Islamic Republic of Afghanistan
Ministry of Public Health
General Directorate of Policy and Planning
Health Economics Financing Directorate
INFECTION MANAGEMENT AND ENVIRONMENT PLAN
DRAFT
August 11, 2009
TABLE OF CONTENTS
TABLE OF CONTENTS 2
ABBREVIATIONS AND ACRONYMS 3
I. Introduction 4
A. Background 4
· SHARP project 4
· Issues and challenges related to health and environmental risks 4
B. Aim of Infection Management and Environmental Plan (IMEP) 6
II. Policies, Legislation and Regulations 8
A. Background 8
B. National Environmental Protection Agency (NEPA) 8
C. Health Policies and Programs 8
III. Organizational Arrangements and Implementation 10
A. National Level 10
B. State Level 10
C. Bio-Medical Waste Management System 10
IV. Operational Framework 12
A. Introduction 12
B. Hospitals and healthcare centers 12
C. Infection Control 13
D. Treatment and Disposal of Bio-Medical Wastes 13
E. Segregation of Waste and Onsite Storage 14
F. Transportation of Bio-Medical Waste 15
G. Handling Sharps 15
H. Use and Disposal of Auto-Disable (AD) Syringes 16
I. Use and Sterilization of Glass Syringes 17
K. Site Selection and Guidelines for Design of New HCFs 18
L. Drug Expiry Management 18
V. Awareness and Training 19
A. Awareness 19
B. Training 19
VI. Monitoring 20
A. Internal 20
B. External 20
REFERENCES 24
TABLES
Table 1: General Waste Management Rules 14
Table 2: BHCs’ Waste 15
Table 3: AD syringes, instructions for use 16
Table 4: Guidelines for use of glass syringes 17
ABBREVIATIONS AND ACRONYMS
BHC / Basic Health CenterCHC / Community Health Center
CWTF / Common Bio-Medical Waste Treatment Facility
EMP / Environmental Management Plan
GD / General Directorate
GoA / Government of Afghanistan
HCF / Healthcare Facilities
HCW / Healthcare Worker
HCWM / Healthcare Waste Management
HNSS / Afghanistan Health and Nutrition Sector Strategy
IMEP / Infection management and Environment Management
MDGs / Millennium Development Goals
MoPH / Ministry of Public Health
NEPA / National Environmental Protection Agency
PPA / Performance-based Partnership Agreement
SHARP / Strengthening Health Activities for the Rural Poor Project
I. Introduction
A. Background
· SHARP project
Strengthening Health Activities for the Rural Poor Project (SHARP) provides the framework for implementation of primary level healthcare services by the Ministry of Public Health (MoPH) for the period, 2009-2013. SHARP is the response to the dire need to continue transforming the Afghan Public Health System into an accountable, accessible and affordable system that provides quality services to its users. The main objectives of the project include:
· Sustaining and strengthening the Basic Package of Health Services (BPHS)
o Well-defined package of basic services including immunization, antenatal, delivery and post-natal care, basic nutrition services and treatment of communicable diseases;
o Provision of services in large areas of the country through contracted NGOs and in certain provinces through the MOPH’s own service system;
o Implementation of the BPHS through Performance-based Partnership Agreements (PPAs);
o Further expansion of health facilities, particularly sub-centers;
o Training of additional midwives and nurses;
· Strengthening the delivery of the Essential Package of Hospital Services (EPHS)
o Evaluation of the impact and lessons learnt from different approaches adopted for EPHS;
o Policy dialogue to develop a systematic and coherent package of hospital policies;
o Monitoring of hospital performance in the country through third party evaluations;
· Strengthening MOPH stewardship functions
o Coordination of central MoPH and the Provincial Health Offices (PHOs);
o Promotion of decentralization;
· Piloting Innovations
o Pilot supply-side intervention as part of an international results-based financing (RBF);
o Payment for performance against achievement of agreed indicators related to Millennium Development Goals: MDGs 4 and 5.
The development of an Infection Management and Environmental Plan (IMEP) is a legal covenant for SHARP to be implemented by the World Bank. In the absence of a national policy document on infection and environmental management for the health sector in Afghanistan, this document was developed with technical and financial support of the World Bank.
· Issues and challenges related to health and environmental risks
· Weak legal framework
Afghanistan still remains below international standards in infection management and healthcare waste disposal. Improper infection management results in significant risks to healthcare workers (HCWs) and in-patients through the potential transmission of nosocomial infections within the Healthcare Facilities (HCFs). In addition, inadequate waste handling and disposal creates poor hygiene conditions: the health and environmental risks linked with their mismanagement remain high.
Afghanistan Health and Nutrition Sector Strategy (HNSS) advocated the development of health-related guidelines, regulations and laws for the public and private sectors. The National Environmental Protection Agency (NEPA) drafted an Environment Law that was approved in 2005. However, the absence of adequate guidelines for Healthcare Waste Management (HCWM), as well as a weak legal and regulatory framework, do not stimulate the management teams of HCFs to set-up a safer HCWM system.
· Poor knowledge and practices of HCWs
With the exception of some work on the proper disposal of the most hazardous categories of waste (needles and syringes used in immunization), there has been little work done in Afghanistan on an effective, hygienic and systematic approach to HCWM. Disposable syringes and catheters undergo inadequate sterilization, and are commonly re-used. General waste is mixed with sharps and infectious waste is disposed of without segregation in open dump sites, usually behind health facilities.
A survey[1] of HCWs in Kabul hospitals, conducted in April and May 2008, assessed practices in handling of sharps. The survey revealed that HCWs scored high on the reported practice of wearing mask, gown, and eyewear. 85 percent of HCWs are complying with the disposal of used needles into a sharps box, and 80.3 percent are applying the universal precautions in situations that might lead to contact with vaginal discharge. However, the majority of HCWs (81.2%) misunderstood that they should apply universal precautions in situations that lead to contact with sweat and almost half of them did not assume that blood and all body fluids of patients are infectious during their professional practice.
· Limited capacity of implementers
HCFs show low compliance with universal precautions due to limited financial resources, insufficient training of HCWs, lack of proper equipment, and absence of adequate recycling infrastructure. While HCWs self-reports show good levels of compliance with international standards, field visits to Kabul hospitals[2] hardly witnessed any compliance with best standard practices.
Box 1: Waste management in Kabul hospitals (Salehi, 2008).
Many respondent during the qualitative research reported that shortage of safety boxes and negligence of personnel led to discard and collect sharps, linen, and solid wastes in the same container. Moreover, the majority of the respondents reported that waste was not incinerated, neither buried nor burned. All types of waste were mixed and sent to a garbage bin out of the hospitals to be collected by the municipality. While waiting for the municipality to collect it, street children rummage around the garbage at the risk of infection. The finding is in line with an assessment carried out in 2002 in 22 developing countries where the proportion of an appropriate waste disposal management ranged from 18% to 64% (48). However, inappropriate waste management could place health care workers, patients, the community, and the environment at a great risk.
· Issues and challenges relevant to HCWM in HCFs
The major issues and challenges relevant to health and environmental risk in healthcare facilities are as follows:
(i) Treatment and disposal of bio-medical waste: currently many healthcare facilities are not managing their infectious waste in accordance with the Bio-Medical Rules promulgated by the internationally accepted standards. The challenge is to get all levels of healthcare facilities to institutionalized proper infection control measures and sound treatment and disposal of bio-medical wastes.
(ii) Disposal of sharps: disposal of sharps is a big issue in rural areas in sub-centers, BHCs and CHCs. There are a very large proportion of injections administered in country are unsafe, and syringes disposal techniques are faulty throughout the country. Institutionalizing good practices in this regards is one of the challenges, as SHARP includes a major immunization component.
(iii) Auto Disable (AD) plastic syringe wastes: there is expected to be a large quantity of plastic waste that will need to be disposed off in an environmentally sound manner. Proper treatment and disposal of these wastes will be another challenge.
(iv) Water and sanitation: in BHCs, provision of clean, potable and continuous water supply is an issue. Associated with it, the treatment and disposal of waste water and sewage and continued operation and maintenance system needs to be addressed.
(v) Design and construction-related issues: there are expected to be a range of new construction, such as sub-centers, BHCs and CHCs, emergency obstetrical care, new-born care corners and blood storage facilities. All these will require proper designing and will also result in the generation of construction waste, which needs to be disposed in an environmentally responsible manner. This should be a minor issue.
(vi) Information, skill and attitude: lack of information, awareness and skills is one of the primary factors for poor implementation of infection control and bio-medical waste management. The challenge is to provide healthcare workers with skills training, protective equipment and appropriate tools to bring about a fundamental shift in their mindset and behavioral patterns.
Wastes generated in healthcare facilities include different kinds of infectious and non-infectious waste. It is important to keep in mind that, if the infectious wastes are not separated from the common waste. The complete waste volume would need to be considered infectious. For this reason, WHO recommends the daily amount of bio-medical in health care facilities without a proper waste management system be calculated using the estimate of 1kg/bed.
B. Aim of Infection Management and Environmental Plan (IMEP)
The aim of this project is to assist in establishing a set of basic guidelines for HCWM. Follow-on steps include policy discussions and operating principles at the appropriate levels towards creating a proper legislative environment for enforcement of a HCWM plan in Afghanistan.
· Policy Framework: a summary version that gives a broad overview and generic guidance to central and state level institutions on the establishment of a system for sound infection control and bio-medical waste management.
· Operational Guidelines: designed as an instruction manual for healthcare workers at PHC, and provides details of the procedures, plans and guidelines of infection control and waste management procedures.
While the policy framework is targeted to senior management, the operational guidelines are mainly for doctors, nurses and various levels of healthcare workers. Hence, the range of the EMP covers the entire chain of stakeholders in the healthcare system. At this stage, it should be emphasized, that the EMP aims to establish and maintain high quality standards vis-à-vis infection management and environmental management.
The IMEP’s objectives are:
· To adopt and implement the Infection Management and Environment Plan throughout Afghanistan’s HCFs;
· To monitor the performance and review the Waste Management Plan at least annually;
· Adopt a waste minimization policy, which incorporates realistic guidelines;
· Develop concise waste segregation principles and promote practical guidelines for re-usable products;
· Foster commitment from all staff and management to actively participate in waste avoidance, reduction, reuse and recycling programs;
· Introduce a continuing waste management education program for all staff to increase awareness of Occupational Health & Safety issues and waste minimization principles;
· Adopt policies and procedures to minimize the environmental impact of waste treatment and disposal.
Major environmental issues include the lack of segregation of infectious waste and sharps, improper disposal, and improper wastewater management in those facilities fortunate enough to have a functioning water supply. Although waste minimization measures are possible, segregation of waste at the point of generation is the most critical and strategic intervention. In limited-resource settings, chemical disinfectants for decontamination of infectious waste may be appropriate and cost-effective. Hence, the proposed project will address: (a) removal of sharps and segregation of general waste from infectious and hazardous waste; (b) destruction of sharps or their placement in appropriate containers; and (c) deep burial. This approach will be implemented through training, development of an institutional framework, community participation, and monitoring.
II. Policies, Legislation and Regulations
A. Background
The elaboration of the legal framework and the reinforcement of the existing rules and regulatory documents are essential to ensure that proper HCWM practices can be enforced.
B. National Environmental Protection Agency (NEPA)
Afghanistan has now an Environmental Protection Laws enacted by the Parliament, signed and approved by the President and published in the Official Gazette.
· National Environmental Protection Agency (NEPA)
The National Assembly of the Government of Afghanistan (GoA) enacted the Environmental Law, 2005. This Act has been promulgated to give effect to Article 15 of the Constitution of Afghanistan and provide for the management of issues pertaining to the rehabilitation of the environment and the conservation and sustainable use of natural resources, living and non-living organisms. There are some rules and articles that have been brought out under this Act, which are directly relevant to the health sector:
o Article 27: Prohibition against discharges
o Article 28: Pollution control licenses
o Article 29: Reporting and containing discharges
o Article 30: General prohibition and duty of care in relation to waste management
o Article 31: Waste management licenses
o Article 32: Hazardous waste management licenses
Further Environmental Impact Assessment (EIA) regulation is prepared by the NEPA and is under review by the Ministry of Justice (MoJ). The aim of this project is to establish a set of basic guidelines for HCWM in light of the current countries laws and evolving regulations.
A regulation on the Management of Hazardous Waste (that would consider not only HCW but also other categories of hazardous waste such as pesticides, certain industrial waste, etc) should be issued by GoA. Within this law, specific chapters or articles should be devoted to HCWM and contain the general and specific provisions to determine the authorities of enforcement, the obligations of HCWM Producers and Operators, the authorized management, treatment and disposal procedures as well as the range of penalties to be applied;