Activity Narrative: The USAID funded John Snow Incorporated (JSI/Making Medical Injections Safer (MMIS)

project is a PEFAR Track 1 project. It has continued to support the Ministry of Health (MOH) to scale up

interventions aimed at reduction of medical transmission of HIV and other blood borne pathogens through

rapid reduction of unsafe and unnecessary injections. So far, project interventions are benefiting 30 districts.

The project is assisting the MOH to: Implement policy and standards for injection safety and health case

waste management; implement injection safety activities in 30 districts, including improving the managers'

and service providers' skills; supported the MOH and districts to procure and manage safe injection

equipment and supplies; advocate for reduced demand for injections; and develop and implement an

advocacy strategy for wider decision makers' and public understanding. So far, project interventions are

benefiting 30 districts covering 46% of the population. The districts are: Pallisa, Nebbi, Yumbe, Mpigi,

Mbale, Manafwa, Bududa, Budaka, Kayunga, Luweero, Kampala, kabarole, Wakiso, Mbarara, Ibanda,

Isingiro, Kiruhuura, Kabale, Hoima, Mulago, Mityana, Masindi, Sironko, Soroti, Mukono, Rukungiri, Butaleja,

Mubende, Kamuli, and Apach.

Contributions to overall program: The project has continued to register significant progress that includes

introducing syringes with re-use prevention features. To date, a total of 19,702 health workers have been

equipped with knowledge and skills in injection safety and HCWM. A bigger proportion of service providers

(over 85%) are observing critical steps in injection administration. A total of 26,691,250 needles and

syringes have been distributed to the project districts over a period of four years. Findings of observations

made during supervision visits continue to show that 100% of injection devices used on clients come from

new sterile packs making medical transmission of HIV through curative injections very unlikely. The average

number of injections person per year in the project districts is estimated to be 1.3, lower than the national

average of 3 injections per person per year. The majority of health facilities in the project districts and at

PEPFAR implementing sites have a cleaner working environment with over 80% of the health units within

the project area having medical waste/safe injection programs in place. This is a great improvement from

the baseline of 15% when the project started four years ago. Data on progress made and lessons learned

has been systematically collected, documented and disseminated to stakeholders. All information collected

is shared with the district health teams and individual feedback is given to each facility supervised by the

project staff. Mechanisms to achieve national coverage through stakeholder support and policy change

have been put in place and will continue to be pursued to ensure sustainability of achievements.

Intervention areas: In FY 2009 the project will not expand but consolidate the achievements in the 30

districts. Continued funding for the MMIS project through FY2009 will ensure continued injection safety

practices in the current 30 districts and will prevent the districts that are supported through this program to

revert back to the re-usable needles and syringes. A lot of PEPFAR activities are generating a lot of

infectious medical waste. These include Counseling and Testing, laboratory, blood transfusion, sero-

surveys, to mention but a few. At the moment, the MMIS project is the only project that is providing technical

assistance for addressing health care waste management in the country. FY2009 funding for MMIS will

ensure continued improvement and support to all PEPFAR Implementing Partners in health care waste

management. The interventions used for the MMIS program include; supporting the development of policy

guidelines for safe injection practices, improving skills of injection providers, ensuring full supply of injection

commodities therefore eliminating the need to re-use, conducting behavior change campaigns aimed at;

reducing the demand for unnecessary injections among communities, promoting use of and compliance

with oral formulations, and improving stock status for oral formulations. Other intervention areas include

enhancing appropriate health care waste management and promoting health workers safety, through

protection against needle pricks and promotion of Post Exposure Prophylaxis. The project will continue to

advocate for incorporation of injection safety and HCWM activities into on going budgeting processes both

in the government and private sector. Collaboration with the education sector will be strengthened with the

objective of integration of injection safety practices in the medical training curricula. Pre- and in-service

training will be provided to 2000 health workers and 250 waste handlers in the expansion areas each

financial year. The training will be cascaded from national to districts and will be offered to workers both in

public and private facilities. Training topics will include; safe injection practices, appropriate health care

waste management, logistics management and communication and behavior change. During the training,

policy documents and norms and standards on injection safety and HCWM will be widely distributed.

Standard precautions on infection prevention and control will be emphasized. Desired practices will be

further enhanced through on job support supervision and cross unit visits. The project will continue to

support the Ministry of Health (MoH) coordination mechanisms, including the national infection control

committee and the Uganda National Injection Safety task Force (UNISTAF). The private sector will be

supported to implement the injection safety practices, including use of single use injection devices and

health care waste management.

Provision of technical assistance in injection device security: The project will in a procurement review

meeting address knowledge gaps in interpreting the developed injection device specifications among some

procurement and regulation agencies. The specifications will be widely disseminated to local manufacturers

to encourage the companies to start local production. The project will work with the pharmacy department to

revise order forms used at National Medical stores (NMS). Revised forms will be printed and distributed to

the 35 MMIS districts to facilitate health facilities switching back to MoH credit line support. Operators of

private pharmacies and drug shops will be equipped with skills in demonstrating techniques of using new

injection technology. This is to enable the operators provide timely user assistance when introducing the

new devices to their clients' in the private sector. The expansion districts will receive needles and syringes

with re-use prevention features, devices for blood drawing and intravenous procedures, safety boxes, waste

segregation bins, bin liners, and protective gear for waste handlers.

Provision of technical assistance to in HCWM to PEPFAR implementing partners: Recognizing that unsafe

final disposal of HCW poses a risk in medical transmission of HIV/AIDS, and in response to the MoH policy

of allocating at least 10% of the commodity budget to HCWM, FY09 PEFPAR funds will be used to support

the ministry to roll out the health care waste management plan at PEPFAR implementing sites. This activity

aims at improving the working environment of health workers, while at the same time better protecting

patients, and communities against transmission of HIV/AIDS and other pathogens. Priority will be given to

partners generating potentially infectious waste like providers of CT, Blood transfusion, injection safety,

Activity Narrative: laboratory services, and male circumcision. MMIS project will provide technical assistance in areas of

assessing practices, prioritizing interventions, developing work plans, selecting options for safe treatment

and disposal and in supervision. Staff generating waste and waste handlers will be trained in appropriate

ways of waste segregation, storage and selecting final disposal options. Waste handlers from the PEPFAR

programs will be trained to safely handle infectious waste including used needles and syringes, used blood

transfusion sets, soiled swabs, lancets, and gloves, and other health care medical waste materials, and in

proper maintenance of a medical waste pit. PEPFAR programs will be expected to use their program funds

to support the actual cost of their HCWM plans. In addition, the MMIS project will support construction of 60

medical waste pits in six of the MMIS project districts (10 each).

Exit strategy: At the time of inception, the MMIS project supported strategies for sustaining project activities

that include; working within existing structures, improving program efficiency by looking for cheaper

alternatives, and using strong advocates for safe injection practices. The exist strategy for the project that is

to start in FY2009 are:

i. Phasing out the procurement of ADs in the final year of operation (FY2010) and handing over this function

to the National Medical Stores, with the 30 MMIS districts using the credit lines to procure the ADs for their

districts;

ii. Preparation of the private sector to locally produce the medical waste equipment line disposal bins, bin

liners, and equipment for the waste handlers (gum boots, gloves, gowns);

iii. Preparing the 30 MMIS districts to carry out reorientation courses for the service providers; and

iv. Preparing the 30 MMIS districts to implement low cost and affordable technologies for the final disposal

of infectious waste and sharps.

New/Continuing Activity: Continuing Activity

Continuing Activity: 14216

Continued Associated Activity Information

Activity Activity ID USG Agency Prime Partner Mechanism Mechanism ID Mechanism Planned Funds

System ID System ID

14216 4383.08 U.S. Agency for John Snow, Inc. 8348 8348.08 John Snow, $382,500

International Inc./Injection

Development Safety/country

funded

8430 4383.07 U.S. Agency for John Snow, Inc. 4838 701.07 Track 1 $318,336

International

Development

4383 4383.06 U.S. Agency for John Snow, Inc. 3332 701.06 Track 1 $2,392,584

International

Development

Emphasis Areas

Human Capacity Development

Estimated amount of funding that is planned for Human Capacity Development $100,000

Public Health Evaluation

Food and Nutrition: Policy, Tools, and Service Delivery

Estimated amount of funding that is planned for Food and Nutrition: Policy, Tools $120,000

and Service Delivery

Food and Nutrition: Commodities

Economic Strengthening

Education

Water

Table 3.3.05: