This is a continuing activity from FY04-FY07. This is a centrally managed Track 1 award.

Unsafe injections are reported to be responsible for the transmission of various blood borne infections in

Ethiopia, including HIV/AIDS, and Hepatitis B and C. In FY04 and FY05, the Making Medical Injections

Safer (MMIS) project developed and implemented pilot programs to rapidly increase the safe and

appropriate use of injection equipment in Ethiopia. Based on the pilot programs, a multi-component

approach to improve injection safety has been implemented. The core components of the MMIS program

include: (1) commodity procurement and management; (2) training and human capacity building; (3)

behavior change and advocacy; (4) standardizing systems for proper waste management practices; (5)

addressing private providers and the informal sector; (6) policy development; and (7) monitoring and

evaluation.

(1) Commodity procurement and management are critical steps to assure safe injection practices. MMIS is

working to assure both adequate supplies of injection devices as well as appropriate use and management

of stocks at different health service facilities. MMIS has provided and/or distributed syringes, personal

protective equipment, color-coded waste bins with proper biohazard labeling, and other waste management

commodities. FY07 Semi Annual Performance Review (SAPR) data show 86 health centers and 366 health

posts covered with supplies. The commodities are efficiently distributed through a central warehouse in

Addis as well as regional warehouses in Dire Dawa and Harari. Regional health bureau (RHB) storage

capacity is also being built. To manage the commodities, consumption of syringes has been monitored in

several districts to help assure appropriate level of stocks in different settings. MMIS also contributed to

Ethiopian Ministry of Health (MOH)-sponsored national HIV/AIDS five-year forecasting workshop. MMIS

also helps to develop memoranda of understanding (MOU) between RHB and hospitals to use the revolving

drug fund (RDF) in line with government policy promoting healthcare financing as a means of sustainability.

MMIS is monitoring these MOU and making adjustments as effectiveness is assessed.

The Partnership for Supply Chain Management/Supply Chain Management Systems (SCMS) project is

using the inputs provided by MMIS and other stakeholders in updating the five year HIV/AIDS commodity

quantification and costing analysis, and will support distribution of infection prevention commodities through

the parastatal pharmaceutical supply organization, PHARMID, with technical assistance. There is a large

overall funding gap for HIV commodities, and prioritization of procurement using available funds will include

infection-prevention materials, which have the largest funding gap of all major commodity groups, per the

five-year exercise. Technical input from MMIS will be incorporated in this process, and it is expected that,

with SCMS technical support, the MOH will form an HIV/AIDS Commodity Advisory Group, under which

MMIS is expected to be an important member of the infection-prevention sub-group.

(2) MMIS conducts injection safety training in Ethiopia to improve the technical competencies of health

workers responsible for injections, with a focus on: injection prescribers, injection providers, sanitarians, and

pharmacists. Prescribers are trained to reduce unnecessary injections and promote rational use of drugs.

Injection providers are trained on practices and procedures for safe injection administration. Sanitarians are

trained in sharps waste management practices, including the use of personal protective equipment.

Pharmacists are trained in managing the supply of and forecasting the demand for injection devices. In the

FY07 SAPR alone, MMIS had facilitated the training of 2014 health workers in 25 districts, covering 86

health centers and 366 health posts.

(3) MMIS also addresses behavior change regarding injection practices and advocacy for safer injection

practices as part of their package of services. In order to facilitate and support behavior change among

health workers regarding injection practices, MMIS distributes communication materials (leaflets, posters,

pocket size reference guide, quarterly newsletter, and documentary film on safe injection practices) to all

new expansion sites other materials as needed. On the advocacy front, in collaboration with MOH, MMIS is

encouraging other donors and international organizations to create a national-level initiative to highlight and

address injection safety across all HIV/AIDS programs where injections are an issue. MMIS is also working

in collaboration with the MOH and other donors who are refurbishing health centers to assure high quality

infection prevention, universal precautions, blood safety, and injection safety issues, including the

maintenance of incinerators and the provision of waste receptacles.

(4) MMIS also helps to guide the development of standard systems for safer waste-management practices.

MMIS organizes workshops for RHB, hospital, and other health administrators to address the issues of

healthcare waste management (HCWM) in a systematic way. The workshops present standards and

options for appropriate HCWM, and support the development of roles and responsibilities for different

entities in supporting a set of HCWM standards. Through these workshops, a minimum set of standards

have been developed in the hopes of applying a standard set of minimum provisions for HCWM throughout

the country.

(5) Beyond the injection safety needs of the public-sector health network, MMIS also addresses injection

safety issues among private providers and the informal health sector. As a result of a literature review

revealing a high demand for injections through the informal sector, MMIS is attempting to address the

informal sector through: national strategic frameworks; guidelines; communication and advocacy strategies;

strengthening policy development serving both the formal and informal sector; and attempting to reduce

demand in the public for injections in the informal sector by raising risk perceptions related to this practice.

MMIS is also working with Ethiopia's Medical Association of Physicians in Private Practice (MAPPP) to pilot

some standards for injection safety and infection prevention/universal precautions in private practice,

including a centralized incineration system.

(6) In addition to the development of standard systems at various sites, MMIS is supporting efforts for

national-level policy on waste management guidelines. Policy options have been presented to the MOH and

the State Minister, including options for health facilities at all levels to tailor plans to their particular

circumstances.

(7) MMIS regularly conducts monitoring and evaluation of health facilities in order to measure progress and

address problems. A supervisory checklist serves as a standard data collection tool as a way to compare

progress in the aggregate, while onsite analysis during monitoring visits can result in additional trainings,

etc.

Activity Narrative: In FY06, MMIS services covered 392 health centers and 1,335 health posts, as well as a number of private

clinics. Collaboration with the MOH and RHB to carry out behavior change, advocacy, and policy and

guideline development was also achieved. In FY07, MMIS services are covering 23 hospitals, 66 health

centers, 86 nucleus health centers (these are health posts that have been upgraded to health centers) and

677 health posts. Where MMIS is working at the hospital level, they are collaborating with JHPIEGO to

assure that injection safety activities are not duplicated. At hospitals where both partners are present, MMIS

focuses on commodity supply, and waste management with all relevant employees, where JHPIEGO

focuses more on training on infection prevention for clinicians.

It should also be noted that there was a drastic cut in central funds in FY07. Planned expansion of MMIS

activities was significantly curtailed, some commodities were not delivered, and several trainings were

cancelled.

In FY08, funding is expected to be restored to '06 levels, allowing the expansion of sites as well as trainings

and commodity delivery to resume to normal levels. The restoration of funds will permit an expansion of

activities to an additional four federal hospitals in Addis Ababa, 100 additional health centers and 500

additional health posts. At each level of the healthcare system, MMIS will work with other providers working

in sites to avoid duplication of efforts and to leverage each partner's strengths. Collaboration with JHPIEGO

and other partners engaged in injection safety and waste management will continue.

Injection safety relates to all invasive procedures in testing volunteer samples, treatment of patients for any

medical reasons including treatment of opportunistic infections. Proper forecasting of injection safety

supplies coupled with proper handling of sharp and infectious wastes contribute significantly to the reduction

of medical transmission of blood borne pathogens including HIV. The activity will continue to support the

PEPFAR Ethiopia program by expanding training to all health centers, health posts and selected private

clinics within the ART health network. The implementing partners will collaborate with other PEPFAR and

USG partners working infection prevention and control activities.

The activity trains several categories of health professionals in the public, private, and informal sectors:

prescribers, providers, sanitarians, healthcare facility waste handlers, and facility management. The ultimate

beneficiaries of the activities are individuals who require medically invasive procedures and injections.