Injection Safety in Namibia



Based on assessments conducted in Namibia in 2004, the average number of injections prescribed per person per year was 11.2. The injections were prescribed and administered by 73% of health care workers (HCWs) interviewed, and sometimes by pharmacists.  Most injections were prescribed for conditions that could be treated with oral medication, as a significant proportion of patients who visited health facilities, (39%) preferred injections. In some facilities, injections were not prepared in a designated, clean area and 61.8% facilities reported the presence of sharps in the immediate surroundings of the facilities, posing a risk of needlestick injury to HCWs and the community.  Injection safety boxes were only observed in a handful of facilities; the majority used plastic containers or carton boxes for the sharps.  Recapping of needles was seen in majority of the health facilities assessed.

The objectives of the improvement work are to:
·      promote medical injection safety
·      improve health care provider knowledge on infection control and occupational safety
·      promote safe management of health care waste

The Ministry of Health and Social Security (MOHSS) and HCI are promoting rational use of medication in order to reduce the demand for injections and the prescription of unnecessary and potentially unsafe injections. The program focuses on both what is done (content of care) and how it is done (process of care). To improve the content of care, compliance with the evidence-based guidelines is being improved though training, better communication of guidelines/protocols, and supervision.  The process of care is being improved through a better understanding of the system, bringing changes in injection practices and by reorganizing care or waste disposal practices to decrease needle stick injuries and the inadvertent spread of HIV and other blood borne pathogens among health workers and patients.

The objectives are to:
·      Development and implementation of policies and guidelines, working with National Injection Safety Group (NISG),
·      Capacity building of healthcare workers on injection safety and health care waste management, including Coordination and collaboration with pre-service training institutions and district infection prevention and control (IPC) committees,
·      Supportive supervision activities,
·      Strengthening of the procurement and logistics system for equipment and commodities for injection safety and health care waste management and transitioning it to the MOHSS,
·      Behavior change communication (BCC) to reduce the prescription and demand for unnecessary injections,
·      Improvement of medical waste disposal including sharps disposal, and
·      Establishing a monitoring and evaluation system and integrating related indicators into the national health reporting system.


Policy level advocacy:
Using information from the baseline survey, the Project convened a National Injection Safety Working Group (NISG) to develop or review national policies and to prepare a national plan.  The NISG is now embraced by MOHSS and now advices on policy issues.
Key policies that have been developed include:
·      National Infection and Prevention and Control Guidelines, incorporating tuberculosis infection prevention
·      HIV Post-Exposure Prophylaxis (PEP) guidelines and job aids
·      National Waste Management Policy
·      Integrated Waste Management Plan and guideline in final stages of review
·      Revised Hepatitis B Policy
·      Quality Assurance (QA) Policy: Assessment on QA structures in the country ongoing. Findings shall be used to  update the current QA policy
Infection control and waste management committees
The project also established infection control-waste management committees at the regional, district and facility levels. The committees, with clear terms of reference, are entrusted with ensuring the implementation of the policies and ensuring availability and use of infection control guidelines. URC and committees are developing regional and district IPC plans which will include identification of key staff in facilites, training of HCWs, procurement of necessary supplies, and supportive supervision of services. 


Capacity building
Providing safe injections as well as reduction of medical injections prescriptions among public and private healthcare providers will be reinforced through training, feedback sessions, and improvement plans. The project has trained over 12,000 health care workers on safe injection practices and waste disposal topics such as reducing unnecessary injections, filling out monitoring paperwork, reporting needlesticks, use of PEP, and management of medical waste.
The trainings have also been integrated into institution-based in-service training and into pre-service training institution curricula University of Namibia School of Medicine and Nursing, National Health Training Center, five Regional Health Training Centers, and Polytechnic.
The project has also strengthened the capacity of MOHSS staff through training on quality improvement approaches, mentorship and strengthened supervision. The supervisory system has been reinforced through joint visits, developing/reviewing supervision tools, and by regular reports on the program to identify specific areas that require strengthening
Commodity management
Access to safety boxes for discarding sharps as well as color coded waste disposal bags for discarding medical and infectious waste. Based on these finding, HCI worked closely with MOHSS to develop a short-term strategy for providing these supplies using the project funds. The project procured over 350,000 safety boxes, personal protective equipment for waste handlers, and color coded disposal bin liners. 
The medium-term strategy was to help the Central Medical Stores to develop a procurement strategy for safety boxes and personal protective equipment. The procurement of commodities was then transitioned to MOHSS and integrated with the government tendering system. HCI provided training to procurement officers on forecasting and ordering, promoting the use of stock cards and collecting data on monthly consumption that is then submitted to the procurement agency. The MOHSS continues to procure standard sharps boxes and all facilities are reporting having standard sharps boxes.
Behavior change communication
Community and provider perceptions play a big role in demand for injections.  In some communities in northern Namibia, communities have a strong belief that you will only get cured if you are injected.  If an injection is not received, the patient will simply move to a different clinic. Some providers also believe that injectables are more efficacious than oral medication.
HCI developed a communications strategy for the safe injection program. HCI is working closely with MOHSS and IEC in the development of communication materials targeted to improving knowledge about safe injection issues and to reduce demand for and prescription of unnecessary injections. HCI is using community educators to raise awareness within the community regarding rational use of medication in order to reduce demand for unnecessary injections and ensure proper disposal of infectious waste produced by some community members, such as insulin-dependent diabetic patients. The educators are reaching out to the community with Injection Safety and Waste Management messages translated into vernacular languages. HCI has also developed posters and wall charts along with simple job aids for healthcare workers to promote rational use of medical injections and safe disposal of sharps and medical waste.

Knowledge of safe injection has generally improved. Injection process continues to maintain a high standard. Each facility appointed a ‘point person’ to advocate for and supervise safe injections and related practices. The on-site person conducted quarterly facility audits, taught staff, worked with infection control and quality assurance committees and reviewed prescriptions. Patients are more and more often counseled on treatment options with emphasis on oral medication. Responsibility of facility assessment and auditing of injections that was carried out by facility supervisors has now been taken over by nurses in charge of facilities. When visiting teams monitor their knowledge on use of MIS data tools, they immediately notice shortcomings themselves and take note for sharing with others to improve the situation.The average number of injections administered per patient per year declined from 11.2 to less than 2 in facilities reporting by June 2011.   Variation is mostly as a result of lack of Standard Treatment guidelines, disease outbreaks like malaria, inadequate supply of oral medication, and community and provider perception about injections. The aim is to keep the average number of doses administered per patient to less than two.


Audits also indicate that most of the injections (over 60%) are from 35 hospitals out of the 411 health facilities in the country. The project is now focused on the 35 hospitals to further eliminate unnecessary injections in Namibia. Efforts have further been boosted by the launch of the Namibia Standard Treatment guidelines that promotes rational use of medication in health facilities.

The program also monitors the injection process in supported facilities. All facilities are now providing therapeutic injections with new, disposable, single-use injection equipment. The project has also seen an improvement in the practice of not leaving needles on multidose vials after injection. However, challenges are still experienced especially when it comes to attitudes of staff towards this practice and the use of multidose vials in general. Almost all facilities use multidose vials as opposed to the recommended practice of single-dose vials. If not used appropriately, the multidose vials can become contaminated and be a source of outbreaks in health facilities. HCI is working to ensure the multidose vials are used appropriately and at the policy level, advocating for a change towards single-dose vials. Disposal of needles without recapping has also seen a great improvement and has led to a reduction in needlestick injuries experienced in health facilities. The practice was reinforced with the availability of sharps safety boxes introduced by the project and continuously procured by the MOHSS.

Nurses have commented that the project has reduced the prescription of medication by nursing staff. In the baseline survey 65% of the nurses said that they were prescribing injections. In the past, they explained, nurses used their discretion and gave injectable medication to patients. Now if the patient required an injectable medication, they were instructed to refer the patient to the physician for assessment and a physician’s prescription. Nursing staff commented that they were better able to explain to patients the efficacy of oral medication and were able to persuade patients to try oral medications first.
HCI, together with MOHSS staff, developed various facility monitoring tools. 
Indicators monitored by each facility include:
·      availability of policies at facility level
·      availability of safe injection commodities
·      immediate disposal of syringes and medical sharps into sharps container at the point of use
·      number of needle stick injuries per quarter and percentage injured put on PEP
·      separation of sharps waste from regular waste at the point of use
·      use of sharps containers that are leak proof, puncture proof, closeable, and stackable
·      minimal handling of used sharps before disposal
·      replacement of sharps containers when they are ¾ full to avoid overfilling that can result in needles piercing the sides
·      average number of injections per patient per quarter
·      type of medical injections targeted with non-injectable medicines and compliance with standards for injection preparation and giving of injections
Quarterly assessments are performed to evaluate progress and identify good practices as well as quality gaps. The assessments are followed by quarterly Plan, Do, Study, Act (PDSA) meetings where results are evaluated and shared and improvement plans are adjusted according to need. HCI will support the MOHSS with continuous monitoring and evaluation at all participating facilities as well as the national and regional improvement interventions.
 Lessons learned
·      Prescription of unnecessary injections is still common and requires a multipronged strategy focusing on HCWs and the community.
·      The use of data to track progress and provide feedback at all levels is essential if change is to be achieved.
·      Continuous monitoring and in-service training are important components for the program.
·      Use of multidose vials in disregard to recommendations.
·      Irregular supply of waste management commodities especially the color-coded bags and IPC products such as alcohol hand-rubs.
·      The promotion of rational use of medication requires the development and printing of BCC tools that the program cannot support due to financial constraints.
·      High staff turnover in the rural Primary Health Care facilities.


Key recommendations
·      Engagement of MOHSS and other stakeholders at all levels and continuous communication is key to a successful implementation.
·      Create an enabling environment through development of policies and guidelines.
·      Improve supply chain management system for injection safety and waste management commodities.
Next steps
·      Provide technical assistance to the Division of Quality Assurance to be able to provide guidance on implementation, and monitoring and evaluation of the program.
·      Support the development of common indicators for rational use of medication, an audit and a feedback system.
·      Support the targeted training of 100 staff on rational use of medication.
·      Review treatment protocols for at least 5 common complaints and diagnosis with MOHSS staff with an aim of promoting rational use of medication.
·      Develop case studies to help demonstrate to districts infection control committees how to synthesize information, analyze problems, set priorities, and devise action plans with measurable outcomes.
·      Strengthen the capacity of the district infection control committees through supportive supervision and build in transition plans.
Report Author(s): 
Aziz Abdallah
USAID Health Care Improvement Project
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