quality delivery of, essential health services in Lesotho. This update takes into consideration the review (see below the paragraph on the situational analysis) carried out between December 2009 and March 2010 by Between December 2009 and March 2010, the Ministry of Health (MoH), with technical input provided by the Millennium Challenge Account - Lesotho (MCA-L) carried out a review (Situational Analysis) of the 2005 NHCWMP. The review was done through the appointed consulting firm, COWI A/S. To buttress the NHCWMP the MoH subsequently developed the Health Care Waste Management Policy in July 2010; Health Care Waste Management Strategic Plan in August 2010 and the Health Care waste Management Implementation Plan in November 2010. In August 2012, with the advent of the Lesotho Maternal and Newborn health Performance- Based Financing Project, MoH undertook an exercise to consolidate the various HCWM instruments and policies to come up with one Health care management plan. The consolidated HCWM Plan intended to synthesize the various documents that were developed as part of the updated HCWM, including: (i) the Situational Analysis; (ii) HCWM Policy; (iii) HCWM Strategic Plan; (iv) HCWM Implementation Plan; (v) HCWM Monitoring Plan and (vi) HCWM Support Document. The document provided a detailed consolidated overview of the management of healthcare waste in Lesotho, and was geared to be used as the safeguards instrument accompanying the Lesotho Maternal and Newborn health Performance-Based Financing Project. The generation of increased healthcare waste as a result of project-financed activities mandated the need for such a consolidated HCWM plan to accompany the project. The consolidated HCWM plan was not applied to the project alone but became a national document. However the implementation of the plan was faced with immense challenges as the 1 health sector is under great pressure due to a number of factors: high population growth rate, increasing morbidity and mortality, insufficient financial and logistic support, deterioration of physical infrastructure, inadequacies of supplies and equipment, shortage of adequately and appropriately trained health personnel, high attrition rate as well as inadequate referral system. This pressure is resulting in high prevalence of communicable and non-communicable diseases such as Malaria, Diarrhoea, Upper Respiration Tract Infection, Tuberculosis, and HIV/AIDS and its spread. However, the HCWMP points out that most of these diseases can easily be prevented if appropriate environmental and lifestyle measures are taken, with more attention paid to development of health promotion and prevention actions than merely focusing on curative care alone. The Government is cognisant of the effects of the environment on the socioeconomic growth and development including health. Environmental health and safety is an important determinant of health outcomes and still remains a major challenge for the Ministry of Health and partners. Hence one of MoH’s policy drives is to reduce the frequency of environmental health and safety related diseases/conditions. This will be achieved through enforcement of environmental health related Acts, and Instituting proper management of solid, gaseous and liquid wastes. As part of this main component, the proper management of all health care waste is of prime importance, thus the development of the Health Care Waste Management Plan (HCWMP) for Lesotho. The current plan then brings in the holistic approach to HCWM to embrace the legal and institutional aspects and to involve all the appropriate stakeholders in the sector. Such a plan is necessary in order to prevent and mitigate the environmental and health impacts of Health Care Waste on Health Care Staff and the general public. The objective of this report is to elaborate an Infection Control and Management Plan (ICWMP) appropriately assessed, with clear institutional arrangements for proper implementation. The plan of action was developed as a result of an assessment of Health Care Waste Management (HCWM) in a sample of the Health Facilities in Lesotho. The Health Care Facilities can be divided into several categories; 1. Referral Hospitals 2. Hospitals 3. Reproductive and Child Health (RCH) Clinics 4. Minor Health Centres 5. Major Health Centres 6. Private For Profit 7. Private Non-Profit 8. Primary Health Care (PHC) - Key Villages 9. Primary Health Care (PHC) - Villages And the other institutions which are related to them and generate similar waste are: 1. Veterinary Hospitals 2. Pharmaceuticals 3. Blood Transfusion Services 4. Local Authorities 2 5. Analytical Services Providers (Laboratories) 6. Medical Research Council 7. Regional Health Teams In order to come up with a holistic HCWM plan, the situation at all the health care facility categories, including the associated institutions was assessed and the desired level of operations determined. The following is an outline of the situation and the final plan of action that was derived from the exercise. 1.2 PROJECT DESIGN CONSIDERATIONS The broad design considerations for the project includes three mutually reinforcing components which will assist Lesotho on its part, to mount an effective response to the burden of TB, with emphasis on TB in the mining sector. The project will apply the following approaches: (i) Using a phased project implementation approach to enable the roll-out of the interventions gradually before going to full scale; (ii) Targeting the poor and vulnerable with evidence-based interventions via innovative service delivery strategies. The project will provide targeted interventions to underserved populations with a high burden of TB, using innovative delivery strategies. (iii)Strengthening TB and occupational health services as well as broader health systems. These include strengthening laboratory systems, skilled human resources and disease surveillance capacity, whose benefits cut-across health systems. Implementation and coordination arrangements would be as simple as possible; performance-based with clear responsibilities and accountability; and strategies to encourage innovations and scaling up of successful interventions would be incorporated. 1.3 PROJECT STRUCTURE The International Development Association (IDA) is financing the Southern Africa Tuberculosis and Health Systems Support Project (P155658). The project will be effected in four countries; Lesotho, Malawi, Mozambique, and Zambia. Lesotho will be supported by an amount of US$15 million equivalent. The project objectives will be achieved through the implementation of two technical components and one component dedicated to management, coordination and monitoring. It should be noted that the first two technical components raise the principal safeguards issues associated with the project. The three components of the project are outlined below: 1.3.1 COMPONENT 1: INNOVATIVE PREVENTION, DETECTION AND TREATMENT OF TB SERVICES The proposed activities will be derived from the National TB and Leprosy Programme strategic plan, with a vision of making the Kingdom of Lesotho free of TB through the provision of quality TB prevention, diagnosis, treatment and care services with due attention to universal access, equity, affordability and gender mainstreaming. The overall goal is to reduce TB prevalence and mortality rates 3 by 25% and 50% respectively relative to the 2012 rates. This component has the following sub- components: Subcomponent 1.1: Harmonized Package of TB services 1.1.1 Points of Care/One Stop Shop services 1.1.2 Patient Referral System 1.1.3 TB control in correctional services 1.1.4 Decentralization of occupational health services 1.1.5 Provision of Nutritional support 1.3.2 COMPONENT 2: STRENGTHEN REGIONAL CAPACITY FOR DISEASE SURVEILLANCE, DIAGNOSTICS AND MANAGEMENT OF TB AND OCCUPATIONAL LUNG DISEASES This component will cover retaining experts and skills in Lesotho by improving the health care infrastructure and equipment and their general working conditions. It has the following sub- components: Subcomponent 2.1: Human Resources for Health 2.1.1 Retain specialized expertise and skills to support Ministry of Health 2.1.2 Capacity building for surveillance and other public health events through short and long term training, mentoring, training institution capacitation 2.1.3 Capacity building on mine health and safety Subcomponent 2.2: Disease Surveillance 2.2.1 Support the TB prevalence survey 2.2.2 Purchase ICT and software programmes for use to strengthen cross border disease surveillance Subcomponent 2.3: Strengthen Diagnostic Capacity 2.3.1 Strengthen laboratory information systems and networking 2.3.2 Procure diagnostic technology for TB and TB/HIV 2.3.3 Upgrade Laboratories (physical) 2.3.4 Laboratory supplies 2.3.5 Biomedical waste management Subcomponent 2.4: Strengthen Regulatory Capacity 2.4.1 Mapping of the local mining landscape using geomapping tools 2.4.2 Develop guidelines for mine health inspection, occupational health and compensation systems 2.4.3 Procurement of dust monitoring equipment 4 1.3.3 COMPONENT 3: STRENGTHEN LEARNING, KNOWLEDGE AND INNOVATION This component would establish effective programme management and administrative systems, ensuring coordination between the programme and other initiatives and national institutions in the sector. The proposed structure would include the following sub-components: Subcomponent 3.1: Project Management and implementation, monitoring and evaluation 3.1.1 Staff salaries for running the project implementation unit - PIU (project coordinator, financial management specialist, procurement specialist and M&E specialist) 3.1.2 Support for operations of the PIU 3.1.3 Training on financial management, procurement and risk based auditing 3.1.4 Attendance at regional meetings 3.1.5 Support the M&E systems (project M&E and NTP M&E?) 3.1.6 Annual level joint review – National 3.1.7 National steering committee – training and meetings Subcomponent 3.2: Support evidence based policy analysis and health financing innovations 3.2.1 Operations research 3.2.2 Monitoring and evaluation 3.2.3 Policy Analysis and Advocacy (Chiefs, research organizations, CSOs, NGOs, FBOs, traditional healers, private sector, social partners) Subcomponent 3.3: Innovation – Centres of Excellence 3.3.1 Operation Screening of all members of households for TB 5 2. BASELINE DATA 2.1 INTRODUCTION Lesotho is endowed with diverse natural resources, which include some of the most fertile soils, forest and water resources which accommodate diverse species of flora, fauna and fish resources. However these resources are currently challenged by complex interaction of several factors which include the rapid rate of population growth of about 21% per annum, the slow economic growth, and the TB - HIV/AIDS disease burden amongst many other pressures. The current and estimated TB - HIV/AIDS burden have had and will continue to have devastating effects on life expectancy and productivity. This is imposing ever intensive pressures on the economy, natural resources utilisation, leading to unsustainable natural resources utilisation, loss of biodiversity, heavy soil erosion and water pollution. Furthermore, the country’s health system is challenged by this relentless increase of the disease burden, and a lack of expertise and human resources. Lesotho has the third highest prevalence rate of HIV/AIDS in the world, which according to recent estimates, is about 27%. It also has high TB incidence of approximately 960 cases per 100,000 people, a 74% HIV/TB rate of co-infection and significant numbers of MDR-TB cases. The disease burden has reduced the average life expectancy to 40 years for men and 44 years for women mainly because it is burdened by HIV and AIDS. (UNAIDS 2006 Report on the Global AIDS Epidemic,) The national TB program faces several challenges, including: a reduction in case notifications, while MDR-TB and other resistant strains are on the increase; and limited access to services in terms of operating clinic hours and distance to health centers. Efforts to combat the epidemic have been stemmed by the nation’s lack of infrastructure needed to fully deal with such a disease burden. Further, Lesotho is struggling to retain its medical staff as many physicians and nurses are drawn away to Britain, Canada, and South Africa by better pay and infrastructure. The following paragraphs review some of the key country’s background information on environmental and social issues as regards the Health delivery system. 2.2 GENERAL LESOTHO GEO-PHYSICAL CONDITIONS The following is an outline of the general geo-physical conditions of the project area: 2.2.1 Location, Size, and Extent Lesotho is a land locked state in Southern Africa which is completely surrounded by the Republic of South Africa. It is situated approximately between 28° S and 31°S latitudes and longitude 27° E and 30° E. Lesotho is a predominantly mountainous country, with an average altitude of more than 1600 metres above sea level. It covers approximately 30 350 square kilometres and has limited natural resource endowments (GoL, 2006). Lesotho’s highlands constitute two-thirds of territory; less than 10% of which is suitable for cultivation. Lesotho has a population of 2.2 million growing at an average rate of 21% per annum, mainly with a literate but largely unskilled labour force. Some 70% of the total population lives in the fertile lowlands, where the land can be most readily cultivated; the rest is scattered in the foothills and the mountains. It was estimated by the Population Reference Bureau that 28% of the population lived in urban areas in 2001. 6 The capital city, Maseru, had a population of 373,000 in that year. Other large towns are Leribe, Berea, and Mafeteng. The urban population growth rate for 2000– 2005 was 4.6% (EoN, 2015a). More recently, the World Health Organization Statistics 2006 have recorded the following statistics relevant to this report as follows: Table 2-1 Demographic and Socio-economic Statistics: Population - 2005 1 795 million Annual growth rate 1995 - 2004 0.6% Population in urban areas - 2005 18% Adult literacy rate 2000-2004 81.4% Net primary school enrolment ratio males 1998 – 2004 83% Net primary school enrolment ratio females 1998 - 2004 89% The prevalence of HIV/AIDS has had a significant impact on the population of Lesotho. The United Nations estimated that 30.1% of adults between the ages of 15 to 49 were living with HIV/AIDS in 2001. The AIDS epidemic increases death and infant mortality rates, and lowers life expectancy (EoN, 2015a). In Lesotho in 2001, the United Nations recorded 25% of people between the ages of 15 and 49 were infected with HIV/AIDS and this rate has increased each year. Lesotho's major health problems, such as pellagra and kwashiorkor, stem from poor nutrition and inadequate hygiene. As of 2000, 44% of children under five years of age were considered malnourished. Famines have resulted from periodic droughts. In 2000, 91% of the population had access to safe drinking water and 92% had adequate sanitation. Tuberculosis and venereal diseases are also serious problems. In 1994, children up to one year old were vaccinated at the following rates: tuberculosis, 55%; diphtheria, pertussis, and tetanus, 58%; polio, 66%; and measles, 82%. There were an estimated 542 cases of tuberculosis per 100,000 people in 1999 while the rates for DPT and measles were 85% and 77% respectively. About 43% of children suffered from goiter in 1996 (EoN 2015b). The World Health Organization Statistics of 2006 recorded the following health status statistics mortality: Table 2-2 Health Status Statistics Mortality: Indicator Life expectancy Females 2004 44 years Life expectancy Males 2004 39 years Probability of dying per 1 000 live births under 5 years 2004 82 Infant mortality rate (per 1 000 live births) 2004 55 Maternal mortality (per 100 000 live births) 2000 550 7 2.3 BASELINE DATA AND BACKGROUND OF HEALTH CHALLENGES The government of Lesotho is working to rehabilitate some hospitals and is making an overall effort to strengthen health care services. However it is facing an acute human resource for health (HRH) crisis. A third of MoH labour force consists of support staff. Nurses constitute 73.3% of the workforce in MoH followed by physicians at 6% with other health cadres constituting a low percentage of the workforce. While there is a general shortage of staff, it should be emphasized that Lesotho generally experiences an acute shortage of specialized health cadres. (Lesotho National Health Strategic Plan) Laboratory services in the health sector remain understaffed and laboratory personnel who are specialized are very few in the system. As a result of this shortage, at health centers level health center staff collect specimen for processing at the district hospital. In addition to lack of personnel, there are interrupted supplies of commodities and some gaps are being filled by development partners who purchase laboratory reagents among other things. (Lesotho National Health Strategic Plan). 2.4 THE STRUCTURE OF THE HEALTH CARE SYSTEM The formal system of Lesotho health facilities are divided into the national (tertiary), district (secondary), and community (primary) levels. The community level includes both health posts and health centers. The district level comprises hospitals that receive patients referred from the community level and filter clinics. The national level consists of one referral and two specialized hospitals. Any patients with conditions that cannot be addressed at the national level are referred to South Africa for care, through the national referral hospital. In Lesotho, 42 percent of the health centers and 58 percent of the hospitals are government owned, 38 percent of the hospitals and 38 percent of the health centers fall under the control of the Christian Health Association of Lesotho (CHAL), and the remaining facilities are either privately owned or operated by the Lesotho Red Cross. In addition to the hospitals, filter clinics, health centers, and health posts recognized within the Government of Lesotho (GOL) system of health facilities, there is also an extensive network of private surgeries, nurse clinics and pharmacies providing care and/or medicines. In terms of HCWM the Ministry of Health is assisted by Lesotho Millennium Development Authority (LMDA) for collection and treatment of HCW in its facilities. LMDA has sub-contracted other companies for this function. The contracted companies are expected to supplier the health facility with waste management equipment (container, liners). It collects HCW from the Health facilities for treatment at the incinerator at the hospitals. It is also mandated to maintain day to day running of the incinerator. They are again expected to collected and transport general waste from the hospital for disposal at a designated disposal site. National level: At the national level, Lesotho has three tertiary-level hospitals: Queen Momahato Hospital, Mohlomi Mental Hospital, and Bots`abelo Leprosy Hospital. Queen Momahato Hospital is the national referral hospital. It is a large tertiary public-private partnership hospital. Any cases that cannot be treated at Queen Momahato are referred to South Africa. It is linked to a network of filter clinics. District level: Districts have filter clinics and district hospitals. Filter clinics are a first point of care intended to lighten the load of district hospitals and function as “mini-hospitals,� offering curative and preventive services and limited inpatient care. Unlike health centers, filter clinics are staffed by doctors and some have pharmacy technicians. They also offer selected laboratory and radiology services (administered through the hospitals). 8 Although district hospitals provide both inpatient and outpatient care, their services vary widely depending on the availability of financial resources, equipment, and human resources. Treatment and diagnostic services are more complex at this level. These facilities provide minor and major operative services, ophthalmic care, counseling and care of rape victims, radiology, dental services, mental health services, and blood transfusions as well as preventive care. Some specialized care is also available for TB, HIV, and non-communicable diseases. Community level: Communities offer health posts and health centers. Health centers are the first point of care within the formal health system. Staffed by nurse clinicians with comprehensive skills in preventive and curative care and in the dispensing of medication, health centers offer curative and preventative services, including immunizations, family planning, and postnatal and antenatal care on an outpatient basis (with the exception of services to expectant mothers). Their mandate also extends to supervising the community public health efforts and training volunteer community health workers (CHWs). Health posts provide community outreach services and are typically managed by volunteers. Generally, health posts are opened at regular intervals (not daily) and provide promotive, preventive, and rehabilitative care in addition to organizing health education gatherings and immunization efforts. Volunteer CHWs include traditional birth attendants and community-based condom distributors, among others. 2.5 HEALTH CARE DELIVERY SYSTEM Tuberculosis is straining the health-care system to maximum capacity. The government is sponsoring aggressive prevention, control, and screening programs for both tuberculosis and venereal diseases. In 2000, the World Bank issued a US$6.5 million credit to improve access to quality preventive, curative, and rehabilitative health care services (GoL 2005 and GoL 2012). The number of health service providers in Lesotho is low as illustrated by the statistics in Table 2-3. Table 2-3 Health Care Providers (2006) Health Care Provider Number Physicians 89 Nursing and midwifery personnel 1,123 Dentists and technicians 16 Pharmacists and technicians 62 Other health workers 23 Public and Environmental Health Workers 55 Lab Technicians 146 Health Management and Support workers 18 Source: WHO Country Health System Fact Sheet 2006 Lesotho The statistics on the number of nursing and midwifery personnel per 1000 people shows that the human resources available to provide a health care service to the population is very limited as is shown in Table 2-4. Table 2-4 Distribution of HC Providers per population (2002) Distribution per 1,000 population Number Physicians 0.05 Nursing and midwifery personnel 0.6 9 Distribution per 1,000 population Number Dentists and technicians <0.04 Pharmacists and technicians <0.04 Other health workers <0.04 Public and Environmental Health Workers <0.04 Lab Technicians 0.08 Health Management and support workers <0.04 Source: WHO Country Health System Fact Sheet 2006 Lesotho The health system in Lesotho consists of 21 Hospitals and 192 Health Centres (clinics) administered by different bodies. The Christian Health Organisation of Lesotho (CHAL) has, through a memorandum of understanding with the GOL, reached an agreement to remove fees at clinic level and apply uniform tariffs in CHAL hospitals. The GOL in return pays CHAL salaries and compensates CHAL for basic health care services provided. A similar agreement was entered into in November 2009, with the Lesotho Red Cross Society (LRCS). Table 2-5 Distribution of HCFs by Administration (2009) x Health Administered by Hospitals Centres Government of Lesotho (GOL) 12 79 Christian Health Association of Lesotho (CHAL) 8 75 Lesotho Red Cross Society (LRCS) 0 4 Maseru City Council (Maseru CC) 0 2 Private 1 33 Total 21 192 The HCFs are distributed throughout Lesotho, with GOL owning 45%, CHAL 37% LRCS 3%, with 17% being privately owned. Table 2-6 shows a summary of the distribution of hospitals, health centres and filter clinics per district. Table 2-6 Distribution of HC Facilities per District (2009) Distribution of Health Facilities in Lesotho Health Filter District Hospital Centre Clinics % of Total Maseru 7 48 1 26 Berea 2 21 1 11 Leribe 2 26 1 13 Botha Bothe 2 12 0 6 Mokhotlong 1 12 0 6 Thaba-Tseka 2 17 0 9 Qacha’s Nek 2 11 0 6 Quthing 1 9 0 5 Mohale’s Hoek 1 15 0 7 Mafeteng 1 21 0 10 Total 21 192 3 10 2.6 THE HEALTH SECTOR REFORM PROCESS The Government of Lesotho has been working continuously on improving the health status of its people. One of the major initial initiatives was the adoption of the Primary Health Care strategy for service provision in 1979. However many of its initiatives haven’t been very effective as mentioned in the Health and Social Welfare Policy (2003) which stated that during the 15 years preceding 2003, the initial improvements seen in health indicators had shown a decline due to the TB – HIV/AIDS burden, general economic decline and unhealthy lifestyles. For this reason the MoH embarked on a restructuring of the health system under the Lesotho Health Reforms Plan 2000. The Health sector reform was also a response to the rapid increase in demand for health services coupled with dwindling resources for the sector. The intended outcome of the process was to improve management systems in the sector so that the scarce resources would be used more efficiently. The reform process, which was a ten year phased programme, was implemented in 2002 following wide consultations with all stakeholders of the sector. The key partners supporting the programme were Lesotho Government, Development Corporation of Ireland, European Union, World Health Organisation, African Development Bank and the World Bank Phase One (2002 – 2005) focused on institutional capacity building; Phase Two (2005 – 2009) on policy and institutional reform; Phase Three (2010 ---) involved sector-wide implementation of guidelines and protocols developed in the first two phases. The reform programme entailed a rearrangement of structures and definition of policies so that the service delivery system becomes more responsive to the needs identified at the community level. It set out to achieve a sustainable increase in access to quality preventive, curative, and rehabilitative health care services. Specifically, the program targeted a huge imbalance between over-crowded government health centers and the non-governmental health centers, the high cost of medical care, long distances to medical facilities in mountain areas, and the insufficient numbers of health personnel, especially in rural areas. The project not only assembled and deployed outreach-based District Management Health Teams to deliver community health services, but it was highly instrumental in the launch of the first-ever Public- Private Partnership (PPP) among International Development Association (IDA) African countries for replacing the national hospital. Under the PPP, the government of Lesotho selected Netcare, one of Africa’s largest health care providers through a bidding process to design, construct, and operate a new national hospital for 18 years. The government’s payments to Netcare will be performance -based. This PPP is expected to improve both access and quality of clinical services in the country. The Health Sector Reform Program has successfully helped the country improve essential health care services for the poor through improved antenatal care, reduced hospital waiting time, a higher tuberculosis cure rate, and expanded access to services preventing mother-to-child transmission of HIV/AIDS Health Care Waste Management is a cross-cutting issue and spans several components of the plan, one of the more important components for HCWM being the District Health Package where environmental health (which incorporates HCWM) is included as part of the Essential Health Service package. 2.7 WASTE MANAGEMENT IN LESOTHO 11 2.7.1 Categorisation of HCW in Lesotho Health Care Waste (HCW) is usually divided into the two main categories: Health Care General Waste (HCGW) and Health Care Risk Waste (HCRW). HCGW consists of the general household (domestic) waste and much of this waste can be recycled. HCRW is the more hazardous part of the waste generated from health care facilities and comprises: infectious waste; sharps; anatomical; pharmaceutical; chemical; and radioactive waste (GoL 2005 and GoL 2012). The need for correct segregation is determined by the different treatment methodologies required for the safe and environmentally friendly treatment and disposal of the different waste streams. In Lesotho, the Hazardous (Health care) Waste Management Regulations of 2012 defines HCRW as waste that is hazardous or which is capable of producing disease, injury or pollution and includes the following: (a) infectious waste; (b) pathological waste; (c) sharps waste; (d) pharmaceutical waste; and (e) genotoxic waste; In Health Care Facilities in Lesotho, the following categories of waste are observed: i. Healthcare general waste: This comprises of the normal ‘household’ waste and is mainly waste coming out of a healthcare facility that has not come into contact with patients, such as plastic bags, boxes, paper, food waste etc. A large portion of this waste can be recycled. ii. Infectious waste: All waste that is likely to contain pathogens (in sufficient concentration to cause diseases to a potential host). These include blood bags, urine, body secretions, etc. iii. Pathological (anatomical) waste is waste that comprises of body parts and blood and includes placentas iv. Pharmaceutical waste: These include expired medication, unused pharmaceutical products, drugs, vaccines, etc. v. Chemical waste: These consist of chemicals that are generated during disinfecting procedures or cleaning processes. vi. Sharps: These consist of all items that can cause cuts for puncture wounds, such as needles, syringes, scalpel blades and slides; vii. Highly infectious waste: This group consists of waste from laboratories, in microbial cultures, and stocks with viable biological agents, etc. viii. Radioactive waste: Includes liquids, gases and solids that spontaneously emit radiation. 2.7.2 Overview of the present HCWM System in Lesotho As part of the World Bank Health Sector Reform Project to increase access to, and quality delivery of, essential health services in Lesotho, an environmental assessment in the form of the National Health Care Waste Management Plan (NHCWMP) (March 2005) was prepared. This NHCWMP evaluated impacts which included: solid waste management; waste water disposal; health care waste generation at hospitals and health centres; determination of disposal sites; communities’ response. As a result of these impacts the report outlined the mitigation measures that included: the development of a Healthcare Waste Management plan that would stop the theft of plastic bucket type medical bins; maintain hospital grounds in a manner deserving of a health care institution; the introduction of a three-bin system with appropriate colour coding for medical staff to separate all hospital waste accordingly; that all infectious waste 12 including sharps and used needles must be incinerated before disposal; employ a system of Medical Wastewater Management that ensures that no chemicals and pathogens from health facilities are dumped into the sewage system; and finally develop and implement a training and awareness education plan for health facilities and relevant institutions’ personnel (GoL 2005 and GoL 2012). This plan recommended that the three-bin system be implemented for the management of HCW using black and yellow waste bags located in separate places away from patient areas. Subsequently a decision was taken by the NHCWM Committee that red would be the colour for the HC infectious waste and black for the HC general waste. A consignment of yellow liners donated by World Bank in 2009 has now created some confusion (in areas where the consignment has not been depleted) as to the recognized colour scheme for the Lesotho HCWM System. The examples of “Potentially Infectious Waste� given in this NHCWMP included all “waste materials contaminated or possibly contaminated with body fluids� and included the pre-treated highly infectious waste from the medical laboratory, isolation patients, human tissue and body parts (GoL 2005 and GoL 2012) The 3-bin concept was therefore introduced to cater for the general Infectious waste (for example, intravenous lines/bags, gloves, dressings, gauze, swabs, urine and blood bags, sump tubes, sanitary napkins) as well as placentas, body parts, isolation waste and pre-treated highly infectious laboratory waste. No differentiation is made between the laboratory waste, isolation waste and pathological / anatomical waste. Sharps are placed into sharps containers and HCGW into black liners. Elements of the existing HCWM System described in the NHCWM Plan include (GoL 2005 and GoL 2012): • The 3-bin system introduced into all the HCFs and placed at all generation points comprises of the following: o one container with a red liner for the infectious waste, o one yellow container or “sharps container� for the sharps and o one container with a black liner for the general waste. • The black and red/yellow liners should be sealed prior to transportation to a temporary storage area. • All the HCW should be collected in rigid two-wheeled containers (120 to 240 litres) with a lid. • These wheeled containers are to be used for transportation of waste directly to the treatment area for the infectious waste and to the temporary central storage area for the general waste. • Infectious waste should be sent for treatment every 24 hours or at least every 48 hours in the case of unforeseen delays. • Every HCF should have ‘storage’ at least in the form of 4-wheeled 1.1m3 “euro bins� or skips with lids that can easily be carried by a truck or tractor to the final disposal site. • Central storage areas should not store infectious waste or sharps; only the ash and general waste must be collected there and emptied at least once a week. • All waste handlers at all levels, cleaners, porters, gardeners and incinerator operators must wear appropriate protective clothing • Designated personnel in each unit must be made responsible for monitoring the HCWM System and ensuring that all bags are sealed when full or before removal. They must also supervise the removal to the temporary storage or treatment areas. NOTE: The suitability of “small bins� was raised as an issue because of the increasing misuse by the public (and possibly, staff) where even the plastic sharps containers are emptied and used in homes for 13 various domestic purposes including fetching water (GoL 2009 b). All Healthcare facilities must have access to a functional waste treatment facility e.g. an incinerator and the ash disposed of appropriately together with the HCGW. The HCWM Plan further describes the requirements for collection, treatment and disposal of the HCW from the HCFs under the headings of Urban, Peri-urban and Rural Areas. Lesotho has also specified minimum requirements for the management of HCRW starting from the generation point to the final disposal. The regulations are to be applied throughout the country, with variations allowed for facilities that are classified as rural or inaccessible. These are summarised in table 2-7 below. Table 2-7 Legal requirements for collection, treatment and disposal of HCW Urban Peri-urban Rural Infectious waste incinerated on Infectious waste incinerated on As the quantities do not warrant site every 24 hours or at least site every 24 hours or at least an incinerator at the HCFs, every 48 hours every 48 hours sharps containers must be securely stored for transport by a hospital vehicle or the flying doctor service to a central hospital on a monthly basis. Collected by the local For HCFs generally accessible by Infectious waste can be buried in municipality for final disposal at vehicles but where there is no a secure, restricted, well-lined an established sanitary landfill local authority refuse removal and ventilated “septic tank� type service, can be collected by a pit where biodegradation can private contractor and taken to a occur. landfill once every two weeks 2.8 HANDLING AND TREATMENT OF HCW The basic setup for HCWM is in place in most of the Health care Facilities it is characterized by a number of deficiencies which include the following: • Lack of formalization of HCWM issues; • Non inclusion in budgets; • lack of plan or internal procedures; • no responsible person/team designated to follow up on HCW management; • absence of data about HCW production and classification; • insufficiency of appropriate collection materials and protective equipment; • ageing equipment and infrastructure; • lack systematic segregation of HCW and mixing with household wastes; 2.9 LEVEL OF AWARENESS OF GOOD HCWM PRACTICES Generally, staff responsible for handling waste throughout the whole chain, i.e. the administrators, Head Nurses, the Waste collectors, the orderlies, the grounds man, are not adequately trained and do not have sufficient knowledge for good HCWM behavior and practices. 14 This is aggravated by the thrust which was on curative medicine, completely sidelining the preventative side. HCWM systems are thus not well known or followed, which is very often a source of accidents, causing wounds and infection. There is a poor level of knowledge and appreciation of the risk associated with HCW; causing staff to deal with HCW casually, store it inappropriately, mix it with general waste and dispose it anyhow. As for the public in general (scavengers, children, and people at landfill sites) the knowledge on risks linked with the handling of HCW is very weak. For these actors, it is necessary to develop information and public awareness programmes on risks linked with HCW. 2.10 THE CERTIFICATION SYSTEM In 2005, Medical Care Development International (MCDI) was hired by the Government of Lesotho to provide technical assistance in the design of a certification system (GoL 2012). The standards, indicators and methods of scoring were developed using the Joint Commission International Accreditation Standards for Hospitals as a basis. The first round of accreditation surveys was implemented during 2006-2007. Sixteen hospitals, three filter clinics and 145 health centres were surveyed to provide a baseline against which the health care institutions could gauge their performance status and against which they would be able to monitor their quality improvement relative to the attainment of accreditation. A second survey followed after the previous one to document performance progress among both CHAL and GOL facilities. It included 4 Red Cross health centres. A total of 163 facilities was assessed: 16 hospitals (8 for GOL and 8 for CHAL) and 147 health centres (72 for GOL, 71 for CHAL and 4 for Red Cross). The set of certification standards is comprehensive, covering the principal areas or domains of hospital and health centre function. The standards are divided into eleven domains which include: (1) Access and Continuity of Care, (2) Patient and Family Rights, (3) Assessment of Patient, (4) Care of Patients, (5) Patient and Family Education, (6) Organization Management, (7) Estate Management and Safety, (8) Management of Information, (9) Staff Qualifications and Education, (10) Prevention and Control of Infections, and (11) Quality Improvement and Patient Safety (GoL 2012. In the certification standards an emphasis is placed on infection control that includes the management of hazardous material and the development of a waste management plan. The tables below are excerpts from the Summary of Result report on aspects that are related to the management of health care waste. Table 2-8 Excerpt of certification results relating directly to HCWM in hospitals. CODE DESCRIPTION Met Partially (%) Unmet (%) (%) COP 2.1 There are policies and procedures in place for 88% 0% 13% blood and blood products EMS 1.4 A hazardous materials and waste management 50% 25% 25% plan is in place PCI 1.1 The organization has an active program to 69% 0% 31% reduce risks of non-socomial infection PCI 1.2 The organization designates an individual to 38% 0% 63% oversee all infection control activities PCI 1.3 The organization has an established infection 19% 0% 81% control committee PCI 1.4 Running water, soap and hand-drying capacity is 31% 31% 38% available at all service delivery points and bathrooms PCI 1.5 Supplies to control infection are available 38% 50% 13% 15 Table 2-9 Excerpt of certification results relating directly to HCWM in HCs. CODE DESCRIPTION Met (%) Partially (%) Unmet (%) EMS 1.4 A hazardous materials and waste management plan is in 23% 35% 42% place EMS 1.9 Organization cleanliness is assured 53% 27% 20% The Accreditation Survey revealed that there were qualitative deficiencies that needed to be addressed to improve the performance of the Health Care Facilities. Some of the deficiencies required significant supplementary resources to remedy them. However, the majority of the deficiencies could be corrected with organization development efforts within each institution. MoH then set itself to increase its support to improve the deficiency areas. 2.11 THE LESOTHO QUALITY ASSURANCE SYSTEM With the assistance of the Council for Health Service Accreditation of Southern Africa (COHSASA), two sets of comprehensive Lesotho accreditation standards for hospitals and health centres respectively are currently being developed and piloted in four hospitals and 8 health centres by the Quality Assurance Unit of the Clinical Services Department of MoH xxii These are expected to replace the current standards by the end of 2010 (GoL 2009 c, GoL 2012). The standards address HCWM more comprehensively than the current MCDI-based standards: they include a requirement for written policies, plans and procedures on handling, storage and disposal of healthcare waste for specific clinical and housekeeping services within a health care facility. HCWM standards are also included in the health and safety and infection prevention and control policies and procedures. Training in HCWM is specified in these standards to ensure that all staff are trained in providing a safe and secure patient care facility. There are further requirements for a representative infection control committee (or appropriate mechanism) with qualified, competent persons to chair the body and to undertake the role of infection control programme coordinator. This body must report on health care data and ensure that communications on the infection control programme are continuous and proactive. The individual, committee, or other mechanism must also monitor those housekeeping and other support service practices which may lead to the spread of infection e.g. waste disposal. Each health facility must have a plan for the handling, storage, treatment and disposal of healthcare and other wastes which is included in the facility’s risk management plan. Housekeeping staff work with the infection control coordinator to ensure colour-coded waste segregation, proper management and security of the waste storage activities and safe waste disposal. 2.12 INFORMATION SYSTEM AND LICENSING At present there is no system to collect data on quantities and types of waste being generated, treated or disposed of in HCFs. A recent study done on investigating how an electronic Health Management Information System will be implemented in Lesotho identified an array of indicators and parameters that will be incorporated into the broader HMIS (GoL 2012). No mention was made at all of a Waste Information System, only scant mention of data relating to environmental health. 16 3. CONTEXT OF THE HCWM PLAN 3.1 INTRODUCTION Over the last fifteen years, The Government of Lesotho has adopted a new republican constitution, and a number of new policies and legislation with the ultimate aim of promoting and consolidating sustainable socio-economic development in the country through the mainstreaming of environmental considerations in project planning and implementation. These include: the National Environmental Action Plan, the National Environmental Policy, the National Health Policy, Healthcare Waste Management Policy, The Health Act, the Environmental Act, and Local Government Act among others. Health is articulated as one of the principles of Equality and Justice in the Constitution of Lesotho of 1993 in Chapter III. As regards Health, the Constitution states that Lesotho shall adopt policies aimed at ensuring the highest attainable standard of physical and mental health for its citizens, including policies designed to - (a) provide for the reduction of stillbirth rate and of infant mortality and for the healthy development of the child; (b) improve environmental and industrial hygiene; (c) provide for the prevention, treatment and control of epidemic, endemic, occupational and other diseases; (d) create conditions which would assure to all, medical service and medical attention in the event of sickness; and (e) improve public health. Government further committed itself to equitable access to standard quality health service in Lesotho in its Vision 2020 statement which reads: “The country will have a good quality health system with facilities and infrastructure accessible and affordable to all Basotho, irrespective of income, disabilities, geographical location and wealth. Health personnel will provide quality health service.� Thus the National Constitution and the Government expressed vision set a good note for the implementation of good health care delivery for all. This chapter describes the context of the Infection Control and Waste Management Plan (ICWMP) for the Kingdom of Lesotho. It highlights the contrast between the relatively developed curative side of the Health Care System as opposed to the poorly developed preventive side suffering from inequitable and unsustainable resource allocation. 3.2 THE POLICY FRAMEWORK Various policies and strategies relevant to Infection Control and Waste Management (ICWM) have been used to inform this ICWMP report. The following is a summary of some of the relevant policies and strategies: 3.2.1 Poverty Reduction Strategy (PRS). The Poverty Reduction Strategy of Lesotho includes the following; employment creation and income generation, Agriculture and Food security, infrastructure development - roads, water, electricity and communication, deepening democracy, governance, Safety and Security, 17 improving quality of and access to essential health-care and social welfare service, improving quality and access to education, managing and conserving the environment and improving public service delivery. The crosscutting issues are scaling up the fight against HIV/AIDS and gender, youth and children. Improving quality of and access to essential health care and social welfare service are a major pillar in the strategy and improved ICWMP is an essential component of its execution. 3.2.2 National Health Policy (2011) The National Health Policy (2011) commits the Government to equitable access to a standard quality of health services for all. This will be implemented through the District Health Package which provides Essential Health Service package components free of charge or highly subsidized to all citizens. The vision of the policy is to have a healthy nation, living a quality and productive life. Its mission is to enhance a system that will deliver quality health service efficiently, effectively and equitably to all Basotho. The general objectives of the policy include the following: • To reduce morbidity, mortality and human suffering among the Basotho. • To reduce inequalities in access to health services. • To strengthen the pillars of health system Its overall objectives are expressed in a series of fourteen components which include; (i) Communicable Disease Control (ii) Sexual & Reproductive Health and rights, (iii) child survival and development (iv) Nutrition (v) Environmental Health (vi) Emergency and Humanitarian action (vii) Occupational health (viii) Health Education & Promotion (ix) Pharmaceutical services and medical technologies (x) Oral Health services (xi) Mental Health Services (xii) Clinical, Diagnostic and Nursing Services, (xiii) Referral services outside the country, and (xiv) Traditional Health Services. Environmental health and Occupational Health are major components of the Policy and the Government committed its self to ensure the same by promoting safe water and sanitation, vector control, workplace safety, waste disposal, food hygiene and port health’. Thus Infection Control and Waste Management feature highly in this Policy. 3.2.3 Lesotho National Environmental Policy (1998) The National Environmental Policy (1998) was crafted to protect the environment in the face of all developmental activities that may be undertaken in Lesotho. Its mission is "to promote and ensure that the present and future development of Lesotho is socio-economically and environmentally sustainable", while its goal is to protect and conserve the environment with a view to achieving sustainable development for Lesotho. The policy has sixteen (16) objectives but its main thrust is embodied in the first three which are outlined below: a) To secure for all Basotho a high quality of environment to enhance their health and well being. b) To use and conserve the environment and natural resources for the benefit of present and future generations. c) To halt environmental degradation, and to restore, maintain and enhance the 18 ecosystems and ecological processes essential for the functioning of the biosphere and to preserve biological diversity. The policy objectives have a direct bearing to the issues of Infection Control and Waste management in Health Care Facilities. The increased Health Care delivery activities after the refurbishments of Health care Facilities and the expanded roll out of the TB-HIV/AIDS programme will generate more Health Care Waste. Good management of Health Care Waste will go a long way in realizing the provisions of this policy. 3.2.4 Healthcare Waste Management Policy (2010) The Health Care Waste Management Policy (June 2010) embodies the vision of Health Care Waste Management in Lesotho, essentially as to minimise the adverse impacts of HCW on the environment and on public health in a sustainable way that will reflect a balance of the economic, social and ecological needs of Lesotho. Its vision, mission and overall objectives are expressed in twelve policy statements which cover (i) Prevention of Pollution of Natural Resources, (ii) Waste Minimisation and Recycling, (iii) HCWM Planning, (iv) Improved Infrastructure and equipment, (v) Appropriate Treatment technologies, (vi) Disposal technologies, (vii) Institutional Arrangements, (viii) Collaboration and partnerships, (ix) Capacity building and Awareness Raising, (x) Financial Management, (xi) Development of Enabling Mechanisms, and (xii) Monitoring and Evaluation The policy emphasises that HCWM will be consistently monitored and enforced through a comprehensive monitoring and evaluation system that ensures compliance with HCWM regulations, standards, guidelines, environmental management systems and quality assurance requirements. The Tuberculosis and Health Systems Support Project will cause an increase in the HCW generated from the health care facilities as they operate with the improved systems. Thus its implementation will be absolutely necessary to avoid any pollution from HCW. 3.2.5 National Tuberculosis Programme: NTP Policy and Manual (Last reviewed 2006): Tuberculosis Infection Control in Health Care Setting This policy and procedure manual gives guidance on how the risk of tuberculosis infection can be reduced by work practice and administrative control measures, and by environmental control measures. The provisions of this policy will be directly triggered by the expanded roll out of the Tuberculosis and Health Systems Support Project and will have a direct bearing on the Health Care waste that will be generated from the Health Care Delivery programmes. 3.2.6 Lesotho Science and Technology Policy 2006-2011 (2006) The Science and Technology Policy recognises that technical and scientific aspects are critical to the health sector making it essential to have trained, qualified, competent and highly motivated personnel to operate effectively; well-serviced, modern equipment and laboratory facilities; and affordable medicines. It highlights the MoH’s roles in training, community education, research and outreach. 19 Its provisions are directly linked with the objectives of the Tuberculosis and Health Systems Support Project which seeks to improve the healthcare facilities including their laboratories. The enlightened staff will also be in a position to handle health care waste professionally. 3.2.7 ICT Policy for Lesotho - 4 March 2005 The Ministry of Communications, Science and Technology is the custodian of this policy. The Policy provides the nation with a vision and strategy for becoming a fully integrated member of the Information Society. It is intended to unite Government, industry, civil society and the general public in the achievement of its national development goals and endeavours to reduce the digital divide between the “haves� and the “have nots,� to promote gender equality, protect the environment and to improve food security and the standard of living of all Basotho. It further strives to promote a healthy society capable of exploiting the full potential of ICTs. The vision of the ICT policy is “To create a knowledge-based society fully integrated in the global economy by 2020.� While its mission is “To fully integrate information and communications technologies throughout all sectors of the economy in order to realise rapid, sustainable socio-economic development.� The policy has nine overall objectives but the most relevant for the Health sector is to “Promote usage of ICTs throughout all sectors of society including disadvantaged groups.� The policy then outlines the role of each sector in implementing it. It then highlights Health as one of the ten (10) cross cutting catalysts that provide the strategic framework needed to guide the successful implementation of the ICT policy and to realise national development goals. ICTs can play an important role in strengthening of health institutions in order to ensure efficient and effective service delivery. It can also provide an effective and cost-efficient means for distributing health and disease prevention information to the public and can further assist health care workers by improving health care administration and management as well as accessibility to medical research, information sharing and training through on-line educational programs. The objectives of e-health are to • Build a health network that will enable institutions and individuals to exchange electronic records, share information and deliver quality services in both urban and rural areas. • Improve the performance of health care facilities through the deployment of Health Management Information Systems (HMIS). • Use electronic systems to ensure an efficient and standardised process for recording patient information. • Increase access to health information for all Basotho through the innovative use of ICTs. • Empower health professionals with the knowledge and use of ICTs. The most appropriate policy measure for the Health sector is to “Use a ppropriate ICTs to dialogue among infected groups and health care providers.� This will be greatly promoted in the expanded roll out of Health Care delivery and will be used to effectively distributing health, HCWM and disease prevention information to the public. 20 3.2.8 National Health Sector Strategic Plan - 2012 - 2017 The Health Sector Strategic Plan (HSSP) takes into account all the relevant policies, legislation and other mandates for which the Ministry of Health is responsible. It also reflects the strategic outcome, oriented goals and objectives which the Ministry of Health will endeavour to achieve over the period 2013–2017. It is also a guiding plan that focuses towards attainment of the Health Policy objectives as outlined in the National Health Policy. The National Health Sector Strategic Plan (HSSP), is the operational manual for the National Health Policy and provides the situation analysis, defines broad goals and articulates the objectives of the strategic plan. Its mission is to enhance a system that will deliver quality health services efficiently, effectively and equitably to all basotho. Its strategic objectives include the following: • To contribute to improved health status through equity and access to quality health care in both public and private domains guided by the principles and strategies of Primary Health Care. • To attain and maintain deployment of right numbers and skills mix of appropriately trained and motivated HRH. • To ensure availability and management of financial resources for improved access to health services and utilization of health facilities. • To ensure that essential, safe, efficacious, acceptable quality and affordable medicines and other therapeutic products, medical devices and technologies are available all the times in health facilities and are accessible to all. • To provide timely, relevant, accurate and complete health information on a sustainable and integrated basis. • To improve delivery of health services by tapping into expertise and skills from the private sector, focusing on the output based partnerships and ensuring an optimal allocation of risk between the private and public sectors. • To ensure that health physical infrastructure are properly designed and constructed and that equipment are properly procured, installed and maintained in accordance with health. This plan will guide the implementation of the ICWMP in its endevour to create clean, healthy facilities free of re-infections and pollution of the environment. 3.2.9 Infection Prevention and Control Policies & Guidelines (2006) The infection prevention and control policy and procedures also deal with HCWM. It covers basic HCWM policies and procedures and is based on the generic document developed by World Health Organisation (WHO). The HCWM policy statements that it outlines include the following: 1. National regulations and legislation shall be observed when planning and implementing waste treatment and disposal guidelines. 2. Every health care facility shall develop a healthcare waste management plan and shall designate a staff to co-ordinate its management. 3. All health care facility and setting staff have a responsibility to dispose of waste in a manner that poses minimal hazard to patients, visitors, health care workers, and other facility workers and community. 21 4. Infectious waste material shall be treated properly to eliminate the potential hazard that these wastes pose to human health and environment. 5. All sharps especially those contaminated with blood, and body fluid and untreated microbiological waste require special handling and treatment. 6. Sharps shall be contained in a puncture-resistant container 7. Sharps and microbiological wastes shall be incinerated or burned and the ashes disposed of in a pit. 8. Infectious waste shall be stored in a designated location with access limited to authorized personnel. 9. Written policies and procedures to promote safety of waste handlers shall be defined with inputs from persons handling the waste. 10. Waste handlers shall wear protective equipment appropriate to the risk (e.g. protective foot wear and heavy work gloves) 11. All health facility staff shall be offered Hepatitis B immunization 12. A “biohazard� symbol is required on all waste packaged for incineration in line with the national guidelines. Regulations regarding colour coding vary from country-to-country. 13. All health care workers shall be familiar with the National Public Health Regulations governing disposal of biohazard wastes. 14. All health care workers and other facility workers shall receive orientation and in-service training on health care facility waste management. These generic guidelines also set out HCWM roles and responsibilities; how to develop a HCWM plan for a facility; how to manage HCWM through containerization; handling of different kinds of waste, transporting, treating and disposing of it; record keeping; training and worker health and safety. 3.2.10 Consolidated Lesotho National Health Care Waste Management Plan Consolidated Lesotho National Health Care Waste Management Plan for the Lesotho Maternal and Newborn Health Performance ----Based Financing Project August 2012 The Consolidated Lesotho National Health Care Waste Management Plan (CLNHCWMP) (August 2012) was developed as part of the World Bank funded Maternal and Newborn health Performance-Based Financing Project. It was a result of a synthesis of the various documents that had been developed as part of the updated HCWM, including: (i) the Situational Analysis (COWI); (ii) HCWM Policy; (iii) HCWM Strategic Plan; (iv) HCWM Implementation Plan; (v) HCWM Monitoring Plan and (vi) HCWM Support Document. The Plan provided a detailed consolidated overview of the management of healthcare waste in Lesotho, and was meant to be used as the safeguards instrument accompanying the Lesotho Maternal and Newborn health Performance-Based Financing Project. The generation of increased healthcare waste as a result of project-financed activities mandated the need for such a consolidated HCWM plan to accompany the project. 3.2.11 National Implementation Plan for the Stockholm Convention The National Implementation Plan for the Stockholm Convention is a compilation of national objectives and action plans aimed at capacitating Lesotho towards implementation and meeting the obligations of the Stockholm Convention. This document is the basis for policy and implementation of sound management of toxic and hazardous synthetic chemical substances known as Persistent Organic Pollutants (POPs). These substances pose a risk to humans and animals, since they are bio-accumulative in organisms through the food chains, and can be transported over long distances from the points of 22 their release through various environmental media such as air, water and migratory species. 3.2.12 Health Telecommunications Technical Assistance Project MCA Final Project Report: Health Telecommunications Technical Assistance Project (2009) This report presents a design of a health information systems and communication network for the Health Sector in Lesotho. It aims to support the Information and Communication Technology Infrastructure of the Ministry of Health for Year 2010 and beyond, within the framework of the MCA Health Strengthening project. It is proposed that the health information systems and communication networks shall be implemented in two phases. Phase I aims at building the major infrastructure and introducing hospital information systems and an integrated health information system while Phase II aims at consolidating the connectivity and the information systems by focusing on broadband connectivity, hospital intranet, national health portal and introducing advanced modules that support a hospital information system. A Health Care Waste Information System must be integrated into this system (GoL 2012). 3.2.13 The Health Services Decentralisation Strategic Plan (2009) The Health Services Decentralisation Strategy addresses three important policy issues in intergovernmental relations to achieve equity in the delivery of health services: • How to balance the need to provide this basic service with macroeconomic constraints that limit the available resources • How to objectively determine the equitable sharing of available resources between the different levels of government • What resources need to be allocated for capital spending in a way that is consistent with the answers to the first two questions. Decentralisation strategy aimed to improve the overall health through the following inter-linked strategic objectives: • Promote community participation in health development • Provide quality primary health services • Strengthen health support systems including its governance • Improve technical and managerial competence of staff for attainment of decentralisation objectives The Strategy adopted an incremental change approach in line with the phases of the overall government of Lesotho which were: • Transition phase: Two years in 2004-05 leading to the introduction of the District Councils and Community Councils and devolution of some functions. • Development Phase: Five years in 2008-11, when additional functions are decentralised. • Consolidation phase. Five years in 2012-16, when operations of the local government are refined and efficiency and effectiveness improved. In this regard, MOH was to decentralise in phases described as follows: • Internal de-concentration: Two years in 2004-2005 (pilot districts) and in two years in 2005-2007 (all districts) • Partnership: actions and collaboration with the councils in 2004-2008 23 • Gradual delegation to the Local Government Councils in 2008-2016 MOH is still in the process of implementing this strategy and is supposed to be in the consolidation phase (2012 -16), which is more of refinement of a systems that’s fully set. On the ground MoH has restructured at Central level and is in the process of implementing the new structures. There are DHMTs in all districts although without the proposed District Director and the DHMTs are being populated and accommodated in designated offices to enable effective service delivery. The sector has included decentralisation process indicators in the monitoring system to track implementation progress. However the progress of decentralization is being stalled by the readiness of the local authorities to take up these functions which need to be decentralized. 3.2.14 Human Resources Development Strategic Plan 2005–2025 (2004) The MoH Human Resources Development and Strategic Plan 2005-2025 is part of the Health Sector Reform initiative. The strategy is still in force and amongst other recommendations, it sets out the approach to strengthening substantive pre-service and post-basic training capacity and developing a National Continuing Education (CE) Program. However the strategy is rather silent on environmental health needs. 3.3 LEGAL FRAMEWORK HCW issues are to one extent or another dealt with under a number of laws. The following sections give an overview of the relevant legislative instruments which support the Infection Control and Waste Management Plan: 3.3.1 Constitution of Lesotho Section 36 of the Constitution of Lesotho lays the foundation for environmental legislation and stipulates that Lesotho will adopt policies designed to protect and enhance the natural and cultural environment of Lesotho for the benefit of both present and future generations and shall endeavour to ensure for all citizens, a sound and safe environment adequate for their health and well-being. Health care delivary and TB-HIV/AIDS control activities in particular have a potential to disrupt the wellbeing of the environment by generating infectious health care waste. Thus the development of the ICWMP will help the Health Care delivary system to conform to the requirement of the Constitution. . 3.3.2 The Environment Act No 10 of 2008 The Environment Act No 10 of 2008 makes provisions for the protection and management of the environment from any negative impacts that may be exerted by any activity such as health care waste generation. It also provides for the conservation and sustainable utilization of natural resources of Lesotho. The act is based on sixteen fundamental principles of which the relevant one are: (a) To assure every person living in Lesotho the fundamental right to a clean and healthy environment; (b) To ensure that sustainable development is achieved through the sound management of the environment; 24 (c) to use and conserve the environment and natural resources of the Basotho Nation for the benefit of both present and future generations, taking into account the rate of population growth and the productivity of available resources; and (h) To ensure that waste generation is minimized and safely disposed of; The Act also imposes a corrective duty to protect, maintain and enhance the environment and defines a “citizen-right� to take legal action against acts or omissions damaging to the environment. The Health Care delivary programmes such as the TB-HIV/AIDS control roll out will generate substantial amounts of waste which can very easily impact on the environment. The relevant clauses that cover the environment’s protection and management follow below: Part VI: Environmental Quality Standards: Makes provision for soil, water, air, waste, noise, ionization, and other radiation, control of noxious smells, guidelines for environmental disasters and other standards. Part VII: Pollution control: Makes provision for prohibition of discharge of hazardous substances, chemicals and materials or oil into the environment and defines the spiller's liability. Part IX: Environmental Management: Makes provision for identification and protection of various natural environments including land use planning and natural heritage sites. Part X: Environmental restoration order: Makes provision for issuance of environmental restoration orders. Part XlI: International Environmental Conventions: Covers environmental conventions or agreements to which Lesotho is a party. The Department of Environment is charged with the responsibility to co-ordinate the functions and activities of all line ministries on environmental issues without interfering with their day to day activities and has the power to review and approve environmental impact assessments. 3.3.3 The Public Health Order No. 12 of 1970 The Order sets out the functions of the Ministry of Health shall, as to promote the personal health and environmental health within Lesotho; to prevent and guard against the introduction of disease from outside; to prevent or control communicable disease; to advise and assist district administrations and local authorities in regard to matters affecting public health; to promote or carry out researches and investigations in connection with the prevention and treatment of human diseases; to prepare and publish reports and statistics or other information relative to the public health; to report on the work of the Ministry to the Minister who may submit such report to the Council of Ministers each year; to provide for the appointment of advisers, advisory bodies or councils to assist the Minister in all matters concerning public health; and generally to administer the provisions of this Order 25 It stresses the notification of Communicable diseases and non-Communicable diseases, the inspection of premises where a person suffering from such a diseases may have entered and the cleansing thereof. The Order also specifies that the Minister may make regulations applicable to all communicable diseases or only to such communicable diseases as may be specified therein regarding the following matters- • the imposition and enforcement of isolation or of medical observation and surveillance in respect of persons suffering from communicable disease • the duties, in respect of the prevention of communicable disease and in respect of persons suffering or suspected to be suffering there from, of occupiers of land on which persons reside • the measures to be taken for preventing the spread of or eradicating smallpox, typhus fever, typhoid fever, cholera, yellow fever, plague, poliomyelitis, tuberculosis or any other communicable disease requiring to be dealt with in a special manner • the conveyance of persons suffering from or the bodies of persons Wh0 have died of a communicable disease Generally the Order makes provisions for all matters concerning public health in Lesotho. 3.3.4 The Water Act 2008 - Water and Sewage Authority – (WASA) The Water Act 2008 provides for the prevention of pollution of water resources through measures such as the control of processes causing pollution, the control or prevention of movement of pollutants, compliance with prescribed standards or management of waste, and the elimination of any sources or potential sources of pollution. These provisions have direct relevance to the activities of the National TB-HIV/AIDS control roll out as a potential source of pollution if not properly handled. 3.3.5 Local Government Act 1997. The Act is in the process of being enforced and in the government has been decentralizing its services to the districts. Under the Act, the government has established the Local Government Service and the interest of the Central Government at district level will be represented by the District Administrator, who coordinates the duties and functions of all public officers in the district. Indeed, all public officers in the district function under the direct supervision of the District Administrator. It should be noted that the district technical staff report administratively to the DA but functionally to the line ministries. The District Administrator reports to the Minister of Local Government. An amendment to this act in 2004 gave legal mandate for the community, rural, municipal and urban councils. These councils are coordinated by the District Development Coordinating Committee (DDCC). The Act also provides for a Local Government Service Commission that recruits, appoints, promotes transfers, dismisses, retires, and interdicts staff in consultation with the relevant local authority (Ref. Health Services Decentralisation Strategic Plan Feb 2009). According to the Local Government Act 1997, Local Authorities are charged with the responsibility of refuse collection and disposal. To this end, local authorities have the power to make by-laws in relation to public health and sanitation (including waste management). Fines for offences committed at the local level with regard to pollution of the environment are dealt with through the by-laws. Further the final disposal sites for the general and treated waste are the sanitary landfills which are run by the local 26 authorities. 3.3.6 The Labour Code Order 1992 - Ministry of Employment and Labour The order, among other things emphasises the Health and safety of employees. However some mines which are generally covered by the Mine Safety Act 1981. However to the extent that any activity involving mining, tunnelling or excavating is not covered by a specific provision of the Mine Safety Act 1981 or regulations made under that Act, this order applies. The order sets out that every employer shall, so far as is reasonably practicable, ensure the safety, health and welfare at work of all of his or her employees, by providing and maintaining plant, systems of work, and a working environment for his or her employees that is clean, safe, without risks to health and adequate as regards sanitary facilities and arrangements for their welfare at work; and making arrangements for ensuring, safety and absence of risks to health in connection with the use, handling, storage and transportation of articles and substances. The employers are also required to ensure that persons not in his or her employment who may be affected thereby are not exposed to risks to their safety or health. There are two sets of relevant regulations which were written under Section 100 of the Labour Code Order. One is the Construction Safety Regulations and the other is the Chemical Safety Regulations. Of particular note is the Chemical Safety Regulations which provide for the establishment of safety and health committees in all work establishments that have a staff compliment of more than 15 employees to deal with issues of safety within the working environment. It also stipulates that employees who work under conditions that could pose a risk to them should be issued with personal protective equipment, for which such employees will not be charged. The order also provides for the notification of the Labour Commissioner of any industrial accidents and dangerous occurrences that may have happened at his workplace. It also provides for the notification of industrial diseases, where a medical practitioner suspects or finds that any person is suffering from any industrial disease specified in the First Schedule to the Workmen's Compensation Act 1977, shall notify the employer of that person and the employer shall further notify the Labour Commissioner of the same. 3.3.7 The Hazardous and Non-Hazardous Waste Management Act, 2008 The Hazardous and Non-Hazardous Waste Management Act covers all aspects of waste management, i.e. both the general or non-hazardous waste and the hazardous waste. It addresses Health Care Waste, - both general and risk waste. The objectives of this Act are to make provision for the generation, transportation, storage, importation, exportation, recycling and disposal of both hazardous and non-hazardous waste. It also makes provision for institutional measures for the control and management of hazardous and non-hazardous waste. 3.4 REGULATIONS 3.4.1 Hazardous (Health Care) Waste Management Regulations (2012) 27 The purpose of the Hazardous (Health Care) Waste Management Regulations (HHCWM) is to operationalise relevant sections of the Environment Act, 2008 in respect of hazardous waste management, specifically Health Care Risk Waste (HCRW) as a component of hazardous waste. Secondly, the regulations will control the manner in which HCRW is managed from the point of generation to ultimate disposal. The HHCWM Regulations apply to all persons and/or institutions that generate, collect, receive, store, transport, treat and dispose of health care risk waste. They make a distinction between minor and major HCW generators and they also impose different requirements on inaccessible health care facilities as opposed to their accessible counterparts. The relaxed requirements for inaccessible HCF will be in force until the facility has been removed from the list of such facilities as it would now be deemed as accessible. The HHCWM Regulations make provisions for: separation at point of generation, internal transport, interim storage, central storage, transportation to a treatment facility, treatment and disposal of HCRW, among other provisions. The central goal of the regulations is to minimize risk to human health as well as the environment. The regulations are specifically for Hazardous (Health Care) Waste, thus they do not apply to; Household/domestic waste, Disposal of animal carcasses, Radioactive and chemical health care waste and; Health care general waste (HCGW). 3.5 INTERNATIONAL CONVENTIONS AND TREATIES Lesotho is a signatory and party to more than twenty one international, conventions, treaties and protocols. Of the many treaties, the following will be triggered by the generation of waste from the roll out of the Tuberculosis and Health Systems Support Project:- 3.5.1 The Basel Convention The Basel Convention Technical Guidelines gives a narrow approach to the definitions and it is focused on reducing the impacts on health and the environment of biomedical and healthcare wastes that is based on the major classification in Annexes I, II, VII of the Basel Convention, but specified for practical use in the healthcare sector. This guideline focuses on: • A strict definition and classification of the relevant waste streams • The segregation at source of the waste • The access to the best available information for the identification of waste. The categories of Biomedical and health care waste requiring special attention have been categorised as follows: • Human anatomical waste (tissue, organs, body parts, blood and blood bags) • Waste Sharps (Needles, syringes, scalpels, slides, ampoules, etc.) • Pharmaceutical waste (e.g. expired medicines) • Cytotoxic pharmaceutical wastes • Infectious Wastes: Discarded materials or equipment contaminated with blood and its derivatives, other body fluids or excreta from infected patients with hazardous communicable diseases. 28 • Laboratory waste (cultures and stocks with any viable biological agents artificially cultivated to significantly elevated numbers 3.5.2 Stockholm Convention on Persistent Organic Pollutants This is an important convention for the proper management of HCW as it recognizes that persistent organic pollutants possess toxic properties that are transported through air, water and migratory species across international boundaries and are deposited far from their place of release, where they accumulate into the ecosystems. The dioxins and Furans from the thermal treatment process of incineration is an important contributor. The Lesotho National Implementation Plan (NIP), produced in May 2005 outlines enabling activities to facilitate early action on the implementation of this convention. In the NIP under Intervention Area 3.3.1 Institutional and regulatory strengthening measures, the GOL undertook to develop an Integrated Waste Management and Pollution Control policy framework and to amend relevant legislation to ensure significant reduction in the release of dioxins and furans. As part of this plan, the Environment Act 2008 was promulgated. 3.5.3 The convention of biological diversity The objectives of this Convention, to be pursued in accordance with its relevant provisions, are the conservation of biological diversity, the sustainable use of its components and the fair and equitable sharing of the benefits arising out of the utilization of genetic resources, including by appropriate access to genetic resources and by appropriate transfer of relevant technologies, taking into account all rights over those resources and to technologies, and by appropriate funding. The Project will impact on biodiversity as the ecosystems are affected by any construction or refurbishment activities at the Health facilities. These disturbances will tend to be minimal since the renovations will basically be within the footprint of existing establishments. 3.5.4 The convention concerning the protection of world and natural heritage. The World Heritage Convention aims for the preservation of the cultural and natural heritage sites of outstanding universal value. Each State, party to this Convention recognizes that the duty of ensuring the identification, protection, conservation, presentation and transmission to future generations of the cultural and natural heritage situated on its territory, belongs primarily to that State. The project area is endowed with a lot of natural and cultural heritage sites. Any excavations for construction work may encounter artifacts, fossils and other items of cultural importance. Thus the Tuberculosis and Health Systems Support Project may trigger this convention. 3.5.5 African convention on conservation of nature and natural resources This Convention focuses on living resources, calling for the creation of protected areas and for the specific conservation measures for listed species. It also provides the grounds for the conservation of other natural resources such as soil and water, for the consideration of environmental concerns in development plans, and for research and education. 29 The renovations, refurbishments and construction works of the Health facilities will have a direct impact on the natural resources by clearing of vegetation, and loosening soils. Thus the requirements of this convention have to be considered in the implementation of the Tuberculosis and Health Systems Support Project. 3.5.6 Summative comment on legislation for HCWM The International conventions, although binding to GOL, are not fully incorporated into the national legislation. It is not possible to prosecute where a breach of these laws has occurred because there are no local laws that deal specifically with items being regulated under these conventions. The new Environmental Law 2008 does go some way to addressing this gap. The Hazardous and Non- Hazardous Waste Management Act, 2008 also go some way to addressing the gap in the control of HCW. 3.6 INSTITUTIONAL FRAMEWORK 3.6.1 Department of Environment In 1994, the National Environmental Secretariat (NES) was established to advise the Government on all matters relating to environment management. It spearheaded the development of Lesotho’s Agenda 21 action Plan adopted in 1995. In 1998 the Department of the Environment, which was then part of the Ministry of Natural resources, was merged with NES and the new institution became the lead institution in environmental management. The Department of the Environment then appointed Environmental Units in line Ministries in order to strengthen the coordination of environmental activities. The units received some training in different aspects of environmental management but they are not fully effective because of under staffing. The Department of Environment’s principal responsibility is coordination, monitoring and supervision of environmental conservation activities. It also has a cross-sectoral mandate to oversee the conduct of EIAs through issuance of guidelines, regulations and registration of practitioners. It reviews and approves environmental impact statements in consultation with any relevant lead agencies. 3.6.2 Ministry of Health (MoH) Ministry of Health (MoH) is responsible for all the Health and Health Care delivery activities in the country. It will be the lead implementing agent for the Tuberculosis and Health Systems Support Project through its various departments at Head Office and its District structures. The responsible directorates at head office will be the (DDC) and the Department of Environmental Health (EHD) and at district level each District Health officer (DHO) and his team will be responsible. A Programme Coordination Unit (PCU) will be established which will be responsible for overall coordination, supervision and monitoring, while programme activities would be implemented by the private sector, NGOs and Government Agencies on the basis of performance-based contracts. 30 3.6.3 Ministry of Labour and Employment (MOLE) Ministry of Labour and Employment (MOLE) is responsible for all the labour related issues in the country. It will be heavily involved in the implementation of the Tuberculosis and Health Systems Support Project as it has to see to it that there is fair treatment of labour at the mines. Although currently there is no provision for compensation for work related illnesses like TB, it is imperative that the labour ministry should be concerned with the welfare of all workers. 3.6.4 Participating Ministries The following Ministries have responsibilities that cover areas relevant to the Tuberculosis and Health Systems Support Project programme implementation: (i) Ministry of Finance and Development Planning (MFDP), The Ministry of Finance and Development Planning is a central coordinating Ministry in charge of reducing poverty levels through increased national and household incomes, economic growth, domestic production, employment, wealth and investment. These are to be attained through formulation of effective development, macroeconomic and fiscal policies and their implementation through best plans and programmes. Thus it will be the lead agency in charge of the financing mechanism. In essence it is the Borrower. (ii) Ministry of Local Government and Chieftainship (MLGC). The Ministry of Local Government is responsible for creating conditions for sustainable local government, poverty reduction and overall human development in Lesotho. These efforts are anchored on the synergy of policies and programmes for citizens’ empowerment and participation, improved management of land and its development, decentralisation of government functions and the pursuit of appropriate rural development technologies. The Health delivery system hinges on adequate land use planning, thus the Ministry will be very important in the area of land allocations and reallocations for project purposes at all its various levels of local government down to the villages. 3.7 PRIVATE SECTOR PARTICIPATION Private sector participation in HCWM in Lesotho is an emerging issue. It was basically the responsibility of hospital staff and the local authorities, but they lacked the requisite capacities and ended up mixing all wastes at the landfill. This posed a limitation to managing health care wastes in a professional manner, as the management skills and financial resources of the private sector were not being tapped. Currently the Ministry of Health is assisted by Lesotho Millennium Development Authority (LMDA) to collect and treat HCW in the Ministry’s facilities. To increase its coverage, LMDA has sub - contracted other companies for this function. The contracted companies are expected to supply the health facilities with waste management equipment (containers, liners etc). It collects HCW from the Health facilities in the districts for treatment at the incinerators at the hospitals which have operational incinerators. It is also mandated to maintain day to day running of the incinerators. The companies are also expected to collected and transport general waste from the hospital for disposal at designated disposal sites. 31 As the private sector slowly realizes that there is business in HCWM they will increasingly take part. Further the proposed action plan for HCWM supports initiatives to develop a partnership between public and private sector with civil society. To accomplish this, it will be necessary to develop sustainable financial resources for HCWM. 3.8 FINANCIAL RESOURCES ALLOCATION Solid waste management suffers from inadequate financing from the state and local planning authorities. The financial resource allocation at all health Care Facilities is skewed towards curative approaches to the detriment of HCWM. This is the reason why major constraints are encountered at all stages of the HCWM cycle; Collectors are not motivated, equipment is hardly replaced and collection is irregular. Without a regular budget allocated to HCWM (mainly in health facilities), it is nearly impossible to improve management. 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. 32 4. DESCRIPTION OF THE ICWMP PROJECT 4.0 INTRODUCTION The Government of Lesotho has secured a grant amounting to US$15 million from the World Bank to implement a Pilot Project and prepare an investment operation using the Results Based Financing for Health approach. These operations will be implemented by the Ministry of Health (MoH) and aims at improving the utilization of a minimum package of health and nutrition services. The Project Implementing Committee intends to apply part of the proceeds of this grant to payments under the Contract to develop an Infection Control and Health Care Waste Management Plan (ICWMP). The ICWMP is a major component of the main Results Based Financing (RBF) program. The main project focuses on building capacity in the health sector which will contribute to delivering adequate health care services to the Lesotho population. It has been designed to accelerate the availability, accessibility and utilization of quality health and nutrition. This approach provides financial reward directly to service providers contingent upon undertaking predetermined actions or achieving certain results or health outcomes. The objective for the development of the Infection Control and Management Plan (ICWMP) is to identify the level of Health Care Waste Management that will be relevant to help implement and enforce proper health and environmentally sound, technically feasible, economically viable, and socially acceptable systems for management of health care waste during and beyond the implementation of the Project. 4.1 THE ICWMP GOAL The goal of the ICWMP is to prevent, reduce and mitigate the environmental and health impacts on health care staff and the general public caused by poor health care waste management (HCWM), through the promotion of best practices and the development of safety standards. 4.2 THE ICWMP OBJECTIVES The ICWMP Goal may be further broken down into the following broad objectives: • To prevent or reduce infections that may arise from poor HCWM • To mitigate the impacts of HCW on health care staff and the general public; • To create an enabling legal environment for conducive and effective HCWM • To establish a sustainable multi-sectoral institutional framework for a concerted effort in HCWM. • Improve services in HCWM by mobilizing requisite resources 4.3 THE ICWMP STRATEGIC OBJECTIVES The rapid field assessment observed the following constraints on the HCWM system: • Non formalization of HCWM in the institutions • Absence of specific operational policy about HCW; • Weak HCWM legislative regime 33 • Absence of standard HCWM operational procedures • Inadequate budgetary resource allocations; • Limited qualified human resources; • Technological challenges in handling, treatment and disposal facilities. • Subdued and insufficient knowledge about HCW (staff and Public). • Absence of private sector participation To improve HCWM in a sustainable way, the ICWMP should address these main constraints. It should initiate a process and support the national response to these questions. It must focus on preventive measures, mainly the initiatives to be taken in order to reduce the health and environmental risks associated with mismanaged waste. It should also focus on the positive pro-active actions, which, in the long term, will allow a change of behavior, sustainable HCWM, and protection of actors against risks of infection. To achieve this, the intervention strategy should be organized around the following measures: • Organize training activities for actors concerned (health staff, HCW handlers, municipal collectors of wastes, managers of public landfills, etc.); • Implement information and education campaigns about HCW for the general public; • Reinforce institutional and technical capacities and improve existing regulations; • Support partnership initiatives between public, private and civil society in HCWM. These actions should be accompanied by complementary measures, mainly initiated by governmental programs, in terms of HCWM upgrading in health facilities. 34 5. ASSESSMENT OF HCWM IN THE COUNTRY 5.0 INTRODUCTION The basic assumption is that it is possible - in a short period of time (usually 10-15 days), by questioning main stakeholders and by selecting a number of health care facilities, representative of the country - to gather the essential data necessary to have a sufficient understanding of the situation regarding ICWM at a national level. By analysing the role of each stakeholder along the ICWM stream it should be possible to identify where problems remain and what simple, practical actions should be undertaken to solve them. 5.1 THE ASSESSMENT PROCESS The assessment process that was utilized followed four steps to ensure that the procedure is useful, feasible, ethical and accurate: 1) Engaging all relevant stakeholders, 2) Describing the situation at each facility as observed during visits, 3) Gathering credible evidence of defined quality and quantity of operational parameters at each facility in a systematic manner, 4) Availing all field data collected as Justification of conclusions drawn. The ICWM information was collected in a logical and chronological manner by starting at national (organisations, ministries…) level down to the local (the health facilities) and from the start of the HCWM stream (waste generation) to the end (final disposal). 5.2 THE RAPID ASSESSMENT OF THE INSTITUTIONS The Rapid Assessment Tool developed by WHO was applied and administered to the representative sample of the institutions that deal with HCW, starting with the responsible Government Ministries to the Clinics. So as to be able to extrapolate collected data, a sufficient number of health care facilities representative of the country were visited. To keep things simple, between one and two health care facilities per size and category of structure (private, public, and NGO), type of area (urban, rural) and by Region were selected. This resulted in eleven (11) health care facilities being visited (Table 5-1). 35 5.3 SELECTION OF HEALTH CARE FACILITIES The following institutions were identified as essential stakeholders in the ICWM sector: Table 5-1 Visited health Related Institutions CATEGORY OF NUMBER OF LERIBE MAFETENG MASERU MOKHOHLONG FACILITY INSTITUTIONS Referral Hospitals 1 Queen Mamohato Memorial Hospital Large Hospitals 2 Motebang Mafeteng Hospital Hospital Health Centres 3 Peka Health Motsekuoa Health Ratjomose Centre Centre LDF Health centre Private Non Profit 1 Mamohau TEBA Clinic (NGO) Hospital (CHAL) Private for-Profit 1 Dr. Knight Letseng Mine Hospital Hospital Pharmaceuticals 1 (NDSO) National Drug Supply Organisation Blood Transfusion 1 Maseru Blood Services Bank MDR TB clinic 1 Botsabelo (Multiple Drug MDR - TB resistant TB) 5.4 BASELINE INFORMATION OF THE SELECTED FACILITIES The selected health care facilities showed that they are at different stages of development in terms of waste disposal services. Some are poorly developed, whilst some displayed state of the art waste handling systems. The outline of the site profile of each of the selected health care facilities is detailed in Annex 2. 5.4.1 General observations Generally the assessments revealed that: • All staff were aware of the issue of Health Care Waste Management but were not taking it with the seriousness it deserves. At times segregation was not done properly, spillages were not disinfected, storage areas were not secured and most of the temporary storage area designed for waste were now being used to store other things like mattresses while waste was just being piled outside. 36 • All the government incinerators and other equipment and treatment facilities need continuous maintenance in order to perform to required levels. Currently most are operating inefficiently and not treating the waste at all. • Most incinerators are also poorly located, too close to the health facility and in between residential housing. • HCWM has not been institutionalised in the Health Care delivery system and thus it has been sidelined. Besides such institutions as the Letseng Hospital and the Queen Mamohatu Memorial Hospital, most institutions do not have departments or staff designated to this function. • Most institutions do not have a functioning system of reporting accidents or even a procedure to follow, in case of one. Theoretically they refer to the Post Exposure Prophylaxis (PEP), but in practice its non functional. • Most institutions do not have any policies related to HCWM in place and thus have not formalized it. • The facility operators are in most cases not trained and sometimes do not have proper protective gear. HCWM related training has been minimal and the Ministry of Health hopes to embark on this drive and not only train staff but also to raise the awareness of the general public. • Generally the final disposal facilities leave much to be desired. The pits are not lined, mostly they are open pits and not secured, exposing the scavenging communities to infections. • Only Queen Mamohatu Memorial Hospital weighs its waste, thus the amount of waste being generated in the country is difficult even to estimate. • The sanitary facilities at most health care facilities are generally not sufficient and not in good working condition. • The private sector is totally excluded from HCWM at all institutions. It is also the aim of the Ministry to rope in the private sector in the HCWM arena so that the nation can benefit from the resulting Public – Private Partnership. • Currently most of the HCWM facilities are being slowly neglected and starting to malfunction. The first step would be to bring them to good working condition. The next major step would be to update and streamline the legislative side of things to be supportive of HCWM issues. This will then be followed by bringing together all the major players and clearly define each other’s roles in the HCWM field. The Health care Staff generally don’t want to do anything about HCW. Finally there is need to develop some sustainable financing mechanism to drive the process forward. 37 5.5 SUMMARY OF THE ANALYSIS At all the Health Care Facilities issues of concern were noted and the following is a summary of the issues: Table 5-2 Summary of issues found at institutions ISSUE Referral Large Health Private Private Local Analytical Blood Hospitals Hospitals Centres For Non- Authorities Services Transfusion Profit Profit Providers Services HCWM not formalised X X X X X X X X No policies or procedures X X X X X X X X HCWM not included in budgets X X X X X X X X No department or staff responsible for HCWM X X X X X X Staff not trained in HCWM X X X X X X X X Accident reporting not happening X X X X X X X X Waste not being weighed X X X X X X X X HCW handling is not proper X X X X X X X X Consumables like plastic liners always out of stack X X X X X X X X temporary storage of waste not suitable X X X X X X X X Incinerator not functioning properly X X X X X X X Incinerator not secured from public Incinerator poorly located X X X Incinerator operators not trained X X X X X X X X Incinerator operators not protected X X X X X X Pit not lined or sealed X X X X 38 Final disposal not suitable X X X X X X X X Final disposal not secured from public X X X X X X X X External players not in place X X X X X X X X Sanitary facilities not sufficient X X X X X Sanitary facilities not functioning properly X X X X X KEY X Issue affects the facility Issue does not affect facility 39 5.6 GENERAL RECOMMENDATIONS To alleviate the current low level of Health Care Waste Management in the country, the following recommendations can be made: 1. It is recommended that the following legal instruments be developed: a. ICWM Regulations b. ICWM technical guidelines c. Standard operating procedures 2. ICWM be institutionalized and formalized in all Health Care facilities by making it mandatory that: • ICWM be included in Budgets • Staff be assigned to this function • Records be kept of this activity • Control flow of HCW in institutions • Regular reporting on ICWM issues at all institutions • Accident reporting protocols be adhered to strictly 3. The health care facilities must be provided with adequate HCW handling equipment a. Colour coded bins and liners b. Correct sharps containers c. Full protective gear 4. The treatment facilities to be located/relocated at appropriate places that minimise affecting communities. If there is no space at the health facility, consideration should be given to establishing the facility off site and may be allow private players to run it. 5. Particular attention must be taken to ensure that the final disposal method being employed completely eliminates the possibilities of infections or poisoning. 6. ICWM Training programmes for trainers, medical staff, General staff, supplies staff and any other staff of related fields should be embarked on and pursued vigorously. 7. ICWM awareness raising campaigns should be developed and utilize the following: a. Televised messages b. Radio messages • Posters in Health centers • Public animation sessions 8. Private players be encouraged to take part in the ICWM programmes to tap into the Public- private partnership programmes. 9. A system to be put in place to monitor and evaluate the progress of implementation of the ICWMP. 40 6. TRAINING NEEDS ASSESSMENT 6.0 INTRODUCTION From the general assessment of the Health Care Facilities conducted with the rapid assessment tool critical training requirements were noted. Correct attitudes for effective ICWM result from knowledge and awareness regarding the potential risk of healthcare and administrative procedures for handling the waste. Apart from a general understanding of the requirements of waste management, each category of actors (doctors, nurses, caretakers, ward attendants, ground workers, administrative staff, environmental health practitioners etc.) working within the health care facility has to acquire his or her own individual waste management skills. Staff must be taught and trained in ICWM approaches. For the training to be successful and to lead to changed behaviour, participants must become aware of the risks linked to ICWM. The training needs were assessed taking into consideration the two broad groupings, Health Care Facility staff and General Public or non Health Care staff. Both groups displayed certain levels of ignorance which may be solved by training and awareness raising: 6.1 TRAINING NEEDS FOR HEALTH CARE STAFF This group includes: (i) Management and administrative staff; (ii) Medical and laboratory staff; (iii) Environmental Health Staff; (iv) ward attendants, caretakers, ground workers and (v) other support staff; i) Management and administrative staff It is the task of the management to build up the awareness of waste management in each type of health facility. The survey revealed that at times the management itself was not totally aware of all the risks resulting from HCW, and in many cases did not know much about appropriate waste management technologies and procedures. ii) Medical and laboratory staff Due to their professional training, doctors, nurses and the other medical staff have the broadest knowledge about health risks resulting from HCW. They, in turn, should create awareness among the other members of health facility staff. Although, they may be aware of the health risks, doctors, nurses and other medical staff displayed a need for training in proper waste management and handling technologies and procedures as these are not their speciality. iii) Ward attendants, ground workers, caretakers and other support staff Ward attendants, ground workers, caretakers, cleaners, kitchen and laundry personnel constitute the group of people having the greatest daily contact with HCW and the least knowledge about health risks or waste management practices. The assessment revealed a 41 serious lack of appreciation of risks associated with their tasks. Therefore, they need extensive training and regular supervision to ensure the desired improvement in waste management practices actually occurs. iv) Environmental Health Staff These include Environmental Health Officers, Environmental Health Technicians, Health Orderlies and Field Orderlies. They inspect, licence, monitor and evaluate; advise and educate staff and communities. The following are the needs which were identified for the Health Care Facility staff: Table 6-1 Topics of training and public awareness -Health Staff TRAINING SUBJECT CATEGORY OF TARGET GROUP A B C D Basic knowledge about HCW Waste categories X X X X Hazardous potential of certain waste categories X X X X Transmission of nosocomial (hospital acquired) infection X X X Health risk for health care personnel X X X X Proper behaviour of waste generators Environmentally sound handling of residues X X X X Waste avoidance and reduction possibilities X X X Identification of waste categories X X X Separation of waste categories X X X Knowledge about appropriate waste containers X X X X Proper handling of waste Adequate waste removal frequency X X Safe transport containers and procedures X X X X Recycling and re-use of waste components X X Safe storage of waste X X Cleaning and maintenance of collection, transportation and storage X X facilities Cleaning and maintenance of sanitation facilities, drains and piping X X Handling of infectious laundry X X Handling of chemical and radioactive waste, outdated drugs X X X X Maintenance of septic tanks and other sewage treatment facilities X X Maintenance and operation of incinerator for infectious waste X X Maintenance and operation of waste pit and landfill site X X Safety regulation in waste management, protective clothing X X X X Emergency regulations in waste management X X X X A B C D Establishment of a waste management system Establishment and implementation of a waste management plan X Sampling of waste quantities, monitoring and data collection X X X Monitoring and supervision of waste management practices X X X X Cost monitoring of waste management X Establishment of a chain of responsibilities X X X X Set-up of occupational safety and emergency regulations X X X X 42 TRAINING SUBJECT CATEGORY OF TARGET GROUP Interaction with Local Authorities or private sector waste handling X structures Public relation and interaction with local community X A: Management and administrative staff B: Medical and laboratory staff C: Ward attendants, caretakers, ground workers and other support staff; D: Environmental Health Staff 6.2 TRAINING NEEDS - GENERAL PUBLIC/NON HEALTH CARE STAFF This group includes: (i) Patients and visitors (ii) Contracted workers (iii) Private players (iv) Suppliers i) Patients and visitors Due to the permanent fluctuation of patients and visitors, it is virtually impossible to teach this group of people systematically about the principles of ICWM. One possibility may be to offer advice on basic ICWM subjects during the waiting periods. Patients and visitors should be made aware of the proper use of waste containers to dispose of their waste. Attentive hospital staff might guide patients and visitors from time to time regarding their waste management practices. Relevant posters may often provide the public with additional information. ii) Waste Management Operators The waste operators have a daily and direct contact with HCW because they are mainly responsible for waste handling. They seemed to be so used to HCW that the risks associated with it were being disregarded. For this reason, they need to be informed on risks and advised about infection prevention and security protection. vi) Waste Transportation Staff Waste transportation staff (mainly off-site transportation) were noticed to be very casual about HCW and treated it like general waste. They need to be trained because HCW should be 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, and because handling and transportation require specific protection equipment to prevent infection by HCW. vii) Treatment Systems Operators HCW treatment systems operators require specific capacities. In all facilities visited this was seriously lacking and the operators were just picked at random. The operators in charge need to be trained in order to master the operating process, to know health and security related to the 43 operating system (mainly the procedures in emergency cases), to learn how to care for the equipment. viii) Disposal Managers The staff (municipal staff) who manage the final landfill disposal need to be informed about health and security linked to HCW. At the visited sites the managers were handling HCW like any other waste. They must be aware of the necessity of protection equipment and personal hygiene and they must control scavenging activities and recycling of used instruments inside these specific sites. The following are the needs which were identified for the non Health Care Facility staff: Table 6-2 Topics of training and public awareness guide (Non-Health Facility Staff) TRAINING SUBJECT CATEGORY OF TARGET GROUP E F G H I Basic knowledge about HCW Waste categories X X X X Hazardous potential of certain waste categories X X X X X Transmission of nosocomial (hospital acquired) infection X X X X Health risk for health care personnel X X X X Proper behaviour of waste generators Environmentally sound handling of residues X X X X X Waste avoidance and reduction possibilities X X X X X Identification of waste categories X X X X Separation of waste categories X X X X Knowledge about appropriate waste containers X X X X Proper handling of waste Adequate waste removal frequency X X Safe transport containers and procedures X X Recycling and re-use of waste components X X X X Safe storage of waste X X X X Cleaning and maintenance of collection, transportation and storage X X X X facilities Cleaning and maintenance of sanitation facilities, drains and piping X Handling of infectious laundry X X Handling of chemical and radioactive waste, outdated drugs X X Maintenance of septic tanks and other sewage treatment facilities X Maintenance and operation of incinerator for infectious waste X X Maintenance and operation of waste pit and landfill site X X X Safety regulation in waste management, protective clothing X X X X Emergency regulations in waste management X X X X Establishment of a waste management system Establishment and implementation of a waste management plan X Sampling of waste quantities, monitoring and data collection X Monitoring and supervision of waste management practices X X X X Cost monitoring of waste management X Establishment of a chain of responsibilities X X X X Set-up of occupational safety and emergency regulations X 44 TRAINING SUBJECT CATEGORY OF TARGET GROUP Interaction with Local Authority or private sector waste handling X X structures Public relation and interaction with local community X X E : Patients and visitors F : Waste management operators G : Waste transportation staff H : Treatment systems operators I : Disposal managers 6.3 TRAINING STRATEGY The training program should aim to operationalize the ICWMP by: promoting the emergence of experts and professionals in ICWM; raising the sense of responsibility of people involved with ICWM; and safeguarding health and security of health staff and waste handlers. The training strategy will be articulated around the following principles: 1. Training of Trainers: This involves training the senior officers in health centres (doctors, EHO, and technical services’ supervising staff in Local Authorities). The training sessions will be held in each District, (10 trainers per District, during 5 days, nearly 600 person/day) ; 2. Training health care staffs in health centres (medical staff, nurses), This should be done by the already trained senior staff members. ( 80 participants for each Distract, during 3 days, nearly 3000 person/days); 3. Training HCWM supporting staffs All support staff (ward attendants’, ground workers, cleaners) will need this training. These training sessions will be held in each health centre and will be performed by already trained key staff (3000 person/days, with 3 agents during 2 days, for nearly 100 health facilities). The training modules will deal with risks in the handling of HCW: sustainable management process (collection, storage, transportation, treatment, disposal); good behaviours and practices; caring for installations; protection measures. The training of medical and paramedical staff remains a priority if the program is to have a major impact on ICWM. The recommended content of these training modules is presented below: 1. Training module for waste management operators a) Information on the risks; advice about health and security b) Basic knowledge about procedures of wastes handling, including the management of risks. c) The use of protection and security equipment. 2. Training module for waste transportation staff a) Risks linked with waste transportation; b) Procedures for waste handling: loading and unloading; c) Equipment such as vehicles for waste transportation; 45 d) Protection equipment. 3. Training module for treatment systems operators a) treatment and operating process guidelines; b) health and security related to the operating system; c) procedures in emergency cases and help; d) technical procedures; e) caring for equipment. f) control of waste production; g) watching over the process and the residues. 4. Training module for disposal managers a) Information about health and security b) Control of scavenging activities and recycling of used instruments; c) Protection equipment and personal hygiene ; d) Secure procedures for the management of wastes at the disposal site ; e) Measures concerning emergency cases and help. 5. Training modules for HF staff a. Administrative staff 1) Information on the risks 2) Advice about health and security 3) Basic knowledge about procedures of ICWM; 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 ICWM. b. Doctors, clinicians, nurses, midwives, etc. 1) Information on the risks; advice about health and security 2) Basic knowledge about procedures of ICWM waste collection, storage, transportation, treatment and final disposal including the management of risks. 3) The use of protection and security equipment (protective clothes) 4) 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 safe from injury or hazards resulting from HCW 5) HCW segregation at source 6) How to orient the staff on the guidelines for waste management 7) Good practices on ICWM c. Cleaners, ward attendants, grounds attendants, other personnel in touch with waste, etc. 1) Information on the risks; advice about health and security 2) Basic knowledge about procedures of ICWM waste collection, storage, transportation, treatment and final disposal including the management of risks. 3) The collection and transportation of HCW containers 4) The use of protection and security equipment (protective clothes) 5) Good practices on ICWM 6.4 PUBLIC AWARENESS STRATEGY The awareness raising strategy will aim at the general public and scavengers. They must be informed about dangers associated with HCW handling. This objective can be achieved through information and awareness campaigns on local radio (120 messages, 2 message per month, during the 5 years period) and television (30 messages, 6 messages per year, during the 5 years period), but mostly, by animation sessions organized by NGOs and CBOs active in health and environment management (nearly 120 46 animations, 20 per District x 10 Districts). These actions can be reinforced by education campaigns (1000 posters, 20 units for 500 health facilities) in health facilities in other highly frequented places. Another concern is to ensure that HCW from home care are well-managed. In fact, advances in medicine now allow monitoring family health and treating some sickness at home. Such activities have the effect of introducing infectious wastes closer to households. These health care wastes include: used razor blades, needles, syringes and lancets, medicine unused or outdated, broken thermometers, etc. These must be managed at home where health care is practiced, to avoid their mingling with household wastes and increasing hazardous risks. It is therefore necessary to elaborate information and awareness programs through most forms of media (newspapers, flyers, radio, television, etc.) towards the health agents (professionals, traditional, and family members) who exercise in the home. The targeted actors must be advised to have specific containers for needles, sharp objects (box, empty bottles, etc.) and other HCW (cotton, gloves, bandages, etc.) and not to mix the HCW with the general household or office wastes. Used needles, syringes, lancets and other sharps may be safely disposed with other home solid wastes, provided that special care is taken while packaging them. The safe packaging of these wastes 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 be recycled or returned to a store; needles and syringes don’t need to be recapped. The rigid bottle will minimize possible needle pricks and when they are full, the lid should be tightly fixed and the bottle placed with other solid waste for disposal. Unused and expired medicines stored at home are considerable risks for children and careless people. These medicines may be safely disposed of, by throwing them into a flushing toilet or Pit latrine. A thorough 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 of children who should not play with unclean empty medicine containers. Contaminated bandages, pads, gloves, etc., may be double bagged in plastic waste bags and securely fastened. This material should be taken back to the Health Care Facility or be thrown into a Pit latrine. Condoms are not considered as Health Care Waste (they are protective materials against HIV/AIDS infection). It is possible, in the programs for public awareness raising, to draw people’s attention to the 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 or throw in a pit toilet 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 also have sterilizing products in order to sterilize all the HCW before disposal. The needles must be buried if there is a place for this inside one’s premises; if not, they must be put into bottles or other closed boxes, and then evacuated to the public landfill (or health care facility). Other HCW (cotton, gloves, bandages, etc.) could be disposed in the public landfill after sterilization. Gloves should be torn to prevent people from re-using them and risking infection. 47 7. THE INFECTION CONTROL AND WASTE MANAGEMENT PLAN (ICWMP) 7.1 MAJOR OBJECTIVES OF THE ICWMP The following is an outline of the major objectives of the ICWMP: OBJECTIVE 1 : REINFORCE THE NATIONAL LEGAL FRAMEWORK FOR ICWM. The legal framework needs to be improved. In particular, it is necessary to set up a legal regime that spells out the illegality of mismanaging HCW, legal requirements for all persons in the HCW field, including codes of practices and methods of enforcement of the requirements. Strategy: a) Creating, consolidating, reviewing and updating laws, bylaws and regulations related to ICWM ICWM is currently weakly dealt with in various pieces of legislation and a thorough reviewing and consolidation is necessary to bring the whole legal basis for ICWM up to speed with the current developments in the country. The legal update should result in a law that includes the following: a clear definition of roles and responsibilities of such institutions as the MTEC, and MoH and the Municipalities, a clear and properly categorized definition of hazardous waste; detailed legal requirements for all persons who are producers, carriers, or who are engaged in the treatment and disposal of hazardous HCW so as to prevent harm to human health or pollution of the environment; the methodologies for record keeping and reporting; a regulatory system for enforcing the law; the penalties applicable to offenders; and the designation of the law courts where cases will be tried. The legal system must be laid out in such a way that at each Health Care Facility, the ICWM will be regulated as follows: ▪ The roles and responsibilities for ICWM will be defined; ▪ An internal HCW management plan is established and implemented; ▪ An office responsible for monitoring the ICWM plan is designated; ▪ The treatment system for the Facility is defined and known; ▪ Financial provision for ICWM in the health centers budget is scheduled and assured; ▪ Procedures of positive and negative sanctions for staff, according to their involvement in HCW management are adopted and implemented. b) Development of technical guidelines for HCWM The MoH must undertake to develop Health Care Waste Management Guidelines. This should be possible using the information gathered from the rapid assessment programme. The technical guidelines should be practical and directly applicable, and include the following specifications, with a sufficient degree of detail such as: i. legal framework covering safe health-care waste management; hospital hygiene and occupational safety and health; ii. limits on emissions of atmospheric, land and water resources pollutants and releases into water resources; 48 iii. responsibilities of health-care facilities, health-care waste producers, and public waste disposal agencies; iv. safe practices for waste minimization; v. Segregation, handling, storage and transport practices of health-care waste; recommended treatment and disposal methods for each health-care waste category. c) Establishing control procedures for HCW management within all institutions generating and handling HCW Information about any activities at the Health Care Facilities is hard to come by due to lack of standard operating procedures (SOPs). This makes planning a very difficult process as no baseline data can be availed. The following can assist to bring about control and maintenance of records: o Elaborate specific EIA guidelines for waste management, including HCW; o Implement clear directives for health control agents; o Set up a waste generation register for HCW quantities produced by health centers; o Define the mechanisms of control in needles and sharps collection and disposal process; o Organize regular monitoring by technical staff in District Health Offices. OBJECTIVE 2 : TO IMPROVE THE INSTITUTIONAL FRAMEWORK FOR ICWM The institutional framework needs to be carefully worked on and improved. In particular, it is necessary to set up a structure to coordinate and to follow up the Plan of Action (POA) and to develop specific technical guidelines for the health centers in terms of definition of responsibilities and setting standards and norms for good ICWM practices (e.g., reduction, selection and separation at source), and procedures for storage, handling, transformation, treatment and disposal. Strategy: a) Defining and harmonizing the duties and responsibilities of each actor involved in ICWM process at all levels. The various actors in ICWM are not sure of their parameters and limits to the extent that functions tend to overlap, causing confusion to the clients and at times leaving gaps as people will be unsure whose responsibility it would be. A roundtable of all the players is thus needed firstly to sensitize them on the Rapid Assessment findings and then agree on the roles and responsibilities of each player. b) Establishing of Taskforces/Working Groups (coordination structures) on health care waste management at national level This structure would include all the actors involved in ICWM (MoH, MTEC, NGOs, Local Authorities, Health facilities, etc.) c) Facilitating the establishment of inter-sectoral taskforces/working groups and focal points at all operational levels A similar structure to the national level structure must also be established at operational levels, i.e. a structure which includes all the actors involved in ICWM (MoH, MTEC, NGOs, Local Authorities, Health facilities, etc.) d) Creating awareness and lobbying for support for the ICWM program Generally HCW is treated as general waste and the risks associated with it are not taken into consideration. It is thus imperative that awareness levels be raised to acceptable levels and that support be garnered at all possible levels for this program to the extent of being included in national budgets 49 e) Conducting operational research and development related to ICWM There are a lot of grey areas in the field of ICWM especially in the area of disposal. It would be worthwhile to at least support one operational research every year. This would go a long way in opening up a once dark and stigmatized field. f) Developing of Monitoring and Evaluation plan Implementation of ICWM plans needs to be monitored and evaluated in order to assess success of the program. Monitoring and Evaluation tools need to be developed and surveillance be undertaken. OBJECTIVE 3 : TO ASSESS THE ICWM SITUATION, PROPOSE OPTIONS FOR HEALTH CARE FACILITIES AND IMPROVE THE ICWM IN HEALTH CARE FACILITIES. The Infection Control and waste management system implementation in the country is generally deteriorating, but the extent of deterioration needs to be more thoroughly assessed (beyond what the rapid assessment did) using a well stratified sample of all the Health Care facilities in the country and then derive the best technical options for HCW segregation, collection, containment, storage, transportation, and disposal according to type of HCW and size and location of Health Care Facility. The provision of infrastructure and equipment must be attached to strict directives and guidelines that must be adhered to in implementing the programme. A centralized approach in which major equipment is centralized at Municipalities or District Health Management Teams(DHMTs), will help reduce the equipment requirements as the surrounding facilities can all use one set of treatment facility. Strategy : a) Carrying out a National Inventory of Health Care Facilities {HCFs} to help establish the ICWM situation in the country. A well stratified sample of all the health care facilities in the country must be taken and assessed to ascertain the true picture of current status of ICWM. b) Choosing the best technical options for HCW segregation, collection, containment, storage, transportation and disposal according to (a) type of HCW (b) the size and location of the HCF. c) Implementing pilot projects. Before full scale implementation of the ICWMP is developed, it is advisable to carry out pilot programmes to test the feasibility of the proposed plans of action. d) Providing infrastructure, materials and equipment to HCFs based on conditions on site. Each Health care Facility requires a different approach to handling HCW. This must be assessed correctly and the best practicable option determined. This will be cost effective and will provide each institution with exactly what it needs: i. Supply the health facilities with collection and storage materials; ii. Implement an efficient HCW treatment system (for example modern incinerators for Municipalities, DHMTs, Central and Regional Hospitals; local incinerators in minor and major health centers); iii. Install liquid waste treatment systems in health facilities (septic pits/tanks with a chemical disinfection system for the District hospitals, health centers; as for central and general hospitals, a physical and chemical treatment is recommended); 50 iv. Operate systematic HCW segregation procedures. Note: The health centers should be supplied with specific containers for needles and other sharp objects. Already used empty bottles (flacons, mineral water bottles, etc.) could replace these boxes. Plastic containers for temporary storage should be supplied to health care rooms. e) Ensure appropriate protection equipment to health staff HCW handling is risky business and those involved in it must be properly protected. All necessary protective gears must be availed to them to protect them as they carry out their duties. OBJECTIVE 4 : TO CONDUCT AWARENESS CAMPAIGNS FOR THE COMMUNITIES AND PROVIDE TRAINING FOR ALL ACTORS INVOLVED IN ICWM The general public is unaware of the risks associated with HCW and worse still when it is mixed with general waste which they target for scavenging. A serious awareness drive must be targeted at the general public to raise their awareness as they are in danger of handling infectious and toxic wastes unawares. Awareness programs for the general public should mainly be aimed at scavengers, children playing on the landfills, population performing or receiving home health care, those using recycled objects, and people living near the landfills. NGOs and Community Based Organizations (CBOs) enjoying a large experience in community communication and health activities would be best suited to conduct them. The staff members of Health Care Institutions also require training so that they can handle HCW appropriately in order not to expose themselves and the general public to infections. Strategy : a) Inform population of dangers linked with bad HCW management practices i. messages on television (about dangers related to the handling of HCW); ii. radio messages (mainly in local languages); iii. National awareness raising campaign (posters in health facilities, billboards, monthly public animation sessions in the Districts). b) Inform population of dangers linked to scavenged HCW materials i. messages on television (about dangers related to the handling of HCW); ii. radio messages (mainly in local languages); iii. national awareness raising campaign (posters in health facilities, billboards, and fliers) c) Inform home-based care givers / traditional healers of risks linked to improper HCW handling For more detailed information on the target groups and content of the proposed public awareness programs, please see Chapter 6 on Training needs analysis. d) Conducting awareness campaigns on proper handling of HCW Properly structured and planned, targeted awareness campaigns need to be carried out to raise the level of awareness about risks associated with HCW, of all sections of the society to acceptable levels e) Elaborate training programs and Train trainers i. Identify the training needs and the groups to be trained in the health facilities; ii. Train trainers. 51 - Organising training programmes for all stakeholders involved in ICWM with special emphasis on medical and non medical staff i. Train health staff in health facilities, Municipal Technical Services providers and other stakeholders; ii. Train waste handlers in health facilities (ward attendants, ground workers, cleaners, etc.). iii. It is recommended to update pedagogical references of training institutions in medicine, midwives, nurses and other health care training institutions by integrating ICWM issues in their pre-service training programs. f) Evaluate training program implementation HCW monitoring in health facilities should be carried out regularly, in order to improve waste management and to ensure that good practices are performed after training. Measures should be adopted to ensure that problems and risks involved are identified to enhance safety and preventing the development of future problems. Supervision should be in the following areas: i. segregation, ii. collection routines and labelling, iii. internal treatment system, iv. internal storage of HCW, v. transportation, vi. worker safety measures, vii. disposal at sanitary landfill, OBJECTIVE 5 : SUPPORT PRIVATE INITIATIVES AND PARTNERSHIP IN ICWM The private sector and other private individuals are currently not involved either in solid waste management or ICWM. Supporting the private sector to participate will be beneficial to the system as this will ensure injection of private sector funds into the system and introduce some business sense in the HCW arena. Strategy: a) Inform private companies of the business opportunities in solid waste management Business is not aware of the potential that awaits it in this sector, which is currently clouded by none funding of the programmes. Once funding start flowing in that direction, private players will be attracted. Government must support and promote this side of things. b) Develop sustainable financing mechanism for ICWM activities Innovative means of developing sustainable financing mechanism for the sector must be sought, including attracting the banking sector and NGOs. c) Set up framework and partnership between public sector and private sector in ICWM Such a partnership will be beneficial to the sector as financing will become more available and the private sector will have the assurance of the support of the public sector in its endeavours. OBJECTIVE 6 : DEVELOP AND OPERATIONALISE SPECIFIC FINANCIAL RESOURCES TO COVER THE COSTS OF THE MANAGEMENT OF HEALTH-CARE WASTES 52 It is absolutely necessary to develop and operationalize specific financial resources to cover the cost of ICWM for the purposes of sustainability. This means having specific budget lines for health care waste management issues from national to local level as a mandatory requirement. The execution of the plan then needs regular and sustained monitoring and evaluation. This will be done by establishing a reporting structure that has to be adhered to. Strategy : 1. Developing specific budget lines for ICWM at all levels of the accountancy (from national to local). 2. Lobby for prioritization and mandatory budgeting for ICWM. 3. Mobilising financial resources for ICWM capital and running costs. Resources can be mobilized nationally by using such instruments as the polluter pays and the user pays principles 4. Identifying the appropriate institutions through which the recovery mechanism can be implemented. If business sense is brought into the field of ICWM and acceptable segregation practices are adhered to, appropriate institutions can be attracted to engage in recovery programmes. 5. Monthly operational control reports Regular reporting has to be institutionalized and formalized in all Health Care Institutions. This will assist in the regular monitoring and evaluation of the execution of the programme. 6. Mid-term evaluation (end of year 2) Regular evaluation will assist in the regular monitoring and assessment of the execution of the programme. 7. Final Evaluation (end yr 5) There will be a final evaluation at the end of the 5 years. 53 7.2 THE ICWMP ACTION PLAN Table 7-1 ICWMP ACTION PLAN - LEGAL OBJECTIVE 1 : TO REINFORCE THE NATIONAL LEGAL FRAMEWORK FOR ICWM. Result 1: Enabling legal environment for ICWM available. Strategies • Developing a national policy for ICWM • Creating, consolidating, reviewing and updating laws, bylaws and regulations related to ICWM • Development of technical guidelines for ICWM • Establishing control procedures for HCW management within all institutions Procedures in place generating and handling HCW Activities Indicators Responsible Time frame Cost $US Person 2014 2015 2016 2017 2018 UNIT QNT UNIT TOTAL Y COST COST USD USD Analyse all existing laws, bylaws -Number of review Working X X X X 65 000.00 and regulations meetings held. Group -Number of HCW legal documents analysed. Develop regulations and bylaws -Availability of Director X X X 60 000.00 clearly highlighting the different gazetted regulations and Environmental responsibilities at all levels relating bylaws Health to ICWM Establishing procedures and roles -Standard Operating Director X X X 80 000.00 for controlling the flow/s of HCW Procedures which Environmental and increasing the responsibilities define roles and Health of all stakeholders responsibilities in place Develop the National Healthcare Final draft for the Working X X 45 000.00 waste Management guidelines. National guidelines. Group SUB - TOTAL 250 000.00 54 Table 7-2 ICWMP ACTION PLAN - INSTITUTIONAL ARRANGEMENTS OBJECTIVE 2 : TO IMPROVE THE INSTITUTIONAL FRAMEWORK FOR ICWM Result 2: Responsibilities, standards, and sanctions are clearly defined Strategies • Defining and harmonising the duties and responsibilities of each actor involved in ICWM process at all levels • Establishing of Taskforces/Working Groups (coordination structures) on health care waste management at National level • Facilitating the establishment of inter-sectoral taskforces/working groups and focal points at all operational levels • Creating awareness and lobbying for support for the ICWM program • Conducting operational research and development related to ICWM • Developing of Monitoring and Evaluation plan Activities Indicators Responsible Time frame Cost $US Person 2014 2015 2016 2017 2018 UNIT QNTY UNIT TOTAL COST COST USD USD Organise a national -National workshop Director X 5 000.00 workshop and give held Environmental feedback on findings of - Workshop report Health the Rapid Assessment produced Survey and expected roles and responsibilities of different players Cascade sensitization and -Number workshops Director X X 4 000.00 formation of taskforces at held Environmental operational levels -Number of taskforce Health committees formed Facilitating conduction of -Number of research All Focal X X X X X 30 000.00 at least one operational proposals submitted Persons research per year on and funded ICWM 55 -Number of researches conducted Development of -Availability of a Working X X X 5 000.00 Monitoring and surveillance system groups Evaluation tools for and baseline database ICWM including on ICWM establishment of a -Availability of M&E surveillance programme checklists on accidents related to ICWM Ensure ongoing and final -Updated ICWMP Director X X X X X 6 000.00 evaluation and updating of - M & E biannual Environmental the ICWMP as necessary. reports Health SUB-TOTAL 50 000.00 56 Table 7-3 ICWMP ACTION PLAN - SITUATION ANALYSIS AND IMPROVEMENT OBJECTIVE 3 : TO ASSESS THE ICWM SITUATION, PROPOSE OPTIONS AND IMPROVE THE ICWM IN HEALTH CARE FACILITIES. Result 3: Appropriate options available for the different categories of Health care facilities and HCW collected and treated in a safe and secure way Strategies • Carrying out a National Inventory of Health Care Facilities {HCFs} to help establish the ICWM situation in the country. • Choosing the best technical options for HCW segregation, collection, containment, storage, transportation and disposal according to (a) type of HCW (b) the size and location of the HCF. • Implementing pilot projects before setting up the ICWMP. • Providing infrastructure, materials and equipment to HCFs based on Number of equipment conditions on site. • Ensure appropriate protection equipment to health staff Number of equipment Activities Indicators Responsible Time frame Cost $US Person 2014 2015 2016 2017 2018 UNIT QNTY UNIT TOTAL COST COST USD USD Conduct a National Inventory of Inventory Director X 80 000.00 ICWM in Health Care Facilities document DEH (HCFs.) Analyze the inventory data and Report Working X 15 000.00 develop options group provision of adequate collection National Working X X 80 000.00 equipment, sanitation and proper standard group disposal of wastewater. procedures in place. 57 Carry out requisite Maintenance Treatment Working X X X X 215 000.00 works at the different treatment facilities group facilities. selected Build stabilized concrete lined Infrastructure X X X X X 110 000.00 pits in rural health centers, and equipment Steering Clinics, and for home based care. availed committee SUB-TOTAL 500 000.00 58 Table 7-4 ICWMP ACTION PLAN - TRAINING AND GENERAL PUBLIC AWARENESS. OBJECTIVE 4 : TO CONDUCT AWARENESS CAMPAIGNS FOR THE COMMUNITIES AND PROVIDE TRAINING FOR ALL ACTORS INVOLVED IN ICWM Result 4: All ICWM actors are conscious of risks and demonstrate good ICWM practices Strategies • Inform population of dangers linked with bad HCW management Posters, radio and televised messages, practices public animations sessions, etc. • Inform population of dangers linked to scavenged HCW materials • Inform home-based care givers / traditional healers of risks linked to improper HCW handling • Conducting awareness campaigns on proper handling of HCW • Elaborate training programs and Train trainers Programs elaborated and Number of trained trainers • Organising training programmes for all actors involved in ICWM % of trained staff with special emphasis on medical and non medical staff • Evaluate training program implementation Appraisal reports Activities Indicators Responsible Time frame Cost $US Person 2014 2015 2016 2017 2018 UNIT QNTY UNIT TOTAL COST COST USD USD Develop specific ICWM -Availability Working X X X X X 135 000.00 Information Education and of specific Group/ Health Communication (IEC) materials IEC materials Promotion Directorate Initiate a national awareness -Number of Working X X X X X 106 000.00 campaign through various media awareness Group/ Health e.g. posters, print media, electronic campaigns Promotion media, and group discussions. held Directorate Conduct a training needs analysis -Number of Working X X X X X 20 000.00 for actors involved in ICWM. training needs Group/ Health identified Promotion Directorate 59 -Training program developed Lobby to include ICWM in the -Number of Head of X X X X X 18 000.00 training curricula for health meetings held Environmental personnel -Availability Health of reports Conduct on the job training of -Number of Working X X X X X 50 000.00 trainers (TOT) on ICWM and TOT sessions group cascade training to operational held levels -Number of trainers trained -Number of trainings cascaded SUB-TOTAL 329 000.00 60 Table 7-5 ICWMP ACTION PLAN - PRIVATE SECTOR PARTICIPATION OBJECTIVE 5 : TO SUPPORT PRIVATE INITIATIVES AND PARTNERSHIP IN ICWM Result 5. : Private players involved in ICWM Strategies Inform private companies of the business opportunities in solid waste Awareness programs management Develop sustainable financing mechanism for ICWM activities Annual financial Flows Set up partnership framework between public sector and private sector in ICWM Number of Partnership Agreements Activities Indicators Responsible Time frame Cost $US Person 2014 2015 2016 2017 2018 UNIT QNTY UNIT TOTAL COST COST USD USD Organise a workshop for -National workshop Director X 15 000.00 potential Private players and held Environmental appraise them on the potential - Workshop report Health role they can play produced Establish Private – Public sector -Number Director X X X X 10 000.00 partnership forum. consultations made. Environmental Health -Number of taskforce committees formed Establish financing mechanisms -Banking sector Director X X X X 5 000.00 to attract business community involvement secured Environmental to participate in ICWM. -Donor community Health sensitized. -Waste generators budgeting for its management. SUB-TOTAL 30 000.00 61 Table 7-6 ICWMP ACTION PLAN - FINANCIAL AND OPERATIONAL ISSUES OBJECTIVE 6 : TO DEVELOP AND OPERATIONALISE SPECIFIC FINANCIAL RESOURCES TO COVER THE COSTS OF THE MANAGEMENT OF HEALTH-CARE WASTES. Result 6: ICWM activities are budgeted for, monitored, evaluated and documented Strategies • Developing specific budget lines for ICWM at all levels of the accountancy (from national to local). • Mobilising financial resources for ICWM capital and running costs. • Identifying the appropriate institutions through which the recovery mechanism can be implemented. • Monthly operational control reports Monthly reports • Mid-term evaluation (end yr 2) Evaluation report • Final Evaluation (end yr 5) Evaluation report Activities Indicators Responsible Time frame Cost $US Person 2014 2015 2016 2017 2018 Lobby for the establishment of a ICWM budget Steering X 10 000.00 specific budget line for ICWM line item Committee established Mobilize resources utilizing Resources Steering X X X X X 20 000.00 instruments such as the ‘Polluter mobilised Committee Pays Principle’ Raising financial resources through Funds raised Working X X X X X 20 000.00 User Fees charges for private HCW group generators SUB-TOTAL 50 000.00 62 7.3 SUMMARY OF COSTS Table 7-7 Summary of costs OBJECTIVE TOTAL COST $US 1. TO REINFORCE THE NATIONAL LEGAL FRAMEWORK FOR ICWM. 250 000 2. TO IMPROVE THE INSTITUTIONAL FRAMEWORK FOR ICWM. 50 000 3. TO ASSESS THE ICWM SITUATION, PROPOSE OPTIONS FOR HEALTH CARE FACILITIES AND 500 000 IMPROVE THE ICWM IN HEALTH CARE FACILITIES. 4. TO CONDUCT AWARENESS CAMPAIGNS FOR THE COMMUNITIES AND PROVIDE TRAINING FOR 329 000 ALL ACTORS INVOLVED IN ICWM. 5. TO SUPPORT PRIVATE INITIATIVES AND PARTNERSHIP IN ICWM 30 000 6. TO DEVELOP AND OPERATIONALISE SPECIFIC FINANCIAL RESOURCES TO COVER THE COSTS 50 000 OF THE MANAGEMENT OF HEALTH-CARE WASTES. GRAND TOTAL 1 209 000 Due dates and source of financing are indicated in table 7-6. 63 8. BUDGET FOR THE ICWMP 8.1 INTRODUCTION The estimated cost of implementing the ICWMP and enhancing this process of proper handling, disposal and management of medical waste is US $ 1 209 000.00. The estimated costs of implementation for the ICWMP will be covered by the MOH, the IDA project and other development partners as detailed below: 8.2 ESTIMATED COST OF IMPLEMENTING THE ICWMP Table 8-1 below provides details of the implementation costs per component of the ICWMP, and Table 8-2 provides estimated yearly costs of the ICWMP implementation. Table 8-1 Implementation costs of the ICWMP OBJECTIVES STRATEGIES UNIT QUANTITY UNIT TOTAL COST USD USD Reinforce the Development of HCW Policy, Man/day 348 400 138 000 National legal Regulations, technical guidelines and framework for standard operational procedures ICWM. Printing the documents for circulation U 7857 14 112 000 Sub-total 250 000 Improvement of Workshops 10 000 institutional Taskforce business 7 000 Arrangements Awareness and lobbying 10 000 Operational research 23 000 Sub-total 50 000 Improvement of Piloting some technologies in the various 80 000 ICWM in the categories. health facilities Supply the health services with adequate 80 000 HCW collection equipment Build low cost, local material U 10 25 000 230 000 incinerators in health centers, clinics and Public Health Units. Build stabilized concrete lined pits in U 200 550 110 000 rural health centers, Clinics, and for home based care Sub-total 500 000 Training programs formulation of comprehensive training Man/day 125 400 50 000 and Public manuals relevant to the target groups awareness Printing the documents for circulation U 2572 14 36 000 Training of trainers Man/day 233 120 28 000 Training of medical staff Man/day 750 120 90 000 Training of supplies staff Man/day 500 100 50 000 Televised messages U 19 900 17 000 64 OBJECTIVES STRATEGIES UNIT QUANTITY UNIT TOTAL COST USD USD Radio messages U 70 400 28 000 Posters in Health centers U 3333 6 20 000 Public animation sessions U 25 400 10 000 Sub-total 329 000 Supporting Private Advocacy and lobbying at different fora Man/day 200 100 20 000 Initiatives Public-Private partnership Forum 10 000 business Sub-total 30 000 Support for the Plan starting activities and Man/day 50 100 5 000 execution of institutionalizing ICWM ICWM Plan Establishing the User Pays and the Man/day 50 100 5 000 (Management Of Polluter Pays Systems Health-Care Monitoring at national and local level Man/day 42.5 200 8 500 Wastes) Halfway evaluation Man/day 30 450 13 500 Final evaluation Man/day 40 450 18 000 Sub-total 50 000 TOTAL 1 209 000 Table 8-2 Annual costs of the ICWMP implementation ICWM Plan Activities YR 1 YR 2 YR 3 YR 4 YR 5 TOTAL Reinforce the National legal framework for ICWM. 250 000 ---------- --------- --------- --------- 250 000 Improvement of institutional Arrangements 50 000 ---------- -------- --------- --------- 50 000 - Improvement of ICWM in health facilities 200 000 100 000 100 000 50 000 50 000 500 000 Training for health staff and others actors active in 369 000 220 000 115 000 15 000 10 000 329 000 ICWM and Public awareness (general public) Supporting Private Initiatives 20 000 5 000 5 000 ------- --------- 30 000 Support for the execution of ICWM Plan (Management 25 000 10 000 5 000 5 000 5 000 50 000 Of Health-Care Wastes) TOTAL 914 000 335 000 225 000 70 000 65 000 1 209 000 8.3 MOH CONTRIBUTION TO THE IMPLEMENTATION OF THE ICWMP Table 8-3 MHSW Contribution to the Implementation of the ICWMP Source of Type of Committed or Value of contributions contribution contribution projected US$ MoH Cash Projected 75 000.00 Labour Projected 15 000.00 TOTAL Organization 90 000.00 contributions 65 8.4 CONTRIBUTION FROM IDA PROJECT Table 8-4 Contribution From IDA Project Source of Type of Committed or Value of contributions contribution contribution projected US$ IDA Cash Projected 300 000.00 TOTAL Organization contributions 300 000.00 8.5 CONTRIBUTIONS FROM OTHER SOURCES/PARTNERS Table 8-5 Contributions from Other Sources/Partners Source of contribution Type of Committed or Value of contribution projected contributions US$ WHO Projected 15 000.00 US AID Projected 34 000.00 TOTAL Organization contributions 49 000.00 8.6 PROJECT FUNDING SUMMARY Table 8-6 Project funding summary FUNDING SOURCE DUE YR 1 YR 2 YR 3 YR 4 YR TOTAL DATE 5 US$ Contribution from IDA project 300 000.00 MoH contribution 90 000.00 Contributions from WHO, US-AID 49 000.00 Contributions from Other 1,169,600.00 Development Partners TOTAL PROJECT COST 1 209 000.00 The IDA project will cover some of the training and general public awareness costs as outlined in tables 7-4, 8-4 and 8-6. The MoH will thus require a further US $ 1 218 600.00 external support from other developing partners to be able to implement the ICWMP effectively. 66 9. ICWMP IMPLEMENTATION MODALITIES 9.1 INSTITUTIONAL FRAMEWORK The ICWMP falls directly under the responsibility of the Environmental Health Department (EHD) of MoH. The Department will coordinate the implementation and apply a multi-stakeholder approach to embrace all the relevant players to include MTEC, Local Authorities, NGOs, and other private players. 9.2 RESPONSIBILITIES Part of improving ICWM involves clarifying who is responsible for what functions and identifying the fields of competencies of each institutional actor involved in this process. The following roles and responsibilities are suggested: At the central level: The MoH is responsible for the national health policy and ensures the guardianship of the health facilities. The Environmental Health Department (EHD) will take the lead in coordinating the implementation of the ICWMP because: i. it is part of its mission, ii. it has competent staff in this field, iii. it has decentralized services down to District level and iv. it has capacity to offer Health Education Service, public information and awareness raising. The Environmental Health Department will be heavily involved in overseeing the following ICWM activities: a) Procurement of consumables (sharp containers, colour coded bin liners) b) Procurement of re-usable waste receptacles c) Running maintenance of existing incinerators d) Ensuring availability of land for new sites for installation of new waste treatment and disposal facilities e) Organising /facilitating capacity building on ICWM amongst Health Care Workers f) Providing human resources (waste handlers, incinerator attendants etc.) MoH has no direct budget for Healthcare waste management activities but to implement such a programme MoH has been spending around US$ 74 750.00 annually (See table 9-1 below). 67 Table 9-1 MOH Estimated Annual Expenditure on ICWM No. EXPENDITURE CATEGORY TOTAL (US$) 1. Personnel/Labour 20 000.00 2. Equipment/materials 11 000.00 3. Training/seminar/workshops 9 000.00 4. Contracts 12 000.00 5. Other costs (Transport and allowances) 8 000.00 6. Incidentals 2 000.00 7. Admin (10%) 6 200.00 8. Contingency (5%) 3 100.00 TOTAL 71 300.00 (Source:.... derived estimates from Lesotho Health Profile and interviews with MoH) The Environmental Health Department (EHD) is the lead agent for this programme and its work plan is as outlined in table 9-2 where it will be guiding the whole process. The Environment Department of MTEC will be responsible for monitoring of the implementation of the ICWMP. It has the overall responsibility of protecting the environment and thus ultimately the activities of the Environmental Health Department of MoH must conform to the requirements of the Environmental Management Act. It will watch over the whole chain of HCW from generation to final disposal. The Environment Department is also responsible for developing norms and standards for soil, water and air protection, mainly as they relate to the use of landfill sites for HCW disposal. This function is very important as this assures an independent control and monitoring mechanism for the system to bring about safe handling of HCW throughout the system. At the District / Local Authority level: The Districts and Local Authorities will need to put in place arrangements to make sure that HCW are not mixed with general wastes in their public landfills. This is becoming a challenge, with the advent of home based care in urban areas and innovative ways of convincing the public to separate at source have to be found. The Districts and Local Authorities must ensure, either by themselves or through partnerships, that facilities capable of handling all the HCW generated in their areas of jurisdiction are in place. They should be responsible for a centralized ICWM regime within their areas of jurisdiction. They should also give their opinion about the ICWMP activities proposed for health facilities in their jurisdiction, in case some may have negative impacts on the local population’s health. Coordination of the ICWM activities will be exercised by their respective Environmental Health Departments. The Districts and Local Authorities should design their landfills according to the norms and standards defined by the Environment Department (MTEC), in order to avoid soil, water and air pollution in case of reception of HCW. To accomplish safe disposal of HCW, especially the ash from incinerators, specific areas should be reserved for that purpose. In addition, local governments should enact regulations to: (i) refuse to receive mixed HCW with non infectious wastes at local landfills; (ii) forbid uncontrolled HCW disposal; and (iii) set up strong waste management controls in their landfills (materials for covering, restriction for non authorized public access, equipment protection, etc.). 68 At the health care facility level: The manager of each health care facility shall be responsible for ICWM in his/her establishment. The manager must ensure that a ICWM plan is prepared and then institute all the requirements of the national policy, regulations and standard operating procedures. S/he must designate the officers/teams charged with HCW segregation, collection, transportation and treatment and be overally responsible. 9.3 INSTITUTIONAL ARRANGEMENTS FOR ICWM IMPLEMENTATION Effective implementation of the ICWMP components requires that institutional arrangements and responsibilities be clearly defined. The following institutional arrangements are proposed: i) Improvement of institutional and legal framework The co-ordination structure should be set up by the Environmental Health Department (EHD). This Unit should take the lead in developing the HCW regulations and technical guidelines. ii) ICWM improvement at health facilities The improvement of ICWM at health care facilities should be managed by the Environmental Health Department (EHD) and Health facility managers working together. For example, EHD should regulate the ICWM in health facilities, in line with their own regulations and MTEC requirements. MoH should supply the health facility managers with ICWM equipment and materials, but actual execution of ICWM improvement programs should be conducted by health care facility managers and their staff. Health care facility managers should promote use of recyclable materials and set up control procedures in HCW management, under the supervision of EHD. iii) Training Training activities should be led by the EHD of the MoH. This structure has competence in ICWM and could be supported by training and higher learning institutions like the University, the Polytechnic, and other institutions. At District level, management of training activities should be assigned to the District Health Management Teams(DHMT). The specific training activities will be done in the first two years of the programme. National Consultants will train key staff as trainers in health facilities and other institutions like the Municipalities. The trained key staff should then train the other employees. The EHD may not have the human resources to prepare and diffuse the training courses about ICWM. The EHD could prepare the TORs, and do the control and supervision at national level while District Health Management Teams(DHMT) would assume the monitoring at local level. In other words: a) The EHD prepares the Terms of Reference for developing the training programs, and does the control and supervision at national level ; b) Health Training Institutes or National Consultants having acquired a large experience in ICWM will prepare the training courses; c) In each District, a training of trainers workshop will be held and will be conducted by Training institutions or national consultants, under the supervision of the DHMTs. The latter must prepare periodic reports to be sent to the central level (EHD/MoH); 69 d) In each health care facility, the supervising staff trained in the District workshops will ensure the training of all medical staff, orderlies, cleaners, etc., under their supervision. The heads of the health establishments must supervise this work and prepare periodic evaluation reports. iv) Public Awareness The Health Education/Environmental Health Department of the MoH will lead the activities intended to increase the awareness of the general public about the risks associated with HCW. At local level, DHMTs will do the supervision. These activities will cover the 5 years of the program, through Public animations, radio and television messages, posters, etc., and will be done as follows: 1. The Health Education/Environmental Health Department of the MoH will elaborate the content of these messages, of posters and public animation; 2. The televised messages will be diffused by the National Station; 3. The radio messages will be diffused by the local radio stations, in English and local languages, under the supervision of District Health Teams 4. Private companies (printing enterprises) will make posters to be used in the health centers; 5. Public animation sessions will be led by NGOs acting in the health and the environmental field, under the supervision of District Management Teams. v) Strategy for private sector involvement and partnership The elaboration of measures to involve private companies more directly in ICWM will be coordinated by the MoH, in collaboration with other stakeholders. vi) Baseline Survey and Activity Planning National Consultants, supervised by DHMTs and EHD, will carry out a baseline survey at the beginning of the investment phase. During this task, the consultants will indicate the situation prevailing presently in the health facilities, elaborate evaluation criteria, and prepare the execution plan. vii) Monitoring of the ICWMP At the local level, it is recommended that the DHMTs ensure regular program oversight and provide monthly monitoring reports, while the six-monthly follow up will be realized by EHD. viii) Evaluation of the ICWM Plan It is recommended to assign this evaluation to international consultants (under the supervision of EHD), to ensure its neutrality. This evaluation must be done halfway through (at the end of the 2nd year) and at the end of the first phase of the program (year 4). The following table shows the implementation responsibilities for the ICWMP. Table 9-2 Implementation Responsibilities by Component COMPONENTS AND ACTIVITIES EXECUTION CONTROL AND SUPERVISION Improvement Set up a structure for coordination EHD MoH/MTEC of ICWM and follow up the POA institutional Develop regulations for ICWM Consultants EHD/ MoH and legal Develop technical guidelines for Consultants EHD/ MoH framework ICWM 70 COMPONENTS AND ACTIVITIES EXECUTION CONTROL AND SUPERVISION Improve Regulate the HCW management in EHD EHD/ MoH and MTEC ICWM in health facilities. health Supply HF with ICWM equipments Health facilities EHD/ MoH facilities and materials. Ensure appropriate protection Health facilities EHD/ MoH equipment for health staff. Promote use of recyclable materials. Health facilities EHD/ MoH Set up procedures of control in Health facilities EHD/ MoH HCW management. Training Elaborate training programs and Consultants/training EHD/ MoH train trainers. Institutes. Train all health staff active in Supervising staff/ EHD/ MoH ICWM Training Institutes. Evaluate the training program Heads of Health centers EHD/ MoH implementation Health Districts Public Televised messages National Television Health Education /EHD awareness Messages radio local Radios Health Education /EHD Posters in health facilities Printers societies Health Education /EHD Public animation sessions NGO and CBO Health Education /EHD Support the Diffuse information about business EHD MoH private opportunities in solid waste initiatives and management partnership Develop partnership arrangements EHD /Health Facilities MoH / Ministry of Local in ICWM between public sector and private Region and Local Government sector for ICWM Authorities Support the Plan ICWM activities National Consultants EHD/ MoH execution of Monitor the execution (national and Health District EHD/ MoH ICWM local level) Plan Evaluation of the ICWM POA International EHD/ MoH, /MTEC and (halfway and final) Consultants Local Authorities 9.4 IMPLEMENTATION TIMEFRAME The following timetable shows the proposed implementation schedule of the ICWM Plan over a five year period. Table 9-3 Implementation Timetable ICWM Plan Activities YR 1 YR 2 YR 3 YR 4 Development of ICWM policy Regulation of HCW management Development of technical guidelines and standard operation procedures for ICWM Institutional arrangements - Set up a structure for coordination and follow up of the POA Improvement of ICWM in health facilities Elaboration of training programs and training of trainers Training for health staff active in ICWM Public awareness (general public) Supporting private initiatives and partnership in ICWM Monitoring and evaluation of the ICWM plan 71 Before such an elaborate plan is implemented, certain activities can be started immediately, and others may be realized over the medium/long term. The following actions could be realized immediately: • set up a structure for coordination and follow up of the Plan of Action (POA) • elaboration and dissemination of Policy, regulations, technical basic guidelines and standard operational procedures in ICWM • elaboration of ICWM training program • elaboration of public awareness training modules and supports • set up ICWM procedures in health facilities, including health staff responsibilities In the short term: • training of trainers • training all the stakeholders involved in the ICWM • dissemination of public awareness programmes • assessment of training program implementation • halfway appraisal In the medium/longer term: • improvement of the ICWM in the health facilities • Supporting of the private initiatives and partnership in ICWM • Monitoring and evaluation of the ICWM plan 9.5 POTENTIAL PARTNERS AND FIELD OF INTERVENTION Delivery of essential health services relies on the involvement of a wide range of actors -- public and private sectors, NGOs, and civil society. So it is necessary to establish a partnership framework to identify the roles and responsibilities of each category of actor. Table 9-4 Potential field of intervention ACTORS POTENTIAL FIELD OF INTERVENTION Technical services of the - inform the local and national authorities State (MoH / MTEC) - facilitate co-ordination of ICWM plan activities - supply technical expertise - execute control and monitoring activities - train the health staff - supervise the training process, monitoring and evaluation Local Authorities / - participate in the mobilization of populations Districts - ensure HCW are properly disposed in their landfill - participate in training, monitoring and evaluation Public health facilities / - participate in training activities Private health facilities - supply staff with security equipment - elaborate internal plans and guidelines about ICWM - allocate financial resources for ICWM - ensure HCW management plan is implemented Private operators - invest in ICWM (e.g., treatment, transport, disposal) - operate as sub-contractors (Local Authorities / Districts / Health Facilities) 72 ACTORS POTENTIAL FIELD OF INTERVENTION NGOs and CBOs - inform, educate and make population aware - participate in / offer training activities Training - provide health staff training Institution 9.6 INVOLVEMENT OF PRIVATE COMPANIES IN ICWM HCW collection is a major concern for public and private health facilities. According to environmental regulations, health facilities must ensure sustainable management of their wastes. However, in practice health care facilities have very limited financial resources, and no public health establishment has funds to pay for collection or disposal services for wastes. For health care facilities having incinerators, waste collection is less of a concern. For private facilities, the major constraints are the absence of alternative solutions to their present practices; HCW co-mingled with general wastes and crude disposal. Most of them can’t afford appropriate equipment for treatment. In terms of HCWM the Ministry of Health is assisted by Lesotho Millennium Development Authority (LMDA) for collection and treatment of HCW in its facilities. LMDA has sub-contracted other companies for this function. The contracted companies are expected to supplier the health facility with waste management equipment (container, liners). It collects HCW from the Health facilities for treatment at the incinerator at the hospitals. It is also mandated to maintain day to day running of the incinerator. They are again expected to collected and transport general waste from the hospital for disposal at a designated disposal site. Both public and private facility managers and staff express a willingness to participate in an institutional arrangement whereby costs of treating their HCW could be shared under a common agreement. Such a public-private partnership arrangement could be put in place on the basis of the following principles: - selected public health care facilities would be equipped with incinerators to serve a defined geographic radius; - health centers equipped with incinerators would agree to accept and treat HCW from private facilities and smaller health centers within their service area; - private health facilities receiving such HCW treatment services would agree to pay a collection / treatment fee as per the terms of the cost sharing agreement. Long-term private sector involvement in the ICWM business will depend on whether national, local, and municipal authorities are able to put in place self-sustaining sources of financing to cover investment and operating costs for this critical environmental and public health service. If the financial equation is solved, then private sector operators can be expected to identify their individual comparative advantage and explore contractual arrangements to provide a range of services for health care facilities and landfill sites (e.g., transport, treatment, and disposal). 73 10. HANDLING HEALTH CARE WASTE STREAMS 10.1 RECOMMENDED SYSTEM FOR HANDLING WASTE The management of waste must be consistent from the point of generation (“cradle�) to the point of final disposal (“grave�). The path between these two points can be segmented schematically into eight steps. The following is an outline of the recommended system for handling waste streams in Lesotho: Step 1: waste minimization This first step comes prior to the production of waste and aims at reducing as much as possible the amount of HCW that will be produced by setting up an efficient purchasing policy and having a good stock management, for example. Step 2: HCW generation This is the point at which waste is produced. Step 3: segregation and containerization The correct segregation of waste at the point of generation relies on a clear identification of the different categories of waste and the separate disposal of the waste in accordance with the categorization chosen. Health care waste can generally be classified into four fractions; (i) sharps, (ii) infectious or contaminated non-sharps (healthcare risk waste – (HCRW)), (iii) non-infectious or healthcare general waste (HCGW) and (iv) medical devices and radioactive materials. Segregation must be done at the point of generation of the waste. To encourage segregation at source, (reusable) containers or baskets with liners of the correct size and thickness are placed as close to the point of generation as possible. They should be properly colour-coded (red for infectious waste and Black for general waste) and have the international infectious waste symbol clearly marked. When they are 3/4 full, the liners are closed and sealed with plastic cable ties or string and placed into larger containers or liners of the same colour coding at the intermediate storage areas. Suitable latex gloves must always be used when handling infectious waste. 74 Table 10-1 Categories, Labelling And Containers For Health Care Waste No,. Waste Category Labelling Type of Container Colour code 1. Sharps Needles, infusion sets, Sharps Purpose – made puncture proof Yellow scalpels, knives, blades, container lancets and broken glass. 2. infectious or Contaminated non-sharps e.g. Infectious Strong, leak proof plastic bag Red contaminated non- Gauze, Cotton wool, or container sharps (healthcare dressings, blood, swabs, risk waste – sample vials. (HCRW)) Pathological waste Pathological Leak proof plastic bag or container lined with leak proof material Pharmaceutical waste Pharmaceutical Plastic bag or plastic lined waste container Genotoxic waste Genotoxic Plastic bag or plastic lined container Chemical waste Chemical Plastic lined container that is leak proof 3. non-infectious or Paper, packaging materials, General Waste Black Plastic Bag or black black healthcare general office supplies, drink plastic lined container waste (HCGW) containers, hand towels, cartons, unbroken glass, plastic bottles and food remains. 4. Radioactive waste Radioactive Lead box labelled with radioactive symbol 5. Pressurized Pressurized Plastic bag (if small) containers containers 6. Medical devices e- waste NB: Liquid pharmaceutical waste shall be put in plastic lined containers in their original bottles. 75 Step 4: intermediate storage (in the HCF) In order to avoid both the accumulation and decomposition of the waste, it must be collected on a regular daily basis. This area, where the larger containers are kept before removal to the central storage area, should both be close to the wards and not accessible to unauthorized people such as patients and visitors (Figure 10-1). Step 5: internal transport (in the HCF) Transport to the central storage area is usually performed using a wheelie bin or trolley. Wheelie bins or trolley should be easy to load and unload, have no sharp edges that could damage waste bags or containers and be easy to clean. Ideally, they should be marked with the corresponding coding colour. The transport of general waste must be carried out separately from the collection of healthcare risk waste (HCRW) to avoid potential cross Figure 10-1 Temporary storage for waste contamination or mixing of these two main categories of waste. The collection should follow specific routes through the HCF to reduce the passage of loaded carts through wards and other clean areas. Step 6: centralized storage (in the HCF) The central storage area should be sized according to the volume of waste generated as well as the frequency of collection. The facility should not be situated near to food stores or food preparation areas and its access should always be limited to authorized personnel. It should also be easy to clean, have good lighting and ventilation, and be designed to prevent rodents, insects or birds from entering. It should also be clearly separated from the central storage area used for Health Care General Waste (HCGW) in order to avoid cross-contamination. Storage time should not exceed 24-48 hours especially in countries that have a warm and humid climate. Figure 10-2 Poor example of a centralized storage. 76 Step 7: external transport External transport should be done using dedicated vehicles. They shall be free of sharp edges, easy to load and unload by hand, easy to clean/disinfect, and fully enclosed to prevent any spillage in the hospital premises or on the road during transportation. The transportation should always be properly documented and all vehicles should carry a consignment note from the point of collection to the treatment facility. Figure 10-3 Example of a hazardous waste transportation vehicle. Step 8: treatment and final disposal There are a number of different treatment options to deal with infectious waste. These are listed in table 10-2 below and then detailed under the “Determination of Treatment Systems and Technologies� chapter. Table 10-2 Treatment And Disposal Methods Suitable For Different Categories Of Health Care Waste Waste Category Treatment Disposal Method a) Sharps - Incineration - Safe burial - Land filling b) Infectious waste - Incineration - Land filling - Chemical disinfection - Safe burial - Autoclaving - Sewage - Biological - Ottway pit c) Pathological waste - Incineration - Safe burial - Biological - Land filling - Ottoway pit * d) Pharmaceutical waste - Incineration - Land filling (small quantities) - Encapsulation - Safe burial (small quantities) - Dilution - Discharge to a sewer - Inertization - Dissolution e) Genotoxic waste - Rotary kiln incineration - Return to supplier - Inertization - Encapsulation (small quantities) - Neutralization 77 f) Chemical waste - Rotary kiln incineration - Safe burial (small quantities) - Treatment lagoons - Return to supplier - Pyrolytic incineration - Neutralization - Encapsulation - Dilution g) Radioactive waste - Decay by storage - Storage h) Pressurized containers - Crushing (damaged - Recycling containers) - Reuse - Return to supplier - Land filling - Controlled explosion (usually done by military specialized units) • Sewage disposal needs approval from the local authority. 10.2 SUMMARY OF THE WASTE HANDLING SYSTEM The Lesotho Health Care Waste handling model is based on having centrally located Modern pyrolitic incinerators at Referral, District hospitals, or other Hospitals. All other health centres then transport their waste to these central places. THE Lesotho Millennium Development Authority (LMDA) assists the Ministry of Health to collect, transport and treat HCW at these centrally located incinerators. The system has not been designed to handle situations of systems failure and as is the prevailing situation, all the government incinerators and other equipment and treatment facilities are in dire need for maintenance and most are operating inefficiently and not treating the waste at all. The Health centres find themselves in difficult situations as they have no alternative waste handling systems in place. It is imperative that the government seriously considers erecting Local incinerators (built with local material) in Health Centres, Private Health Centres and other Public Health Units because of their very low cost and small quantities of HCW produced in these facilities. Also stabilized concrete lined pits should be erected in Health Centres, Public Health Units and for home based care, because of very low HCW production. For effective ICWM segregation, handling and disposal/transportation the following practices should be followed: • The medical waste should continue to be segregated by (i) sharp waste; (ii) infectious or contaminated non sharps; (iii) non infectious or healthcare General waste; and (iv) medical or radioactive devices and hazardous materials. • Segregation should be done as close to the point of generation as possible. (i.e. in all clinical areas, traditional health practices and home based care environments); • HCW receptacles shall be readily available at the point of generation, located away from patient areas to avoid cross infections; should be safe; utilization of the receptacles should be well understood by the medical and other health staff dealing with medical waste; and should be monitored regularly to ensure that the procedures are respected; • Receptacles of appropriate color, size and number should be used, to accommodate and label the different waste types being generated. Labels have to be firmly attached to containers so that they do not become detached during transportation and handling. If general and hazardous waste are accidentally mixed, the mixture should be treated as hazardous 78 HCW. The bags or containers should be resistant to their content (puncture-proof for sharps, resistance to chemicals reaction) and to normal conditions of handling and transportation such as vibration and changes in temperature, humidity or pressure; • Staff involved in HCW management must ensure that the waste bags are properly labeled and sealed to prevent spilling during handling and transportation, and properly removed and should also ensure that for storage purposes, the waste is kept separate, and that the central storage receptacles for each color coded bags be placed in similarly color coded receptacles; • All loading and unloading of waste shall take place within the designated collection area around the storage point; • There should be separate schedules and separate collection times for different color coded containers. Separate vehicles should be used for different types of waste. This is to avoid increased possibilities of wastes becoming mixed and being transported to the wrong disposal routes and sites; • Transportation must be done only by accredited Waste Management Contractors and certified by the local authority, ENA and other relevant departments; • HCW must be transported directly to the disposal or treatment site within the shortest possible time; treatment and disposal of HCW should focus in minimizing negative impacts on health and on the environment; • Capacity building of health facilities workers in all the areas related to health-care waste management should be performed at all levels; • Segregation system should be uniformly applied throughout the country and should be maintained throughout the entire waste cycle up to disposal. • Domestic waste should be dealt separately from health care waste. Table 10-3 Summary on how to improve HCW handling STEP TITLE POSSIBLE IMPROVEMENTS No. 1.0 waste • Take measures that will reduce as much as possible the amount of HCW minimization that will be produced in future. • set up an efficient purchasing policy • set up a good stock management system 2.0 HCW generation • Avoid generating waste as much as is possible 3.0 segregation and • Identify your waste categories containerization • Segregate the waste into these categories at point of generation • Place bins with colour coded liners as close to the point of generation as possible • Observe the procedure of sealing the bags when full and keep them sealed throughout transportation. • Keep the different waste streams separate throughout the process • Have waste segregation policy statements clearly posted in the working areas. • Enforce PPE use at all times when handling waste 4.0 intermediate • Collect waste from working areas regularly and transport it to an storage (in the intermediate storage area. HCF) • Place sealed liners into large containers of similar colour coding • Temporary storage area should both be close to the wards and not accessible to unauthorized people such as patients and visitors. • Infectious waste should be secured away at all times. 79 STEP TITLE POSSIBLE IMPROVEMENTS No. 5.0 internal • use a wheelie bin or trolley to transport the waste to the central storage transport (in the area. HCF) • Transport the different waste streams separately to avoid cross contamination or mixing. • follow specific routes through the HCF • avoid passing through wards or other clean areas 6.0 centralized • size of central storage area must be according to volume of waste storage (in the generated. HCF) • central storage area must be situated away from food areas. • central storage area must be secure and not accessible to everybody. • It should be easy to clean, have good lighting and ventilation, • It should be designed to prevent rodents, insects or birds from entering. • General waste and Infectious waste should be stored in separate areas. • Storage time should not exceed 24-48 hours 7.0 external • Should be done using dedicated vehicles transport • Vehicles should be free of sharp edges, easy to load and unload, easy to clean/disinfect. • Vehicles should be enclosed. • Transportation should always be properly documented. • Vehicles should carry a consignment note from the point of collection to the treatment facility. 8.0 treatment • Appropriate treatment options should be used (table 10-2 and Chapter 11). • Each HCF must have an alternative treatment option in case of failure. 9.0 final disposal • Appropriate final disposal should be used (table 10-2 and Chapter 12). 80 11. DETERMINATION OF TREATMENT SYSTEMS AND TECHNOLOGIES 11.1 INTRODUCTION The relative risk approach will be used in determining the treatment system and technology to be used at each HCF. The criteria for deciding on the system is that it protects in the best way possible, healthcare workers and the community as well as minimize adverse impacts on the environment. Environmentally-friendly and safe options used in high income countries may not always be affordable or possible to implement e.g. due to lack of electrical supply, etc. Health risks from environmental exposures should be weighed against the risks posed by accidental infection from poorly managed infectious waste (sharps in particular). The use of a burial pit or a small-scale incinerator, although clearly not the best solution, is much better than uncontrolled dumping. The main criteria for the selection of a technical option should be that their implementation will offer a level of health protection which eliminates as many risks as possible. The ICWM systems can subsequently be upgraded to reach higher safety standards. 11.2 SOLID WASTES TREATMENT HCW treatment systems should be efficient, environmentally sound, and permit access controls, so as to protect persons from voluntary or accidental exposure to waste during the treatment process. Technology choices should be made according to the following criteria: a) Performance and efficiency of treatment b) Environmental viability. c) Easiness and simplicity in the setting up, the operating and maintenance. d) The spare parts should be available, easy to get. e) Costs of investments and operating. f) Social acceptability In addition to this, the waste treatment system should be close to the waste generating point. The following is an outline of available technologies for treating HCW: a. Microwave disinfection This method is used to disinfect bio-medical waste in stationary or mobile plants. The waste is heated 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 sterilization of reusable medical equipment. In this process, a dry heat sterilizer is used and heat of 180° C is generated for 30 minutes or longer, for activating vegetative micro-organisms and most bacterial spores. This process is able to handle only limited quantities of waste and therefore is commonly used only for highly infectious waste such as microbial cultures from clinical or research laboratories. Autoclaving is environmentally sound, requires fairly high investment and moderate operating costs, and ensures good disinfection efficiency under appropriate operating conditions. However, it cannot be used for all type of waste and generates contaminated wastewater. In addition, operation requires qualified technicians and its shredders are subject to frequent breakdown. 81 c. Incineration Waste incineration is a thermal treatment, which aims at destroying organic waste parts by oxidation. 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 1200° or 1600° C; its initial cost is very high. It also needs highly qualified staff. The remnants of wastes are sent to landfill disposal sites or ash-pits. - Pyrolitic incinerator (modern 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 of investment and care taking are somewhat high; it needs qualified staff; the remnants of wastes are sent to the landfill disposal sites or ash-pits. - Incinerator with combustion room (artisanal construction, with local materials): Its investment and care taking costs are relatively low; it can work effectively, even with low-qualification staff. Incineration provides very high disinfection efficiency and drastic reduction of weight and volume of waste. It is relatively low in cost and does not need qualified staff for operating. But it generates significant pollutant emissions. d. Chemical disinfection Chemical disinfection, frequently used in health facilities to destroy micro-organisms on medical equipment, 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 is more efficient as in disinfection than in sterilization. Chemical disinfection is most suitable for treating liquid waste such as blood, urine, stools or hospital sewage. Solid (and even highly hazardous) biomedical wastes, including microbiological cultures, sharps, etc., may also be disinfected chemically. Chemical products such as hypo-chlorine and other acids are used to destroy pathogens, before wastes are burned or transported to disposal sites. The most frequent chemical disinfectants are: - Chlorine - which is a universal disinfectant, very active against micro-organisms. In case of possible HIV/AIDS infectious materials, concentration of 5 g/litre (5000ppm) of chlorine is recommended. - 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 in water at concentrations of 370 g/litre. This disinfecting product is recommended for Hepatitis and Ebola virus (but not for HIV/AIDS). The risk associated with formaldehyde is that it can cause cancer. The drawback of this system is that the disinfected wastes are still there and other methods of final elimination must be devised. This method gives highly efficient disinfection in good operating conditions, and some chemical disinfectants are relatively inexpensive. But it requires highly qualified technicians for operating the process. e. Burial in municipal landfills This practice consists of disposing of HCW directly in municipal landfills. In fact, this is not a treatment system: the wastes are stored with household wastes. This system requires very low investments, but it presents huge health and environmental risks, in view of scavenging practices at public landfills. However, land filling is better than leaving hazardous wastes accumulated at hospitals or other publicly accessible places. More suitable treatment methods should immediately be envisaged. f. Burial inside health facilities 82 Burial at the origin of HCW production – the health facility - is another form of elimination, mainly used where there is no treatment system or means of waste transportation to public landfills. The risk 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. Concrete Lined Pits Disposal at the origin of HCW production in concrete lined pits at the health care facility - is another form of elimination, mainly used where there is no treatment system or means of waste transportation to public landfills. The risk in this case is reduced by the lining and the pit must be above the water table. However 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. (See Annex 6 for designs) h. Open air burning When done in open air, the burning of HCW constitutes a factor of pollution and harm to the environment. Since HCW is generally burned in a hole, the destruction is never complete: often the quantity of unburned residue constitutes 70 % of the original wastes. This encourages children and scavengers to look for toys and reusable objects. i. Encapsulation This method consists of disposing of wastes by filling metal or plastic containers ¾ full with waste materials and topping the container up with plastic foam, bituminous sand, cement mortar or clay material. The process is cheap, safe and very appropriate for health centres that cannot envisage other methods to treat sharps, chemical and pharmaceutical waste. Encapsulation is not recommended for non-sharps infectious waste. The main advantage is to prevent the risk of scavengers getting access to these wastes in landfills and to reduce mobilization of toxic substances. 11.2.1 Comparative analysis of solid HCW treatment systems Table 11-1 demonstrates the advantages and drawbacks of each treatment system, along with its fitness in the economic and socio-cultural context of Lesotho. 83 Table 11-1 Comparative analysis of solid HCW treatment systems System Technical Feasibility Investment Operating Easiness/simplicity Availability Environmental Viability General Cost Cost of spare Social parts in acceptance Lesotho Autoclave Very efficient but cannot Fairly high Average Very qualified staff Not Ecological, but generates Very good be used for all types of available contaminated wastewater waste locally Microwave Very efficient Very high Very high Very qualified staff Not Very ecological Very good irradiation available locally Pyrolyses Very efficient Very high Average Qualified staff Possible Very ecological Very good Pyrolitic Very efficient Fairly high Average Limited skills Possible Little pollution Very good incinerator (modern incinerator) Local material Fairly efficient Low Low Limited skills Available Polluting Very good incinerator Chemical Fairly efficient Low Low Qualified staff Available Polluting Fairly good disinfection Burial in Inefficient Low Low Qualified staff Available Very polluting and risky Bad municipal public landfills Burial inside Inefficient Low Low Limited skills Available Polluting and risky Bad health facilities Use of Concrete Efficient Low Low Limited skill Available Non polluting Fairly good lined Pits Incineration at Inefficient Low Low Limited skills Available Polluting and risky Very bad open air Encapsulation Very efficient for sharps, Low Low Limited skills available Non polluting Good drugs but not recommended for non- sharps 84 11.2.2 Recommendations for Solid Wastes Treatment The comparative analysis, based on the above mentioned economic and technical criteria, leads to the following recommendations: - Modern pyrolitic incinerators at Referral hospitals, District hospitals, other Hospitals, and the Local Authorities, because of its fairly low cost and operating skills requirements; - Local incinerators (built with local material) in Health Centres, Private Health Centres and other Public Health Units because of its very low cost and small quantities of HCW produced in these facilities; - Stabilized concrete lined pits in Health Centres, Public Health Units and for home based care, 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 can generate dioxins and furans, which are classified as possible human carcinogens and can have other adverse 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 or metal should therefore not be incinerated. To ensure that inappropriate materials are not incinerated, the waste incineration system must be based on a strategy of segregation at source, to reduce as much as possible the infectious waste stream and to prevent the contamination of other wastes (papers, plastic objects, etc.). All types of wastes must not be incinerated, mainly the non-incinerable ones mentioned above. Waste segregation will allow the non-contaminated, non-infectious and non-incinerable wastes to be disposed at municipal landfills. Only the contaminated wastes (needles, sharp objects, blood stained cottons, etc.) are reserved for incineration. The latter don’t produce (or produce very little) toxic elements. In addition, this system of treatment allows a complete melting of needles, which are the main vectors of accidental transmission of HIV/AIDS. Modern 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. Smaller models, built with local materials and able to operate at these high temperatures are currently being field-tested and implemented in some countries. In the health centres, the quantities of HCW produced are insignificant. If waste segregation is performed well, the quantities to be incinerated will be reduced and negative impacts on the environment will be insignificant. In addition, promotion of the use of non-chlorine plastic containers can reduce polluting by-products in solid waste incineration. Although incineration has its critics, it is difficult to choose another system for developing countries such as Lesotho, given the economic and technical conditions. The proposal is not to incinerate all solid urban waste (household wastes, industrial wastes, etc.), but only selected contaminated health care wastes. Appropriate incinerator technology is supported by the WHO elsewhere in Africa. For example, during vaccination campaigns against tuberculosis in Togo and Benin, the WHO has supported, since 2001, a program to produce craft incinerators (made of local materials, cement with clay), in order to destroy the syringe needles used in the vaccination program. WHO organized a workshop in Bamako in 2001 to train some African technicians in the building of these types of incinerators. These models 85 can reach very high temperatures (800° C) able to get the needles and sharp objects melted (the model is shown in annex 4). Presently, there are no environmentally sound options at low-cost for safe disposal of infectious wastes. Incineration of wastes has been widely practiced, but alternatives, which may be preferable under certain circumstances, are becoming available, such as autoclaving, chemical treatment and microwaving. Land filling, when safely practiced, may also be a viable solution for part of the already segregated wastes. Autoclave, microwaves systems are surely more efficient and environmentally sound, but more difficult to operate too; they are very expensive and require qualified staff for operating. They cannot be used for all types of waste and generate contaminated wastewater, and in case of malfunction, the spare parts are not available locally. So, these types of technologies should not be recommended in Lesotho, given the present economic situation. Chemical disinfection requires chemical products permanently and qualified staff for operating; the disinfected wastes must also be sent to landfill disposals or other systems of disposal after such treatment. It is therefore important that where incineration is recommended, it should be accompanied by: (i) appropriate skills training of those who will operate the incinerators; (ii) appropriate and continuous monitoring of level of inflammability and type of waste incinerated. Whenever incinerators become an increasingly difficult option to use, the following treatment systems should be proposed: Chemical disinfection: This method gives highly efficient disinfection, and some chemical disinfectants are not expensive. As for drawbacks, the method requires highly qualified technicians for operating and it is inadequate for pharmaceutical, chemical and some types of infectious waste. In central, general and regional hospitals, which produce rather important quantities of HCW, the latter should be disinfected with chemical products, then evacuated to the public landfills where specific areas have been prepared beforehand. Disposal at municipal landfills: In case hazardous health-care waste cannot be treated or disposed elsewhere, direct burying in the municipal landfill should be recommended. To prevent the important disease burden currently created by these wastes, it is necessary : to prepare specific areas for HCW disposal, to limit access to this place (wire fencing and lock) and to bury the waste quickly to avoid contact with people or animals. It is a temporary solution before more suitable treatment methods are found. Burying inside hospital premises: In health centres where the HCW production is small, a ditch should be dug. Its bottom and walls must be cemented (or stabilized) to avoid contamination of the water table and prevent the walls from collapsing. The HCW thrown in the ditch must be covered with sand. The same procedure is repeated every time a new quantity of HCW is disposed, until the hole is full; in such a case, another hole is dug nearby. The hole must be protected (fence/lock) to avoid access and accidents. The main drawback is that burial places are not always available inside the health centres. 86 In all cases, the principle of waste segregation at source of production must be seriously respected, to minimize the contamination of general wastes by the infectious ones. Sharps and needle treatment Probably the most frequent risk is created by sharps (needles, scalpel blades, blood vials, glassware, etc.) in contact with infectious germs. In health facilities, needles and sharps should be collected in non- reusable containers, such as puncture-proof “sharps boxes�, specific cardboard, metal or plastic boxes, or in empty rigid plastic bottles (with a tight fitting lid), if financial resources are not available. One must not put sharp objects in any container to be recycled or returned to a store. Table 11-2 demonstrates the advantages and drawbacks of each treatment system for sharps, along with its suitability in the economic and socio-cultural context of Lesotho. 87 Table 11-2 Comparative analysis of sharps treatment systems Technology Technical Investment Cost Operating Easiness Availability Environmental viability Social feasibility Cost /Simplicity of spare acceptance parts in The Lesotho Autoclave Very efficient Very high Average Needs very Not Non polluting, but requires Very good Microwave qualified staff available disposal of residue irradiation Melting in Very efficient Medium for modern Low Low skills staff Possible Non polluting Good incinerator (or incinerator) and low needle (for craft ones) incinerator) Chemical Efficient Low Low Qualified staff ---------- Polluting and Requires Fairly good disinfecting disposal of residue Storage in Fairly efficient Very low Low Low skills staff ----------- Non polluting but risks Fairly good specific digging out sharps containers then landfill burial Burial in the Inefficient Very low Very low Low skills staff ----------- risks of digging out sharps Bad site of health centre Mechanical Very efficient High Low Low skills staff Not Non polluting, but ground Good grinding available sharps must be disposed Encapsulation Efficient Low Low Low skills staff ----------- Safe and non polluting Good 88 The melting of sharps in incinerators is very efficient. Whenever incinerators become an increasingly difficult option to use, encapsulation (filling metallic or plastic containers up to ¾ with wastes then filling up with cement, bituminous sand, etc.), chemical disinfecting, storage in specific containers (then landfill burial), should be recommended because of the very low cost. Autoclaving is a very efficient system, but it is very expensive. 11.3 LIQUID WASTES TREATMENT For liquid wastes, there are many treatment systems among which: (i) physical and chemical treatment; (ii) intensive biological systems (activated mud system; biological disk; bacterial field, etc.); (iii) septic pits/tanks; (iv) disinfection; and (v) decanting and digesting basin. Table 11-3 demonstrates the advantages and drawbacks of each treatment system for liquid wastes, along with its suitability in the economic and socio-cultural context of Lesotho. Table 11-3 Comparative analysis of liquid waste treatment systems System of Technical Technical Investment Recommendation for treatment Characteristics Efficiency and Operating Lesotho Cost Decanting and - Mud draining Medium Fairly high Recommended in central digesting basin - very weak area and Provincial hospitals (buried) Septic pits - Mud draining Medium Very low Recommended in health - very weak area centres (buried) Activated mud - sifting Very high Very high Not recommended (very system - mud draining expensive) - ventilation - fairly important area Biological disk, - sifting High Very high Not recommended (very bacterial field - mud draining expensive) - fairly important area Physic and - sifting Very High Very high Recommended for central chemical - chemical products or general hospitals only treatment - fairly important area Chemical - use of chemical High Medium Recommended disinfection products only - little area is necessary - No investments in infrastructure Disinfection is clearly the most efficient way to deal with liquid infectious wastes. That is why this option should be favoured among the other interventions. Consequently, a combined system (disinfection then storage in septic pits) is recommended for the district hospitals, general hospitals, and Health centres, which don’t produce much liquid waste. For the referral and general hospitals, a physical and chemical treatment, comprising a disinfection system, is recommended. The implementation of this option requires a feasibility study. 89 12. DETERMINATION OF DISPOSAL SITES 12.1 CHOICE OF LANDFILL SITES In big cities such as Maseru, incineration residues, which are considered as household waste, can be disposed in the public municipal landfill, if specific burial areas are prepared, mainly to receive sharp objects not melted during the process. These types of waste hurt scavengers and street children even though they are sterilized during incineration. At District and local level, the remaining wastes after burning can be buried inside health centres, away from patient treatment areas. 12.2 DECISION TREE SCENARIOS Five scenarios have been developed to describe the context within which health care facilities 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 to modern waste treatment facilities, and whether facilities are located in urban, peri-urban or rural environments. Five decision trees corresponding to each scenario are presented to show treatment choices and disposal options: - Scenario 1 (Annex 7) : Urban area with access to a modern waste treatment facility or located within reasonable distance of a larger health-care facility with treatment facility - Scenario 2 (Annex 8) : Urban area without access to modern waste treatment facility - Scenario 3 (Annex 8) : Peri-urban area - Scenario 4 (Annex 10): Rural area without access to modern waste treatment or disposal facility - Scenario 5 (Annex 11): Rural area with access to modern waste treatment or located within reasonable distance of a larger health-care facility with treatment facility. 90 13. THE MONITORING PLAN 13.1 PRINCIPLE AND OBJECTIVE Waste management is a continual task demanding a permanent effort from each and every person at the health care facility. During the upgrading phase, the process of ICWM must be investigated and recorded. Once the required level is reached, regular monitoring should ensure that the desired standard is maintained. The monitoring of ICWM is part of the overall quality management system. To measure the efficiency of the ICWMP, as far as the reduction of infections is concerned; activities should be monitored and evaluated, in collaboration with concerned institutions: MoH, MTEC, Local Authority, NGOs, etc. 13.2 METHODOLOGY The ICWMP will be executed over 5 years and implementation monitoring will be carried out as follows: Table 13-1 Implementation Plan for M&E OBJECTIVE TIMING/PERIOD RESPONSIBLE PARTY Development of ICWM policy Legal framework: At the beginning of the program EHD/ MoH • Development of ICWM (first year) policy • Regulation of HCW management • Development of technical guidelines • Development of standard operational procedures Institutional arrangements At the beginning of the program EHD/ MoH • Setting up a structure for (first year) coordination and follow up of the POA • Supporting private initiatives and partnership in ICWM Planning activities At the beginning of the program EHD/ MoH Implementation of health facility Yearly, according to the time- EHD/ MoH ICWM Plan table established Control and follow up of the Daily Health facilities execution of ICWM Plan activities Monthly Health Department in the Districts (MoH) Yearly EHD/ MoH Training : - two first years - EHD/ MoH, National • Elaboration of training Consultants, Training Institutes programs and training of trainers • Training for health staff active in ICWM Awareness - yearly - EHD/ MoH and NGOs, CBOs 91 OBJECTIVE TIMING/PERIOD RESPONSIBLE PARTY • Public awareness (general public ICWM Plan Evaluation Half-way (at the end of the 2nd EHD/ MoH, with the support of year) international consultant At the end of the 5th year EHD/ MoH, with the support of international consultant Supervision Six-monthly EHD/ MoH; MTEC; Local Authority 13.3 MEASURABLE INDICATORS Program level indicators are presented in Tables 7-1 to 7-6 of the ACTION PLAN for the ICWMP. At the facility level, the following framework and measurable indicators could be developed into a standard format to facilitate comparability and usefulness of the data: • HCW management structure: Reduction of waste, increase in efficiency; standard of hygiene; awareness of staff and patients; statistical data on waste generation; financial resources; functioning of responsibilities; training and awareness creation activities; monitoring and recording activities; • HCW collection: Sufficient and appropriate collection containers; efficiency of waste segregation; frequency of waste removal; environmentally friendly handling of waste; responsibilities; • HCW transportation and storage: cleanliness and functioning of transport equipment; execution of recommended transport procedures; status of storage facilities; cleanliness; separate storage of hazardous items; emergency equipment; lock and safety measures; responsibilities; • HCW treatment: Incinerator for infectious waste; proper functioning of incinerator; maintenance procedure; safety regulation for operation; safe disposal of ash; responsibilities; sewage system; functioning of septic tanks; maintenance procedure; wastewater treatment; • HCW disposal: Proper operation of landfill site; proper operation of waste pit for infectious waste; transport of chemical and radioactive waste; responsibilities; • General cleanliness: containers not overfull; no used sharps outside or protruding from sharps containers; no foul- smelling waste in facility or on premises; no litter in facility or on premises; no faeces on premises; waste pits not overfull. 92 14. 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Morija Printing Works, Maseru, Lesotho. • Government of Lesotho (2009 (a)), Lesotho Meteorology Services Unpublished data, Maseru, Lesotho • Government of Lesotho (2010). Ministry of Tourism, Environment and culture, Department of Environment, Guidelines for environmental impact assessment. • Phuka J, Taulo S. and Faye M. M. , 2009, Health care Waste Management Plan of Action for Malawi, Republic of Malawi, Ministry of Health and Population, Lilongwe, Malawi. • UNDP (2007), National Human Development Report 2006 – Lesotho. The challenges of HIV and AIDS, Poverty and Food Insecurity. Morija Printing Works, Maseru, Lesotho. • UNICEF, 2007, Countdown to 2015. • WEDC. lboro.ac.uk/resources/books/Emergency_Sanitation_-_Ch_08.pdf • WHO, Water, Sanitation and Health rapid assessment tool, http://www.who.int/water_sanitation_health/medicalwaste/hcwwmtool/en/index.html • Government of Lesotho (2012), Ministry of Health, Consolidated Lesotho National Health Care Waste Management Plan for the Lesotho Maternal and Newborn Health Performance-Based Financing Project August 2012 • Government of Lesotho (2005), Ministry of Health, National Health care Waste Management Plan, March 2005 page 76 • Government of Lesotho (2009 b), Ministry of Health , Health Services Decentralisation Strategic Plan Feb 2009 • Government of Lesotho (2009 c), Lesotho MoH- MCC Health Telecommunications Technical Assistance Project: Final Project Report, EPOS Health Management, May 2009 • EoN (2015a), Encyclopedia of the Nations; Population - Lesotho - growth, annual http://www.nationsencyclopedia.com/Africa/Lesotho- POPULATION.html#ixzz0kDFD4YMD • EoN (2015b), Encyclopedia of the Nations 93 ANNEXES ANNEX 1 NUMBER OF HEALTH FACILITIES BY CATEGORY NO. INSTITUTION SERVICES OFFERED NUMBER SAMPLE IN THE SELECT COUNTRY ED MINISTRY OF HEALTH 1 1 MINISTRY OF ENVIRONMENT 1 1 INSTITUTI LOCAL AUTHORITIES 6 2 ONS ANALYTICAL SERVICES PROVIDERS 10 1 (LABORATORIES) DHMT DISTRICT HEALTH TEAM 10 3 REFERRAL HOSPITALS In-patients, specialist out- 1 1 HOSPITALS patients, surgery, obstetrics, 5 2 laboratory, intensive care TERTIARY unit, general practice, gynecology, emergency/casualty MAJOR HEALTH CENTRES In-patients, specialist out- 6 4 SECONDAR patients, surgery, obstetrics, Y PRIVATE FOR PROFIT laboratory, 23 2 PRIVATE NON-PROFIT 18 3 VETERINARY HOSPITALS 1 1 PHARMACEUTICALS 1 1 BLOOD TRANSFUSION SERVICES 1 1 94 ANNEX 2 BASELINE INFORMATION OF THE SELECTED FACILITIES A.2.1 Referral Hospitals (i) Queen Mamohato Memorial Hospital Queen Mamohato Memorial Hospital was selected to represent referral hospitals. It is a morden hospital which was recently constructed. It is run by Netcare Pvt Ltd. on behalf of the government of Lesotho and has three filter clinic associated with it; (i) Likotsi filter clinic, (ii) Mabote filter clinic and (iii) Qoaling filter clinic. Netcare has in turn out-sourced some of its services like cleaning and laboratory services. Cleaning has been outsourced to Mediguardwic Cleaning Services whilst the laboratory has been outsourced to Ampath pvt ltd external. Mediguardwic Cleaning Services is cleaning the whole complex and is also servicing the three filter clinics. (Waste from the filter clinics is transported to Queen Momahadu Referral Hospital for incineration.) Mediguardwic Cleaning Services is implementing the three bin system of segregating waste at point of generation. From the small bin the waste is placed in big wheely bin of the same colour coding as the plastic liners and when full the wheely bins are transported to the central temporary storage area. From the temporary storage area the infectious waste is taken for incineration which is on-site and the general waste is collected by the City Council every Monday, Wednesday and Friday and taken to the sanitary landfill. The temporary storage area receives 10 to 30 kg of medical waste per day and any anatomical waste is stored in the cold room whilst awaiting incineration. Card board packaging material is being collected for recycling. The cleaning services are being run professionally with well trained staff. The general staff received in-service training in Health Care waste management, whilst the waste staff further received external formal training in waste management. Three members of staff were also trained to transport the waste from the point of contact to the temporary storage area. The incinerator operators received special training to be able to run the incinerator. Regulations, protocols, and guidelines for HCWM are available and are kept in files which are accessible to all staff. Ampath Pvt Ltd is running the Laboratory services. It follows the three bin system being instituted by Mediguardwic Cleaning Services, who are doing the cleaning even in the Laboratory too. They also generate liquid bio-hazardous waste like urine which they discharge down the sewer system and also the chemical waste from their analysis is flushed down the sink. A.2.2 Large Hospitals (i) Motebang Hospital Motebang Hospital is a large district hospital servicing Leribe District. The hospital offers all possible health services including Laboratory services, Partners-Bayer (Children with HIV), ICAP (TB- HIV/AIDS). The Medical staff only received training on HCWM during their professional training and any further exposure has been through in house workshops. Motebang Hospital is implementing the three bin system of segregating waste at point of generation. From the small bins in the wards, the waste is placed in big wheelie bins of the same colour coding which are located at the entrance of each ward. When the Wheelie bins are full the infectious waste is transported to the temporary storage area located next to the incinerator whilst the general waste is 95 collected by a company which was contracted by LMDA and taken to the municipal landfill. Anatomical waste is temporarily stored in large freezers awaiting incineration. From the temporary storage area the infectious waste is taken for incineration which is on-site. The wheelie bins located at the entrance of wards are not secure and patients are exposed to infection since they are not aware of the risks associated with this waste. Some wards were using the sluice room as a temporary storage area for infectious waste, but this room is not designed for that purpose and still not suitable. The main temporary storage area next to the incinerator is not being used properly either. The infectious waste is being stored in a cage away from the incinerator whilst the designated lockable storage areas are full of old mattresses and other broken down equipment. The HCW is not being serious taken care of as it is being pushed aside while other things are stored in its storage facilities. (ii) Mafeteng Hospital Mafeteng Hospital is a large district hospital servicing Mafeteng district. The hospital offers all possible health services including Laboratory services, TB-HIV/AIDS control, mental health, eye care, pharmacy and mortuary. The Medical staff only received training on HCWM during their professional training and any further exposure has been through in house workshops. In terms of waste management, Mafeteng Hospital is implementing the three bin system of segregating waste at point of generation. From the small bins in the wards, the waste is placed in big wheelie bins of the same colour coding which are located at the entrance of each ward. When the Wheelie bins are full the infectious waste is transported to the temporary storage area located next to the incinerator whilst the general waste is collected by a company which was contracted by LMDA and taken to the municipal landfill. Anatomical waste is temporarily stored in large freezers awaiting incineration. From the temporary storage area the infectious waste is taken for incineration which is on-site. The ash from the incinerator is deposited in an ash pit behind the incinerator. The incinerator is not working efficiently as it is failing to melt needles which can be seen in the ash pit still intact The wheelie bins located at the entrance of wards are not secure and patients are exposed to infection since they are not aware of the risks associated with this waste. A.2.3 Health Centres (i) Peka Health Centre Peka Health Centre is a small clinic situated in Pheka, Leribe district. The clinic offers medicine, children’s services and emergencies services. Although they have five beds, they are only for observations. The Medical staff only received training on HCWM during their professional training and any further exposure has been through in house workshops. The health centre consists of fairly new buildings which were funded by the American Government. However the layout and size of some rooms makes it difficult to deliver Health care smoothly. Certain structures are misplaced and yet other functions are not catered for; (i) the multipurpose hall obstructs the entrance to both the pharmacy store and main entrance for patients because of where it is situated, (ii) .The emergency room is too far and not accessible for taking the client to the ambulance. You have to pass through the waiting area to do so, (iii) there is no cough site for the TB patients and the pharmacy 96 store is too small. is a presentation of a more conducive plan for delivering health care including handling TB patients. In terms of waste management, Peka Health Centre is implementing the three bin system of segregating waste at point of generation. From the small bins in the wards, the waste is placed in big wheelie bins of the same colour coding which are located at the temporary storage area. The wheelie bin for infectious waste is kept in the sluice room. When the Wheelie bins are full the infectious waste is collected by the District Health Management using a contracted company and transported to the district Hospital for incineration. The waste is collected every Friday and Monday. Anatomical waste is temporarily stored in large freezers awaiting the transportation to the incinerator. The general waste is burnt in a pit which is on site. (ii) Motsekuoa Health Centre Motsekuoa Health Centre is a small clinic situated in Mafeteng district. The clinic offers medicine, children’s services, emergencies services, HIV/AIDS, mother and child health services (MCH), prevention of mother to child transmition (PMTCT), TB clinic and male circumcision. The health centre consists of fairly new buildings which were funded by the American Government. The major complaint is that they rooms are too small and always croweded. Further they are not suitably planned to handle TB patients as there are no well ventilated cough sites for patients. The Medical staff only received training on HCWM during their professional training and any further exposure has been through in house workshops. The health centre is implementing the three bin system of segregating waste at point of generation. From the small bins in the wards, the waste is placed in big wheelie bins of the same colour coding which are located at the temporary storage area which is the sluice room. The sharps containers are also kept in the sluice room. When the Wheelie bins are full the infectious waste is collected by the District Health Management Team using a contracted company and transported to Mafeteng Hospital for incineration. The waste is collected every Friday and Monday. Anatomical waste is temporarily stored in large freezers awaiting the transportation to the incinerator. The general waste is burnt in a pit outside the clinic facility. (iii) Ratjomose Health centre Ratjomose Health Centre is a small clinic situated in Maseru district. The clinic offers medicine, children’s services, emergencies services, and HIV/AIDS (ART), The health centre consists of fairly new buildings which were funded by the American Government. The major complaint is that the rooms are too small and always crowded. Further they are not suitably planned to handle TB patients as there are no well ventilated cough sites for patients. The Medical staff only received training on HCWM during their professional training and any further exposure has been through in house workshops. The health centre is implementing the three bin system of segregating waste at point of generation. From the small bins in the wards, the waste is stored at the temporary storage area at the back of the clinic. The bags are carried by hand to the storage area. every Friday and Monday, the infectious waste, it is collected by the District Health Management Team using a company that was contracted by LMDA and transported to Queen II Hospital for incineration. The clinic does not generate any anatomical waste. The general waste is also collected and transported to the municipal landfill. 97 A.2.4 Private Non Profit (NGO) (i) Mamohau Hospital - (CHAL) Mamohau Hospital is a large Primary Health hospital servicing rural Leribe district. It is a semi autonomous institution run by CHAL but also receiving some support from Government. It is basically a primary health hospital reaching out to the rural populations. The hospital offers all possible health services including Laboratory services, TB-HIV/AIDS control, HIV counseling and mid-wifry. The Medical staff only received training on HCWM during their professional training and any further exposure has been through in house workshops. In terms of waste management, Mamohau Hospital is implementing the three bin system of segregating waste at point of generation. From the small bins in the wards, the waste is placed in big wheelie bins of the same colour coding which are located at the entrance of the Hospital. When the Wheelie bins are full the infectious waste is transported to the temporary storage area located next to the incinerator whilst the general waste is burnt at a pit just outside the Hospital premises. Anatomical waste is temporarily stored in large freezers awaiting incineration. From the temporary storage area the infectious waste is taken for incineration which is on-site. The ash from the incinerator is deposited in the open pit used for burning general waste. The incinerator was broken down at time of visit and the medical waste was piling in the store room. The wheelie bins located at the entrance of wards are not secure and patients are exposed to infection since they are not aware of the risks associated with this waste. Generally waste handling at the institution is not very good. Although all staff are aware of the three bin system at times wrongly segregated waste was getting to the incinerator and was raising problems for the operators. There is a general laxity about handling waste in the institution and the waste generators were not taking their responsibility of segregating at source. Transportation and treatment was also not being done with the seriousness it deserved, thus the open pit was full of everything. This may be a result of the fact that the person in charge of HCWM is a carpenter who has taken over the heading of the maintenance unit. It was also noted that spillages are going un-disinfected and the cleaners are being exposed and also spreading the infectious materials all over as they clean with their mops whist the spillage hasn’t been disinfected. The medical staff are the ones in charge of the spill kits and are supposed to disinfect the spillages before the cleaners come to clean it up. But they were not just doing it and leaving it to the cleaners. (ii) TEBA Clinic TEBA has diversified from being primarily a labour recruitment and management service provider to offering a number of additional services including human resources, social and financial services both during and post employment. Thus it assesses people for job readiness, assists in the screening, and recruitment and even in the retrenchment of mine workers. TEBA further serves mines and mineworkers within their rural communities. To this end TEBA has clinics which do the health assessments and treatment. TEBA clinic is a private entity offering medicine and laboratory services specialising in TB treatment. The Clinic is divided into the following sections: 98 (i) Banking Hall The banking hall serves for recruiting new employee, relaying messages to relatives in South Africa and financial services. Care supporters are also located in this hall and help with health talks, filling in of withdrawal slips and some initial screening. They refer any suspects to the clinic. (ii) Clinic The nurse in the clinic does the testing for TB and initiates treatment. The suspects are also offered HIV testing. (iii) Coughing Booth For sputum collection thee is a coughing booth which is located outside where it is well aerated. (iv) Laboratory The sputum is taken to the laboratory for analysis. The laboratory is run by a laboratory technician and uses Gene-Xpert equipment. (v) Counselling room Once the tests are complete the suspects are taken to the counselling room where they are advised of the outcome of the tests and what steps to take. The current set up is serving the mine workers to a certain level but has been found to be deficient. The proposal is to upgrade it to a one stop shop that will handle all the trans-boundary TB cases efficiently, including all follow-ups, compensations, and welfare of immediate family members who may end up being infected. This will include even phone reminders for taking medication. TEBA has got the land required for any expansion at their current site, which include many other buildings which they are currently not using. In terms of waste management, the clinic is implementing the three bin system of segregating waste at point of generation. From the small bins in the wards, the waste is placed in big wheelie bins of the same colour coding which are located at the temporary storage area. When the Wheelie bins are full the infectious waste is collected by the District Health Management Team using a contracted company and transported to Queen II Hospital for incineration. The waste is collected regularly. The general waste is transported to the Hatsosane municipal landfill. A.2.5 Private for-Profit (i) Dr. C. K. Knight Memorial Hospital Dr. C. Y. Knight Memorial Hospital is a large private for profit hospital servicing urban Hlotse in Leribe district. The hospital offers all possible health services except Laboratory services and radiology. The owner of the Hospital, Dr. C. Y. Knight who was running the hospital passed away two years ago. His passing away left a big gap and left the Hospital in a difficult position which has taken long to recover from. During this time most of the staff left the institution, patient numbers dwindled to near zero and the hospital was basically closed to normal business. However in the past six months the situation has been turned around and the hospital has been under refurbishment and staff have been reengaged again. The Hospital will be up and running by end of this month. The Medical staff only received training on HCWM during their professional training and any further exposure has been through in house workshops. The hospital does not have waste treatment facilities 99 on site but has entered into an agreement with the Motebang Government Hospital in Hlotse (Leribe) which collects all the medical waste and treat it at their incinerator. The rest of the general waste is burnt in an open pit. The Hospital has two big rooms which were set aside as laboratories but are not being utilised. Hospital management are offering the TB Project to take them up and utilise them. From the experience they are getting from their current refurbishments the staff members also pointed out that the construction/refurbishment work will produce noise which will disturb patients. Dust will also be produced and needs to be suppressed. (ii) Letseng Mine Hospital Letseng Mine Hospital is a private hospital servicing Letseng mine staff. The hospital offers all possible health services except children’s services. The Medical staff only received training on HCWM during their professional training and any further exposure has been through in house workshops. The Snr Nursing officer is in charge of HCWM in the hospital. The Hospital is implementing the three bin system of segregating waste at point of generation. From the small bins in the wards, the waste is placed in big wheelie bins of the same colour coding which are located at the back of the Hospital, in a lockable cage for the infectious waste, and close to mthe main entrance for general waste. The general waste is further segregated on site to cans, glass, paper, and plastic. These different fractions are being bailed for recycling at the waste sorting area which is next to the incinerator. When the Wheelie bins are full all the waste is transported to the temporary storage area located next to the incinerator were it is stored according to the different categories of waste. From the temporary storage area the infectious waste is taken for incineration which is on-site together with some of the general waste. The rest (glass, card board paper, plastics, etc) are being bailed for recycling. The ash from the incinerator is being placed in 200l metal drums, sealed and transported to South Africa for final disposal at a proper sanitary landfill. The form of transport being used to transport the waste from the hospital to the incinerator is not suitable for the job. They are using any van that will be available. In case the incinerator is not working, the hospital has an arrangement with Butha Buthe, were they can take it for incineration. A.2.6 Pharmaceuticals (i) National Drug Supply Organisation (NDSO) The National Drug Supply Organisation (NDSO) is the central medical stores for the Government of Lesotho. It is mandated to procure, store and distribute essential drugs which include ARVs, small scale laboratory items, family planning commodities, nutritional products, vaccines and TB medicine. NDSO’s major waste problems emanate from expired drugs. Drugs expire because of slow uptake by hospitals and at times because of large volumes of donated drugs failing to be used in time. Donated Drugs should normally have shelf life more than three quarters still left but there has been cases of drugs nearing their shelf life being donated and posing waste problems for NDSO. Although in most instances donations are arranged and agreed upon, there are cases where truck loads have pitched up without notice. However NDSO has found it difficult to reject these donations. 100 Once the drugs have expired NDSO gets approval from MoH to destroy. Sending drugs back to manufacturers has proved to be difficult because of border laws with South Africa which are prohibitive. Handling of waste drugs follows laid down protocol to the level of obtaining a destruction/disposal certificate before destroying the drugs. The expired drugs are recorded, and quantified before destruction. The NDSO staff only received training on HCWM during their professional training and any further exposure has been through in-house workshops. NDSO has an incinerator on site and all the expired drugs are treated here. The rest of the general waste is either burnt in an open pit which is on site or collected by the local authority to the landfill site. A.2.7 Blood Transfusion Services (i) Lesotho Blood Transfusion Service (LBTS) The Lesotho Blood Transfusion Service (LBTS) was created in June, 1984 as an integral part of the Central Laboratory Services by the Ministry of Health. Its goal is to provide safe and adequate blood and blood products to all the hospitals in the country. This is achieved through the recruitment, selection and retention of voluntary non-remunerated blood donors, collection, processing, screening and storage of blood and blood products, distribution of blood and blood products to all the hospitals. In the process of collecting blood LBTS generates medical waste. In terms of waste management, LBTS is implementing the three bin system of segregating waste at point of generation. When the bins are full they are carried by hand to the temporary storage area. From the temporary storage area the infectious waste is transported to Queen II Hospital for incineration while the general waste is transported to the Hatsosane municipal landfill. A.2.8 MDR TB clinic (Multiple Drug resistant TB) (i) Botsabelo MDR -TB clinic Botsabelo MDR -TB clinic is a specialised Hospital for Multiple Drug resistant TB (MDR-TB) and extensively drug-resistant tuberculosis (XDR TB) treatment. It is a private – public partnership, with twenty two (22) beds and offers services like medicine, children’s services, emergencies, radiology and laboratory. Its main thrust is not to keep patients throughout the treatment of the MDR – TB but to handle those who are reacting badly and once stabilized they continue their MDR-TB treatment from home. In terms of waste management, the hospital is implementing the three bin system of segregating waste at point of generation. From the small bins in the wards, the waste is placed in big wheelie bins of the same colour coding which are located at the temporary storage area. When the Wheelie bins are full the infectious waste is collected by the District Health Management Team using a contracted company and transported to Queen II Hospital for incineration. The waste is collected every Friday and Monday. The general waste is transported to the Hatsosane municipal landfill. A.2.9 Major Challenges At The HCF Some of the major challenges (relevant to the current programme) being faced by the healthcare facilities (HFC) that need serious attention include the following; 101 ANNEX 3 GENERAL WASTE MANAGEMENT PRACTICES For analysis purposes the healt facilities will be devided into three; Large hospital, Health centres and Laboratories. At the health care facilities the following was observed: A.3.1 Waste segregation: Health care waste can generally be classified into four fractions; (i) sharps, (ii) infectious or contaminated non-sharps (healthcare risk waste – (HCRW)), (iii) non-infectious or healthcare general waste (HCGW) and (iv) medical devices and radioactive materials. Figure A.3-1 the three bin system. Generally all Health Facilities are practising the three bin system (Figure A.3-1) In all health care facilities that were assessed, the waste that is religiously separated from the rest are needles (sharps) which are placed in designated card board safety boxes or plastic yellow safety containers (Figure A.3-1). The most generally used sharps container is the plastic yellow safety containers, which is supplied by the District Health Management Teamsto all the health facilities. 102 Figure A.3-2 Sharps Containers in common use The non-infectious or healthcare general waste (HCGW) is similar to domestic waste and constituted 75-90% of the waste generated at the facilities. This fraction (HCGW) is made of paper, plastic packaging, food preparation, etc. that have not been in contact with patients. The infectious or healthcare risk waste (HCRW) constituted 10-25% of the waste generated at the facilities. This fraction (HCRW) is the infectious/hazardous waste, which is of concern at Health Care Facilities (HCF) due to the risks that it poses both to human health and the environment. It consists of blood, body parts, contaminated swabs/cotton wool/bandages, contaminated non-sharps, chemicals, and pharmaceuticals. In some instances the infectious and non-infectious waste was not segregated and its handling posed serious challenges as it was not labelled, either on the bin or the plastic lining. The mixed waste was being placed in different kinds of bins ranging from metal, small plastic to large wheeled bins (Figure A.3-2). At times the bins were lined with black polythene bags. 103 Figure A.3-3 General Waste Containers in common use Medical devices and radioactive materials are an emerging health care waste stream. Most of the medical devices posing problems emanate from donated obsolete equipment being dumped by the developing nations in the less developed nations. This includes all sorts of used equipment and computers which never get to work when they arrive in the recipient country and just find their way straight to the dumps. A lot of this equipment is piling at the health facilities (Figure A.3-4). 104 Figure A.3-4 Obsolete equipment piling up at a Health Facility. A.3.2 Temporary storage Before treatment, waste is supposed to be stored under secured conditions. In most health centres there are no appropriate temporary storage facilities and where they are available they are not secured or appropriate. (i) General Waste: From the small bins in the wards the black liners are sealed and placed in black wheelie bins either inside the facility or just outside Figure A.3-5. When the wheelie bins are full the black liners are either taken to a secure storage awaiting transportation to the landfill or deposited in an open pit for burning. 105 Figure A.3-5 Temporary storage for General Waste. In some facilities general waste is also being inappropriately stored. At some health facilities, waste is being heaped at the back yard awaiting collection by the local authority. In smaller facilities, it is piled in the pit until there is enough material for burning. In yet other facilities, the waste is piled in a trailer awaiting the Local Authority tractor to come and pull it to the landfill. In all cases, the storage areas are open, not secured and pose high risk to both humans and animals. (ii) Infectious waste: From the small bins in the wards the red liners are sealed and placed in red wheelie bins either inside the facility or just outside Figure A.3-6. Some facilities were using the sluice room for temporary storage (Figure A.3-7) When the wheelie bins are full the Red liners are either taken to a secure storage awaiting treatment at the incinerator . 106 Figure A.3-6 infectious waste Temporary Storage in large hospital. Figure A.3-7 infectious waste temporary Storage in Sluice Room Figure A.3-8 infectious waste Temporary Storage in cage next to incinerator 107 (iii) Anatomic waste: Anatomic waste is temporarily stored in large freezers awaiting treatment at the incinerators. Large hospitals have coldrooms for this purpose (Figure A.3-9) Figure A.3-9 Cold room and freezer for temporary storage of anatomic waste. (iv) Sharps containers Sharps containers when full are transported to a locable cage generally close to the incinerator. In some facilities the sharps containers were stored in inappropriate places like under stair cases, next to incinerators, in store rooms or in offices until transport is found (Figure A.3-10). Figure A.3-10 Temporary storage for sharps containers, A.3.3 Transportation When the wheelie bins are full they are generally wheeled to the temporary storage areas. The sharps were found to be transported by hand if the treatment was on site, but if it was off-site either a truck or an ambulance was used. At times the truck would be an open truck. 108 The infectious and non-infectious waste is transported using various means which include manually by hands, open trucks, wheelie bins and tractor drawn trailers (Figure A.3-11). Figure A.3-11 Means of transporting infectious and non-infectious waste A.3.4 Treatment and Disposal of Waste. (i) Non infectious (general) waste In the urban areas, general waste is land filled (Figure A.3-12) and in the Districts it is burnt in open pits (Figure A.3-13). The large local Authorities like Maseru and Mafeteng have landfills. The challenge they are facing is the proper running of the landfills as resources are scarce and the proper maintenance procedures are being left undone. There are no official disposal sites in the regions and each centre has to manage its own waste. Operational challenges of landfills include the following: • The infectious and non-infectious wastes are mixed and dumped at the landfills, exposing the scavengers and recyclers to contamination. • The dumps are poorly managed and are a haven for rodents and flies and due to their proximity to residential housing and even medical facilities like the SOS Children’s Clinic, they pose serious health risks. • The waste is ultimately being burnt and a lot of toxic smoke is released into the environment, affecting the nearby residents. Figure A.3-12 Municipal Landfill 109 Most of the Health centres in the Districts, where there is no formal collection of general wastes by a Local Authority practice open burning of the non-infectious wastes. This practice is posing some challenges which include the following: • Air pollution from burning of the wastes • Potential hazard to humans and animals especially if the pit is not secured, and scavengers have access. • Some institutions were not even digging a pit. So the waste was just being heaped on the surface and then later burned. • Littering of the environment with contaminated waste as the institutions tend to pile the waste for some time before burning it. In some cases the institutions were just discarding this waste at any open space, causing pollution. Figure A.3-13 Open pit burning (ii) Sharps and infectious waste Sharps and all infectious waste are incinerated (Figure A.3-14). Most of the Hospitals have incinerators some of which were not working due to lack of maintenance. All government hospitals have the same model of incinerator. They only differed in capacities. Some had a problem of not operating to the recommended minimum temperature of 1 200oC, thus needles were not being completely burnt. In Health cetres and clinics without incinerators, sharps and infectious waste is collected to the nearest hospital which has an incinerator for treatment. The ash from the incinerators is generally disposed off in pits at the hospitals or taken to a landfill site. Some of the government institutions are equipped with incinerators which, need maintenance. The major challenges facing the incinerators include the following: • The firebricks have been burnt out and the institutions do not have a budget to refurbish the incinerators. With worn out firebricks, the incinerator cannot reach the recommended temperatures. 110 • The operators are not well trained in operating the incinerators and at times they overload incinerators, causing them to malfunction and generate partially burnt waste. • The size, capacity and types of incinerators in the institutions is causing the operators to accept sharps only and ignore the rest of the infectious waste since they can’t handle large volumes. Figure A.3-14 Government Hospital incinerators A.3.5 Accumulation of waste When treatment facilities (incinerators) are not working, a lot of the health care waste accumulates, with no one knowing what to do with it. Sharp boxes and plastic bags stored next to incinerators start piling up by the day (Figure A.3-15). The most serious condition was witnessed at Motebang hospital were infectious waste had accumulated, filled the temporary storage cage and was now being stored outside. (Figure A.3-15). This is because the incinerator was down. 111 Figure A.3-15 Sharp boxes, and infectious waste accumulating in temporary storage areas. A.3.6 Sanitation Sanitation is either by Pit latrines (Figure A.3-16), septic tank system or water borne sewage reticulation as in large urban areas. All the Health Care Facilities have separate sanitation facilities for males and females. However the facilities are generally not adequate for the patients and visitors that come to the institutions. In several institutions the facilities could not be used due to lack of running water. Fortunately some of them have got pit latrines which can be used as an alternative. The only problem with the pit latrines was lack of cleaning. (Figure A.3-16) Figure A.3-16 Pit latrines at a Minor Health facility 112 COVID-19 Response ESMF – ICWMP ANNEX 4 MODEL OF “WHO� INCINERATOR MADE WITH LOCAL MATERIALS Some technical characteristics: - Materials : red sand (laterite), clay, white cement - Bricks of cooked sand - Galvanized metal sheet Chimney Structure : - 0.6m x 1mx 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) Page | 113 COVID-19 Response ESMF – ICWMP ANNEX 5 CONCRETE LINED PIT - HOME BASED CARE WASTE DISPOSAL Pit with Pit Latrine for home based care Design: Page | 114 COVID-19 Response ESMF – ICWMP ANNEX 6 CONCRETE LINED PIT - SHARPS AND INFECTIOUS DISPOSAL Page | 115 COVID-19 Response ESMF – ICWMP ANNEX 7 HCW FACILITIES OPERATING SCENERIO 1 Scenario 1: Urban area with access to a modern waste treatment facility or located within reasonable distance of a larger health-care facility with treatment facility Page | 116 COVID-19 Response ESMF – ICWMP ANNEX 8 HCW FACILITIES OPERATING SCENERIO 2 Scenario 2: Urban area without access to modern waste treatment facility Page | 117 COVID-19 Response ESMF – ICWMP ANNEX 9 HCW FACILITIES OPERATING SCENERIO 3 Scenario 3: Peri-urban area Page | 118 COVID-19 Response ESMF – ICWMP ANNEX 10 HCW FACILITIES OPERATING SCENERIO 4 Scenario 4: Rural area without access to modern waste treatment or disposal facility Page | 119 COVID-19 Response ESMF – ICWMP ANNEX 11 HCW FACILITIES OPERATING SCENERIO 5 Scenario 5: Rural area with access to modern waste treatment or located within reasonable distance of a larger health-care facility with treatment facility. 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