Under the U.S. President's Emergency Plan for AIDS Relief (PEPFAR), the Namibian Ministry of Health and

Social Services (MOHSS) with University Research Co., LLC (URC) technical assistance is implementing

several policy and programmatic interventions to improve medical injection and waste management

practices in the country. MOHSS, together with URC, conducted a rapid baseline assessment in June 2004

to identify gaps in existing injection-related practices. Interviews were conducted with health-related policy-

makers, health managers, health care providers (public and private), and community members. The

analysis looked at quality of services, demand for and provision of injections, compliance of providers with

safe injection practices, and other aspects related to injections. The baseline assessment showed a number

of quality gaps: over-prescription of medical injections, improper injection and waste disposal procedures,

among others.

To change healthcare provider practices, the Medical Injection Safety Program is using the collaborative

approach to develop and test, as well as rapidly scale-up best practices. Under the program, four major

strategies are being used: behavioral change communication (BCC) targeted at prescribers and the general

public to decrease prescription of and demand for injectable medication; compliance with infection

prevention and control practices to reduce opportunities for transmission of blood-borne pathogens;

commodity and logistics aimed at strengthening the procurement system and ensuring the availability of

safety boxes to health care facilities; waste management to improve waste disposal practices.

Program interventions have produced dramatic results. URC supported the MOHSS with the development

of and distribution of guidelines and policies related to Injection Safety. Since the program inception 3 years

ago availability of Standard Treatment Guidelines rose from 57 to 93%, of Post Exposure Prophylaxis (PEP)

guidelines from 35% to 96%. Practices on preparation and administration of injections have improved.

Sharp injuries have decreased significantly from 54 in first quarter 2006 to 12 in first quarter 2007, while

96% of health facilities offer access to PEP after injuries from 35%. The proportion of facilities where

needles are removed from multi-dose vials has improved from 47% to 89%. The use of barriers when

opening glass vials has improved from 51% to 88%. Awareness creation about risk of Hepatitis B resulted

in improved vaccination of Health Care Workers. To decrease prescriptions of unnecessary injections,

awareness has been raised regarding rational drug use mainly oral versus injectable drugs. The average

number of types of injections prescribed per patient per treatment has declined from 1.42 to 0.5 in the

health facilities where. Compliance with guidelines has increased. The National Waste Management Policy

is in development process. In the meantime Interim Waste Management Guidelines are developed and

applied by specific decentralized management entities. URC purchased and distributed more than 70,000

safety containers to more than 70% of health facilities. A local producer of safety containers has been

identified and supported. Local production has started during the second quarter of FY2007. A total of 3106

healthcare practitioners (HCP) are trained in injection safety and waste management. Up to June 2007 a

total of 44 Private healthcare providers are integrated into the program and are being supported through

training, procurement of safety containers for a limited period of time. The (BCC) strategy, aimed at

reducing demand for injections, is being implemented through a network of grassroots organizations. In

FY2007 176 community educators have been trained. Supportive supervision activities are being carried out

on a regular basis. A system for continuous monitoring of quality improvement processes in injection safety

using PDSA approach has been established. The Program, which covered 38% of the country the first year

of implementation, is currently covering all 100%.

Despite some positive attitudes of management (Openness to suggestions, participation in problem-

identification, support for corrective actions), some big challenges remain: Waste Management (lack of

knowledge, repetitive stock out of appropriate color coded bags due to weaknesses in procurement system,

incinerators not functioning according to standards); insufficient compliance due to systems weaknesses,

low level of supportive supervision, non integration of the topics of injection safety and waste management

in the regular forum of discussion with relevant HCP, non participation of some categories of HCP in the

quarterly regional feedback (PDSA); barriers to policy implementation due to centralization of decision

making, insufficient coordination among partners, high turnover, unavailability of financial resources. To

address the issues mentioned above, the implementation efforts will increase during FY08. To strengthen

the knowledge, the program envisions training 4000 additional HCP in injection safety, waste Management

and BCC. All regions will be assisted with finalization of Interim Waste Management guidelines. The

National Waste Management Policy will be distributed. Its implementation will be supported. The anticipated

increased volume of waste to be generated by HIV interventions scale up will be dealt with through very

accurate forecasting and procurement of safety containers as well as training on waste management.

Upgrading and Incinerator maintenance will be added as a component of the program, addressed as well in

Blood Safey. Infection control with emphasis on Injection Safety and Waste Management will be

emphasized. Incorporating of private practitioners will continue. Capacity of MOHSS staff, and Community

Organizations to ensure program viability will be built. Monitoring and Evaluation skills will be transferred to

MOHSS staff of the 13 regions. Incorporating of private practitioners will continue. URC will advocate at

MOHSS level for integration of relevant HCP in the Program. URC will work in partnership with CDC for bio-

safety, SCMS for strengthening of the procurement system, RPM+ for training of relevant staff in logistic

and stock management and for support to Therapeutic Committees as part of an effort to reinforce

awareness regarding rational use of drugs and to decrease demand for injection, with Community

Organization to ensure dissemination of relevant health information to community members. A total of 200

additional community educators will be trained in injection safety and waste management messages as well

as strategies for behavior change to mitigate the impact of unnecessary injection to the community. By the

end of FY2008 the total number of community educators trained from the beginning of the project will be

400. In FY2008, community activities will be expanded to 4 more regions. The trainees will disseminate

messages related to safe injections and waste management to 500,000 (25%) community members. In

subsequent years these activities will be extended to all regions. As part of Quality Assurance, quarterly

Feedback to the regions, regular and continuous monitoring activities, and NISG (National Injection Safety

Group) meetings will be conducted jointly with relevant MoHSS and stakeholders staff, to ensure that

activities are carried out according to standard and that the trainees are performing at expected level.