'Protect Human Health And The Environment From Unintentional Releases .

Component 3: Implement Mercury Waste Management and Reduction Activities for the City ofBishkekComponent 4: Monitoring, Adaptive Feedback, Outreach and EvaluationAs one of the steps to achieve the developmental objective of reducing the releases of UPOPs andmercury from healthcare entities, the project aimed to strengthen the regulatory and policy frameworkpertaining to POPs and mercury, as well as to provide training and capacity building. The project wasto directly reduce emissions of UPOPs and mercury through improved healthcare waste managementin eleven hospitals/ polyclinics and 100 rural Health Dispensaries.The project has been implemented using Direct Implementation Modality (DIM) as per UNDP’sprocedures. The project’s Executing Entities were the Ministry of Health and the State Agency forEnvironment Protection and Forestry, whilst UNDP was the Implementing Entity. As the project hasreached its, ‘Terminal Evaluation’ of the project has been carried out in order ascertain the outcomesand impact of the programme, measured against its original purpose, objectives whilst in the processcapturing the evaluative evidence of the relevance, effectiveness, efficiency and sustainability of thisproject, which will set the stage for future similar initiatives. The Terminal Evaluation was carried outby an independent international consultant (Dinesh Aggarwal, India). This report presents the findingsof the ‘Terminal Evaluation’.Project Objectives and Logical Frame WorkTable 2, below provides the Project Objectives along with the summary of the planned outcomes. Italso shows the corresponding set of indicators for monitoring and verification of the achievementsagainst the Objectives and the Outcomes.Table 2:: Project Results Framework (as per Project nvironmentalPractices(BEP) andBest AvailableTechnologies(BAT) in thehealth-caresector to assistKyrgyzstan inmeeting itsobligationsunder theStockholmConvention toreduce UPOPsas well asMercuryreleases.BaselineTargets End of Project UPOPs Kyrgyzstan’s NIP, calculated that the total In total the project expects to reduce UPOPsemissionsreleases of dioxins in 2003 were 30.5 gemissions by 3- TEQ/yr.reduced as aTEQ. The majority of releases wereresult ofindicated to be the result of combustionimprovedpractices, with the greatest contributionHCWMmade by incineration of medical wastes (7treatmentg- TEQ)systems used byHCFsbenefittingfrom theproject. Country The current regulatory framework does Legal and regulatory framework enhancedcapacity built tonot cover all medical waste managementthrough the revision of the national HCWMeffectivelychallenges, which the country is facing,strategy, the development of a nationalphase out andwhile existing guidelines do not have anystrategy for anatomical waste, and thereduce releaseslegal status and as such are notdevelopment of standards and degreesof POPsenforceable.pertaining to HCWM. Mercury No national Mercury Assessment has The phase-out of Mercury containingemissionsbeen undertaken yet, but based on 2011thermometers will result in sustainedreduced as aand 2012 import figures, between 58 andMercury reductions of approximately 160 kgresult of the305 kg of Mercury, contained in medicalHg/year.phase-out ofthermometers, is imported yearly.Mercury1During Project Inception some changes in the Results Framework of the Project were carried out. As can be seen for some ofthe indicators (particularly for Outcome 2.3, the target values has not been specified. At the time of project inception the targetvalues for the indicators for Outcome 2.3 were not specified. The MTR has mentioned that the indicators for Outcome 2.3 do nothave much meaning.Report: Terminal Evaluation of the project ‘Protect human health and the environment from unintentional releases of POPsand mercury from the unsound disposal of healthcare waste in Kyrgyzstan’7

Indicatorcontainingmedicalthermometersand improvedmanagement ofMercurycontainingwastes.COMPONENT 1: StrengtheningOf The National Regulatory AndPolicy Framework For HealthCare Waste ManagementOutcome 1.1 National HealthThe policyCare Wasteframework forManagementHealth CareStrategy revisedWasteand updated.Management NationalenhancedStrategy forAnatomicalWastedeveloped.Outcome 1.2 Number ofThe regulatoryapproved andand policyadoptedframework forstandards andHealth CaredegreesWastedeveloped asManagementpart of theenhanced.project.COMPONENT 2: ImplementationOf Best Available Technologies(Bat), Best EnvironmentalPractices (BEP) For HCWMSystemsOutcome 2.1I-RATsAccuratecompleted forinsight in theeach of the HCFsHCWMsupported by thesituation atprojecteach of theHCFssupported bythe project.Outcome 2.2: DetailedAllocation ofprocurementHCWMand TA plan fortechnologies,thedevices,implementationsupplies andof Phase I.TechnicalUpdatedAssistanceZoning Plant(TA) needsdetermined foreach HCFBaselineTargets End of Project Although a National Strategy (20082012) on HCWM was elaborated, it hasnever been approved/adopted due to lackof funding for its implementation. The collection, safeguarding and transportof anatomical wastes is highly inadequate. National Strategy on Healthcare wastemanagement in the Kyrgyz Republicfinalized. National Strategy for Anatomical Wastedrafted. HCWM related legislation is merelyfunctioning as a framework and reflectsthe general requirements to preventadverse effects on health and theenvironment. However, most of these areguidelines do not have any legal statusand as such are not enforceable. The current regulatory framework doesnot cover all medical waste managementchallenges, which the country is facing. A major challenge remains theimplementation and enforcement ofregulations and guidelines, which areoften issued without providing HCFs orstakeholders with any support or capacitybuilding to enable them meet therequirements set-out in these regulations/guidelines. Standards on technologies for the processingand final disposal of HCW developed. Standards on HCW in immunization officesdeveloped. Standards on DoD developed. Standards on treatment of chemical andpharmaceutical waste developed. Standards on monitoring HCWM practicesdeveloped. Job descriptions for those responsible forHCWM at HCFs developed. Import ban drafted on PVC containingsyringes and other medical products forwhich cost- effective alternative areavailable. Some baseline information is availablemainly from prior HCWM assessments aswell as from the project’s PPG phase. All HCFs have participated in a HCWMassessment. An accurate UPOPs and Hg baseline hasbeen established for each HCF Some information is available on the typeof TA and equipment/supplies that wouldbe required for HCFs, however detailedinformation for each HCFs will berequired to draw up a sound procurementand TA plan. A Zoning Plan was developed in 2012 butis currently outdated. The Zoning Planwill also require revision to reflect theoutcomes of the I-RATs. For each HCF, HCWM equipment,Technical Assistance (TA) and fundingneeds have been determined/calculated forthe first phase of the project. The HCF “Treatment Zoning” plan (usingGIS/Remote Sensing) has beenrevised/updated. A detailed procurement and TA plan hasbeen drawn up for the first phase of theproject’s implementation.Report: Terminal Evaluation of the project ‘Protect human health and the environment from unintentional releases of POPsand mercury from the unsound disposal of healthcare waste in Kyrgyzstan’8

Outcome 2.3:UPOPs releasesreduced as aresult ofimprovedHCWMsystems insupportedHCFsOutcome 2.4:Nationaltrainingmodules onHCWMIndicatorBaselineTargets End of Project % as comparedto I-RATbaselineestablished atthe start of theproject(outcome 2.1) Wastesegregationimproved by xx% Number ofHCFs that sendtheir disinfectedsyringes torecyclersincreased by xx% Average HCFinfectious wastevolumesreduced by xx% No of projectHCFs practicescompostingincreased by xx% Percentage ofproject HCFsthat haveintroduced nonincinerationtechnologies xx% Wastemonitoringinstalled. No. ofincidences/accidents involvinginfectious wastereduced by xx% Transportationof infectiousand anatomicalwasteexclusivelyassumed byauthorizedvehicles. Average costsfor HCWMreduced by xx% At the primary healthcare level,immunization waste is either burned inthe open (in rural areas) or in the case ofBishkek mixed with regular householdwaste ending up on the Bishkek dumpsiteor transported to a boiler house for lowtemperature incineration. At Bishkek hospital level in Bishkek, theprimary method of treating infectiousmedical waste is by chemical disinfectionafter which the waste ends up on theBishkek dumpsite, which is continuouslyon fire, leading to the formation ofdioxins and furans. Common HCWM challenges faced byHCFs are:- Lack of awareness on the dangers ofHCW and the risks to human healthand the environment in combinationwith absence of training opportunities.- Absence of sufficient and adequatetechnologies, devices and supplies tomanage HCW soundly.- Sub-optimal operation of the HCWMmodel in HCFs where treatmenttechnologies have been installed.- Inadequacies in waste flows and- transportation of waste on the premisesof HCFs- Cluster-hub system and HCWtransportation system not yetoperational. MoUs signed between project and each HCF. HCF staff trained in best practices forHCWM, including:- Responsibilities for HCWM assigned andwaste management committeesoperationalized in each project HCF.- HCWM plans drawn up for each projectHCF.- Xx HCFs and xxx staff trained in bestHCWM practices related to wasteidentification, classification, segregation,labelling, packaging, storage, treatment,transportation, etc. at HCF level.- Xx managers and professionals trained onHCWM related procurement, accountingand budgeting; monitoring and reporting;and HCWM related record keeping(incidents, accidents, waste recording,etc.) 8 Bishkek hospitals and 3 policlinicssupported in refurbishing/preparing wastestorage locations and locations fortechnology installation Non-incineration technologies and HCWMsupplies procured and installed for all projectHCFs (11 HCFs in Bishkek, 1 zone and 100FAPs):- Project HCFs equipped with HCWMsupplies and non- incinerationtechnologies- xx Global Fund recipient HCFs equippedwith additional non- incinerationtechnologies/HCWM supplies- zone equipped with sufficient treatmentcapacity/HCWM supplies (including thezone’s hub treatment facility, its satellitesas well as decentralized facilities).- (Pilot) 100 FAPs in rural areas equippedwith pressure cookers and necessarycapacity building and HCWM supplies. Standard Operating Procedures (SOPs) forthe procured technologies prepared/revised. Autoclave operators and other staff trainedon SOPs, safety precautions, and qualitycontrol of the new technology. Draft cost-sharing agreements for infectiouswaste treatment between service HCF andrecipient HCF developed. Optimum transportation routes determined Staff involved in infectious wastetransportation trained on the safe handling ofHCW and Mercury waste Project HCF staff trained in in compostingand plastics recycling. Environmentally sound agreement reachedwith the Bishkek Mayor’s office and theEBRD on the handling of disinfected HCWand Hg containing wastes at the newengineered Bishkek Landfill Trainingpossibilities/opportunities onHCWM offeredby national Lack of a systematic approach to trainingmedical and nursing staff on HCWMresulting in low awareness on the dangersof HCW and the risks to human healthand the environment. Certain HCFs have a contract with a localrecycler, which collects chemicallydisinfected syringes. Although the SRC/MoH has successfullydemonstrated composting at the rurallevel, none of the HCFs in Bishkekundertake composting. Transportation of infectious HCW in thecity of Bishkek is extremely inadequate,more often than not, using passenger carsor ambulances, which are also used totransport patients, healthcare staff, etc. The City Health Department has received1 transport vehicle through the phase IGlobal Fund project, which will soon beused to transport infectious HCW,between HCFs and treatment hubs.However the delivery/pick-up schedulehas not yet been worked out in detail. National training modules developed byPreventive Medicine as well as those used bythe National Training Centre have beenrevised/improved based on the WHOHealthcare Waste Project Global TrainingReport: Terminal Evaluation of the project ‘Protect human health and the environment from unintentional releases of POPsand mercury from the unsound disposal of healthcare waste in Kyrgyzstan’9

available andbeing used bythe MoH(preventiveMedicine),nationaltraining centersand MedicalFaculties.IndicatorBaselineTargets End of Projectteachinginstitutions andschools. As part of the Global Fund Phase IIproject, the MoH institute “PreventiveMedicine” has developed trainingmodules, with support of UNICEF andwill be providing this training to varioustarget groups. The “National Training Center” providespost-graduate training (continuousprofessional development) as well aseducational training for healthcare staff,which contains modules on HCWM.Materials MoUs signed between the project andmedical university faculties and nursingschools. Training modules on HCWM designed andsubsequently embedded in the curricula ofthe Medical Academy as well as the MedicalFacility of the Kyrgyz- Russian-SlavikUniversity and potentially a number ofnursing schools. In Kyrgyzstan, the management ofMercury containing products is not beingaddressed, whether in the healthcaresector or any other sector. When products that contain Mercurybreak or need to be disposed of, suchwastes are being discarded along withregular municipal waste. No special measures are taken to protecthealthcare facility staff, the environmentor people/communities coming in closecontact with such wastes. There are no restrictions on theimportation of high Hg-content lamps(CFLs, tubes) or Hg- containing medicaldevices. Guidelines on the management, storageand disposal of Hg containing lamps arenot available. Maximum permissible concentration(MAC) for metallic mercury (Hg) are setfor air, water and soil. Mercury containing sphygmomanometershave been phased-out approximately 10years ago, however Mercury containingthermometers are still in wide use. In2011 and 2012, respectively 203,121 and116,034 were imported. When products that contain Mercurybreak or need to be disposed of, suchwastes are being discarded along withregular municipal waste. Currently there are no safeguardingprocedures in place at HCF level toensure the safe clean-up, management andstorage of broken thermometers or othermercury containing wastes, as suchexposing healthcare facility staff, patientsor visitors to Hg exposure. National action plan on the LCM of Hgcontaining products developed. National standards/guidelines on themanagement, storage and disposal ofmercury containing products developed forlarge public and private entities, as well asHCFs. MSP degree drafted prescribing a phasedapproach/total phase-out for the use of Hgcontaining thermometers. EU RoHS directives for lighting productstransposed into national regulations througha degree. Assessment of potential Cost- RecoveryMechanisms for the future disposal/treatmentof Mercury containing products conducted.Component 3: Implement MercuryWaste Management And ReductionActivities For The City Of BishkekOutcome 3.1: A regulatoryStrengthenedframeworkpolicy andpertaining toregulatorytheframework tomanagement ofenable theMercuryphase-out/downcontainingof mercuryproducts iscontainingdeveloping andproducts andavailable.encourage Hgfree or lowerlevel HgproductsOutcome 3.2:ImprovedMercurymanagementpractices atHCFs andphase-out ofMercurycontainingthermometer 80% of projectHCFs haveintroducedMercury-freedevices.Outcome 3.3:Intermediateand long-termstorage optionsfor Mercurycontaining Phased-outMercurycontainingthermometershave beensafely disposed Currently such wastes end up at theBishkek landfill site, which is notengineered and doesn’t have any leachatecontrol, allowing Mercury to seep into theleachate and end up polluting nearby soiland water resources. Hg baseline assessments completed for eachproject HCF (as part of the I-RATs, seeActivity 2.1.1). Mercury management and phase- out plansdeveloped and implemented for each projectHCF (included in the development ofHCWM plans as part of Activity 2.3.2). 500 medical personnel trained in the cleanup, storage and safe transport of Hg wastes. Training video produced on "Cleanup andTemporary Storage of Mercury Waste forHealth Care Facilities" in Kyrgyz andRussian and used in training activities. Study on staff preferences for cost- effectiveHg-free alternatives conducted at a numberof project HCFs. Mercury-free thermometers introduced at theproject’s HCFs and personnel trained in theiruse. Eme

Report: Terminal Evaluation of the project 'Protect human health and the environment from unintentional releases of POPs and mercury from the unsound disposal of healthcare waste in Kyrgyzstan' 6 EXECUTIVE SUMMARY Project summary table Table 1: Project Summary Project Title: "Protect human health and the environment from unintentional releases of POPs