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Resilient nations.
Rapid Assessment:
Healthcare Waste
Component of Global
Fund HIV/AIDS Projects
in Uzbekistan
Supplement to the Healthcare Waste Management Toolkit for Global Fund Practitioners and Policy Makers
Author:
Jan-Gerd Khling, Environment and Hygiene Consultant
ETLog Health GmbH, kuehling@etlog-health.de
Rapid Assessment Series Editor: Dr. Christoph Hamelmann
UNDP contact: Dr. Christoph Hamelmann, christoph.hamelmann@undp.org
Other publications of the Rapid Assessment Series on Healthcare Waste
Components of Global Fund Projects:
Disclaimer: The consultant prepared this assessment report for the sole
use of the Client and for the intended purposes as stated in the agreement
between the Client and the consultant under which this work was completed.
The Consultant has exercised due and customary care in conducting this
assessment. The views set out in this assessment are those of the author and
do not necessarily reflect the official opinion of the UNDP. Neither the UNDP
nor any person acting on their behalf may be held responsible for the use
which may be made of the information contained therein.
Design & Layout: Phoenix Design Aid A/S, Denmark
Rapid Assessment: Healthcare Waste Component of Global Fund HIV/AIDS Projects in Uzbekistan
Table of Contents
1
Executive Summary..........................................................................................................................6
Assessed Projects..............................................................................................................................8
Background Information...............................................................................................................10
3.1 Assessment strategy............................................................................................................................................................10
3.2 Provided and reviewed project documents.........................................................................................................11
Legal Framework.............................................................................................................................12
4.1 International conventions................................................................................................................................................12
4.2 National legal healthcare waste framework.........................................................................................................12
7 Annexes.............................................................................................................................................32
7.1 Input analysis............................................................................................................................................................................32
7.2 Organizations and persons met...................................................................................................................................33
Supplement to the Healthcare Waste Management Toolkit for Global Fund Practitioners and Policy Makers
List of Figures
Figure 1: Assessment methodology.................................................................11
Figure 2: Sharp waste container used in Uzbekistan.........................................16
Figure 3: Current disposal scheme of the healthcare waste streams..................20
Figure 4: HCW quantity and quality by service level.........................................26
Figure 5: Main healthcare waste streams and possible treatment strategy........27
Figure 6: Sample national hazardous healthcare waste strategy, Uzbekistan....29
Figure 7: Process flow for decision making, solid waste....................................30
List of Tables
Table 1: Management structure GF projects..................................................9
Table 2: Status of ratification of international Conventions.............................12
Table 3: Estimation of sharps waste generation IDU interventions
(2014-2016).....................................................................................16
Table 4: HCW classification system, Uzbekistan based on the
old SanPin 600.............................................................................21
Table 5: Stakeholders consulted during mission.............................................33
Abbreviations
ACSM
ART
ARV
CCM
DOTS
GF
HBV
HCV
HIV
IDU
IEC
LFA
MARP
MandE
MoE
MoH
NFM
NGO
PIU
PMCT
PPP
PR
PWID
SES
Non-governmental organization
Project Implementation Unit
Prevention of mother-to-child transmission
Public private partnership
Principal recipient
People who inject drugs
Centre of Sanitary Epidemiological
Surveillance
SOP
Standard operating procedure
SR Sub-recipient
STI
Sexual transmitted infection
SSI
Small scale incinerator
SW
Sex worker
TP
Trust points
TB Tuberculosis
UNDP
United Nations Development Programme
WEEE
Waste of electrical and electronic
equipment
WHO
World Health Organization
Rapid Assessment: Healthcare Waste Component of Global Fund HIV/AIDS Projects in Uzbekistan
Acknowledgements
This assessment report is part of the development of a toolkit to improve the planning
and implementation of better healthcare waste systems in future projects financed and
coordinated by of the United Nations Development Programme (UNDP). I would like to
acknowledge the valuable input of the following participants, without whom this research
would not have been possible.
From the UNDP Istanbul Regional Centre for Europe and Central Asia, Dr. Christoph
Hamelmann, Regional Team Leader HIV, Health and Development, coordinated the entire
work and concept and peer reviewed all developed documents. John Macauley provided the
needed continuous management support during the project time.
The assessment included an onsite visit in Uzbekistan from 4 to 8 November 2013. At
that time several UNDP GF projects sites have been visited and relevant stakeholder
interviewed. I would like to extend our gratitude to all the individuals and institutions that
contributed to the planning and execution of this assessment.
Special thanks are also extended to the UNDP country office in Tashkent which hosted
the assessment and provided the local organization of the interviews and site visits,
especially to Mr. Stefan Priesner (UN Resident Coordinator), Mr. Jaco Cilliers (Deputy
Resident Representative), Flora Salikhova (National Officer on Public Health), Abduvakkos
Abdurahmanov (Head of Environment and Energy Unit) and Mr. Zakir Kadirov (Project
Manager of the GF project).
Supplement to the Healthcare Waste Management Toolkit for Global Fund Practitioners and Policy Makers
1 Executive Summary
UNDP has been a strategic partner of the Global
Fund to Fight AIDS, Tuberculosis and Malaria (GF)
for the last 10 years and has acted as interim principal
recipient of last resort for countries in which the GF
cannot identify a national principal recipient (PR) for
its grants. In order to deepen the understanding of the
environmental impact caused by waste created through
its GF project implementations an onsite assessment
of GF health projects with UNDP PR-ship will be
conducted in Uzbekistan, Tajikistan and Zimbabwe.
This report outlines the results of the assessment in
Uzbekistan which was carried out in the context of
the development of a toolkit to improve the planning
and implementation of better healthcare waste
systems in future projects. The lessons learned from
this assessment were therefore crucial for the further
development of the toolkit.
The assessment in Uzbekistan was conducted from
4 to 8 November 2013 and concentrated on the GF
HIV/AIDS grants which are consolidated in a Single
Stream of Funding. Phase 1 of this consolidated grant
will end in 2013 but will be extended by one year. A
second phase for the following years will be developed
under the New Funding Model (NFM) of the GF. The
assessment includes a detailed review of all provided
documents from the Phase 1 and of the previous
application of Phase 2. Furthermore interviews with
all relevant governmental and non-governmental
stakeholders, as well as the visit and interview of
different Sub-Recipients were conducted.
The waste management system, especially the
healthcare waste management system is in an early
development stage in Uzbekistan. The legal framework
for waste management is at the moment reviewed
by the government. For healthcare waste a complete
legal framework has not yet been developed. However,
Rapid Assessment: Healthcare Waste Component of Global Fund HIV/AIDS Projects in Uzbekistan
executive summary
1 Source: http://www.who.int/mediacentre/factsheets/fs281/en/
Supplement to the Healthcare Waste Management Toolkit for Global Fund Practitioners and Policy Makers
2 Assessed Projects
UNDP is a long-term partner of the Global Fund
to Fight AIDS, Tuberculosis and Malaria (GF) and
acts in several countries, including Uzbekistan, as
interim principal recipient (PR). The implementation
of the programmes often results in the generation of
different types of waste which have a possible negative
environmental and public health impact. To minimize
these impacts and to include sustainable environmental
strategies, it is planned to develop a waste management
toolkit to support grant planners, grant reviewers/
approvers, implementers and others in better and safer
waste management.
To better understand the current situation, assessments
on the existing waste management systems were
carried out in three countries. The results of the
assessments will be used to improve the applicability
and practicability of tools to be developed.
The assessment of the GF grants implemented in
Uzbekistan by UNDP as PR was conducted in the
second week of November 2013. The objective was
to assess the current and planned waste management
practices of the following projects:
HIV/AIDS: UZB-311-G06-H
Name: Continuing Scale Up of the Response to HIV
in Uzbekistan, with Particular Focus on Most-at-Risk
Populations:
The programme funded by this grant builds on the
activities initiated and results achieved under the
Round 3 HIV and AIDS grant in Uzbekistan to further
develop and strengthen the national response to HIV.
The programme goal is to prevent the spread of HIV
into the general population by reducing its impact on
the most vulnerable populations, including people who
inject drugs, sex workers and men who have sex with
men. The programme has four objectives:
Rapid Assessment: Healthcare Waste Component of Global Fund HIV/AIDS Projects in Uzbekistan
Assessed Projects
Organization
Global Fund
Country Coordination
Mechanism
Principal Recipient
UNDP, Uzbekistan
PricewaterhouseCoopers,
Uzbekistan
Supplement to the Healthcare Waste Management Toolkit for Global Fund Practitioners and Policy Makers
3 Background Information
Key Country Data:
Full Name: Republic of Uzbekistan
Total Population (2009)*: 28,541,000
Area**: 447,400 sq km
Life expectancy at birth m/f (years)(2009)*: 66/71
Infant mortality rate (2012)**: 20.51 deaths/1000 live births
Hospital bed density (2009)**: 4.5 beds/1000 population
GDP - per capita (PPP)(2012 estimate)**: $3,600
Total expenditure on health as % of GDP (2011)*: 5.4
2 All country data provided in this chapter are sourced from the following:
* World Health Organization Country Data (http://www.who.int/countries/en/)
** Central Intelligence Agencys The World Factbook (https://www.cia.gov/library/publications/the-world-factbook/geos/as.html) current as accessed by the
consultant in 2013 unless otherwise indicated
10
Rapid Assessment: Healthcare Waste Component of Global Fund HIV/AIDS Projects in Uzbekistan
Background Information
e c s it s t
ts o
i te
s
Input- Output
Analysis
r
olde
keh ws
Sta tervie
In
A c
pro
na
u r l ysis
em of
ent G F
pro c
esses
vi
ite oj
s
n
O e pr
th
Supplement to the Healthcare Waste Management Toolkit for Global Fund Practitioners and Policy Makers
11
4 Legal Framework
4.1International conventions
The assessment of relevant international conventions
for healthcare waste management showed that
Status of ratification
Year
Accession
http://www.basel.int/Countries/StatusofRatifications/
PartiesSignatories/tabid/1290/Default.aspx
07/02/1996
http://www.pic.int/Countries/Statusofratifications/
tabid/1072/language/en-US/Default.aspx
Accession
http://ozone.unep.org/new_site/en/treaty_
ratification_status.php?treaty_id=andcountry_
id=169andsrchcrit=1andinput=Display
Both on
18.05.1993
http://chm.pops.int/Countries/StatusofRatifications/
tabid/252/Default.aspx
http://www.unece.org/trans/danger/publi/adr/
legalinst_53_tdg_adr.html
http://www.mercuryconvention.org/Countries/
tabid/3428/Default.aspx
12
Rapid Assessment: Healthcare Waste Component of Global Fund HIV/AIDS Projects in Uzbekistan
Legal Framework
Supplement to the Healthcare Waste Management Toolkit for Global Fund Practitioners and Policy Makers
13
{
{
14
non-hazardous waste
waste (cardboard, foil, etc.)
aper waste
P
eneral office waste (unsorted)
G
P P
acking
P
P
Rapid Assessment: Healthcare Waste Component of Global Fund HIV/AIDS Projects in Uzbekistan
P U
sed
condoms
or unusable products, non-hazardous
(e.g. syringes, condoms, etc.)
azardous waste
H
P Infectious waste (contaminated swabs, syringes,
gynaecological sets)
P S
harp waste (used syringes)
P P
harmaceutical waste (expired STI drugs)
P E
xpired
non-hazardous waste
waste (cardboard, foil, etc.),
P P
aper waste
P G
eneral office waste (unsorted)
azardous waste
H
P Infectious waste (contaminated swabs, minor)
P P
harmaceutical waste (expired or unusable
drugs and diagnostic kits)
P P
acking
{ Improve
P W
aste
non-hazardous waste
waste (cardboard, foil, etc.) from the
disposables
P P
aper waste
azardous waste
H
P Infectious waste (contaminated disposable
products such as blood bags, arterial lines, etc.)
P S
harp waste (lancets, catheters, needles, etc.)
P C
hemical waste (Ash from the hospital
incinerator)
P P
acking
Supplement to the Healthcare Waste Management Toolkit for Global Fund Practitioners and Policy Makers
15
5.0L
Product Size
Length
24.5cm
Width
20cm
Height
16.5cm
Carton Size
51x42x29.5cm
24pcs
G.W. / N.W.
7.5KGS /
6.5KGS
16
Sharp Waste
[ton/year]
70
2015
PWID targeted
30,000
Sharp Waste
[ton/year]
2016
PWID targeted
75
Rapid Assessment: Healthcare Waste Component of Global Fund HIV/AIDS Projects in Uzbekistan
32,000
Sharp Waste
[ton/year]
80
Supplement to the Healthcare Waste Management Toolkit for Global Fund Practitioners and Policy Makers
17
3 Technical assistance in the development of the training module on medical waste disposal in the Republic of Uzbekistan, Gyulyara Efendieva, 25.02.2013.
18
Rapid Assessment: Healthcare Waste Component of Global Fund HIV/AIDS Projects in Uzbekistan
Supplement to the Healthcare Waste Management Toolkit for Global Fund Practitioners and Policy Makers
19
Waste pit
Infectious waste
Chlorine solution
Sharp waste
from programme
Plastic/ Cardboard
Sharps Box
SSI *
Self-made incinerators
Waste pit
Open burning
Open burning
Central Incinerator
SSI
Needles
Other
syringes
Chlorine
solution
Plastic
Chlorine
solution
Self-made
incinerators
SSI *
Pathological waste
Special burial
* SSI = Small Scale Incinerator
20
Rapid Assessment: Healthcare Waste Component of Global Fund HIV/AIDS Projects in Uzbekistan
Table 4: Healthcare waste classification system, Uzbekistan based on the old SanPin 600
Class A
Non-hazardous
{
Class B
Hazardous
Potentially contaminated
wastes.
Pathological wastes
(patients tissues, organs
etc.).
Furniture, broken
diagnostic equipment,
which dont contain toxic
elements.
Non-contaminated paper,
construction wastes etc.
io-wastes of animal
B
research laboratories
Class D
Wastes, close to
industrial wastes
Class C
Extremely hazardous
{
Disinfectants.
astes of laboratories,
W
working with microorganisms of group
1 - 4 of pathogens.
Equipment and
instruments containing
mercury.
Supplement to the Healthcare Waste Management Toolkit for Global Fund Practitioners and Policy Makers
21
22
Rapid Assessment: Healthcare Waste Component of Global Fund HIV/AIDS Projects in Uzbekistan
Supplement to the Healthcare Waste Management Toolkit for Global Fund Practitioners and Policy Makers
23
6.2Context specific
recommendations for the GF
programme in Uzbekistan at
national level
a) Reactivation of the governmental healthcare
waste working group
Current situation: In the past a governmental working
group on healthcare waste existed, however this
working group no longer exists.
Justification/impact: Due to the absence of the
working group it is difficult for the MoH to provide
required feed-back for the review of the national waste
law and the development of a national healthcare waste
strategy and plan stopped.
Recommended activities: To suggest and support
the reactivation of the governmental healthcare waste
working group.
b) Support the setup of an donor coordination
group for healthcare waste (UNDP, WB, WHO,
KfW)
Current situation: Different organizations (including
UNDP, WB, WHO, KfW, etc.) were active, are active or
will be active in the field of healthcare waste.
Justification/impact: In the past different activities
were carried out on healthcare waste management.
Some activities of donors (e.g. guideline development
and training development) overlapped or duplicated
efforts. Possible synergies were not always utilized.
Recommended activities: A donor coordination group
on healthcare waste should be established (e.g. under
the leadership of UNDP) and should meet regularly
(e.g. every 2 months) to discuss achievements, ongoing and planned activities and to coordinate future
investments.
c) Support the development of a national
healthcare waste strategy and development
plan
Current situation: A national strategy which describes
the envisaged future system does not exist and
investments do not always follow a uniform plan.
24
Rapid Assessment: Healthcare Waste Component of Global Fund HIV/AIDS Projects in Uzbekistan
Supplement to the Healthcare Waste Management Toolkit for Global Fund Practitioners and Policy Makers
25
District level
Provincial level
Secondary
level
hospital
Tertiary
level
hospital
Large quantity,
several waste
streams
{ Non-risk,
26
Primary
level
hospital
Central level
P Other
Rapid Assessment: Healthcare Waste Component of Global Fund HIV/AIDS Projects in Uzbekistan
Non-special-risk waste
Biohazardous waste
Transport
Chemical waste
Transport
Treatment
Transport
Landfill
Radioactive waste
Transport
Treatment
Transport
Landfill/
Sewage Treatment
Pathological waste
Interim Storage
Transport
Landfill
Cemetery/
Cremation
Controlled
Storage
Supplement to the Healthcare Waste Management Toolkit for Global Fund Practitioners and Policy Makers
27
28
Rapid Assessment: Healthcare Waste Component of Global Fund HIV/AIDS Projects in Uzbekistan
Valuable Material
Recovery
Valuab. Mat.
CENTRAL LEVEL
Tertiary / National
Hospitals
Hazardous Waste
Treatment
Valuab. Mat.
OBLAST LEVEL
Secondary
Hospitals
Household Waste
Landfill
Central Hazardous
Waste storage
Chemical Waste
Other Hazardous Waste
PROVINCIAL LEVEL
Valuable Material
Recovery
Haz. Waste
Biohazard
Waste
Hazardous Waste
Landfill
} 5 Vol.%
Autoclave
Household Waste
Landfill
Autoclave
Household Waste
Landfill
DISTRICT LEVEL
RAYON LEVEL
Primary Level
Hospitals
Biohazard
Waste
Other small
HCW Producer
Supplement to the Healthcare Waste Management Toolkit for Global Fund Practitioners and Policy Makers
29
BIOHAZARDOUS WASTE
Central
or shared treatment
avail.?
Waste can be
treated?
No
Storage + transp.
nat. haz. cent.
Waste can be
treated?
No
Yes
OBLAST LEVEL
Secondary hospital
Yes
Central
treatm. more
economic.?
No
Yes
Advanced
incinerator
On site
autoclave
Central
Yes
or shared treatment
avail.?
Storage + centr.
treatment
No
No
Storage + transp.
nat. haz. cent.
Autoclaved
system
Yes
Storage + transp.
to oblast hospital
Yes
RAYON LEVEL
Primary hospital
Yes
Central
Yes
or shared treatment
avail.?
Storage + centr.
treatment
No
All Healtcare
facilities in
Uzbekistan
30
Autoclaved
system
Rapid Assessment: Healthcare Waste Component of Global Fund HIV/AIDS Projects in Uzbekistan
No
Storage + centr.
treatment
{ Implementing
{
{ C
learing
Supplement to the Healthcare Waste Management Toolkit for Global Fund Practitioners and Policy Makers
31
7 Annexes
7.1Input analysis
Objective 1 Medicines used for STI diagnosis
and treatment
{ Aciclovir
{ Azithromycin
{ Benzathin benzylpenicillin
{ Ceftriaxone
{ Ofloxacin
{ Clortrimazole
{ Doxycycline
{ Fluconazole
{ Metronidazole
Objective 2 Medicines used for the treatment,
care and support of people living with HIV
{ Abacavir
{ Didanosine
{ Efavirenz
{ Lamivudine
{ Lopinavir
{ Nevirapine
{ Stavudine (d4T)
{ Tenofovir
{ Ritonavir
{ Emtricitabine
Objective 2 - Medicines for the treatment of
opportunistic diseases
{ Aciclovir
{ Amikacin
{ Amoxicillin
{ Amphotericin B
{ Ampicillin
{ Azithromycin
{ Ceftriaxone
{ Ciprofloxacin
{ Clarithromycin
{ Clavulante
{ Clindamycin
32
Clotrimazole
Co-trimoxazole
{ Doxycycline
{ Erythromycin
{ Ethambutol
{ Fluconazole
{ Folic acid
{ Itraconazole
{ Izoniazid
{ Ketoconazole
{ Loperamide
{ Miconazole
{ Moxifloxacin
{ Nalidixic acid
{ Nystatin
{ Primaquine
{ Pyridoxine hydrochloride
{ Pyrimethamine
{ Rifabutin
{ Sulbaktam
{ Sulfadiazine
{ Valganciclovir
{
{
Rapid Assessment: Healthcare Waste Component of Global Fund HIV/AIDS Projects in Uzbekistan
Annexes
Name/Title
UNAIDS
NGO Intilish
CCI Office
Supplement to the Healthcare Waste Management Toolkit for Global Fund Practitioners and Policy Makers
33
Empowered lives.
Resilient nations.