For Water, Sanitation and Hygiene (WASH) Services in ...STANDARDS & GUIDELINES FOR WASH SERVICES IN...

F E B R U A R Y 2 0 1 7

STANDARDS & GUIDELINES

For Water, Sanitation and Hygiene (WASH) Services in Healthcare Facilities in Sierra Leone

GOVERNMENT OF SIERRA LEONE Ministry of Health and Sanitation

STANDARDS & GUIDELINES FOR WASH SERVICES IN HEALTHCARE FACILITIES IN SIERRA LEONEii

STANDARDS & GUIDELINES FOR WASH SERVICES IN HEALTHCARE FACILITIES IN SIERRA LEONE i

The Standards and Guidelines for Water, Sanitation and Hygiene (WASH) Services in Healthcare Facilities in Sierra Leone is the product of a long and

participatory process of intensive consultations, team work on specific assignments, monitoring visits and information gathering. The process involved donors, service providers, civil society organizations, Presidential Delivering team, Healthcare providers, Local councils, development partners and other key stakeholders.

Special thanks go to the Minister of Health and Sanitation for his leadership and guidance during the development of this document. Also special thanks go to the Chief Medical Officer, Deputy Chief Medical Officer I & II and the entire team of the Environmental Health and Sanitation Directorate of the Ministry of Health and sanitation.

The Ministry of Health and Sanitation is very grateful to everyone who contributed to the successful development of these standards and guidelines. Special thanks go to the members of the team that were tasked to contribute to finalizing this document with special thanks provided to: JSI Research & Training Institute, Inc., USAID, DFID and UNICEF. The Government appreciates the support provided by donors and implementing partners for the development of this Standards and Guidelines for Water, Sanitation and Hygiene (WASH) Services in Healthcare Facilities in Sierra Leone.

Finally, the Ministry Health and Sanitation expresses thanks to all other individuals and institutions who contributed their valuable time towards the development of this document.

Dr. Brima KargboChief Medical OfficerMinistry of Health and Sanitation

ACKNOWLEDGMENT

STANDARDS & GUIDELINES FOR WASH SERVICES IN HEALTHCARE FACILITIES IN SIERRA LEONEii

STANDARDS & GUIDELINES FOR WASH SERVICES IN HEALTHCARE FACILITIES IN SIERRA LEONE iii

1 Minimum WASH Package for Health Care Facilities 11.1 Components of WASH Package in Health Care Facilities 71.2 Hardware 71.3 Software7 72 Provision of Hardware Component 82.1 Water Supply 82.1.1 Water Quantity 82.1.2 Water Quality 92.1.3 Water Access 102.2 Sanitation – Excreta Disposal, Showers/Bathrooms/Urinals,

Wastewater disposal and Site Drainage 102.2.1 Sanitation Facility Quantity 102.2.2 Sanitation Quality 112.2.3 Sanitation Access 112.3 Hygiene – Hand Washing Facilities 122.3.1 Quantity of Hand Washing Facilities 122.3.2 Quality of Hand Washing Facilities 122.3.3 Access 122.4 Storm Water Drainage Systems 132.4.1 Quality 132.5 Laundry Facilities 132.5.1 Quantity of Laundry Facilities 132.5.3 Access 142.6 Healthcare Waste Management Facilities 142.6.1 Segregation 142.6.2 Collection of Health Care Waste 152.6.3 Transportation of Healthcare Waste 162.6.4 Healthcare Waste Storage 162.6.5 Healthcare Waste Treatment and Disposal 16 Annexes: Typical Designs 18

TABLE OF CONTENTS

STANDARDS & GUIDELINES FOR WASH SERVICES IN HEALTHCARE FACILITIES IN SIERRA LEONEiv

Figure 1: Typical Design for Pour Flush Latrine Block (with a provision for the disabled) 18

Figure 2: Typical Design for Pour Flush Latrine - Left Elevation 19Figure 3: Typical Design for Pour Flush Latrine - Section 19Figure 4: Typical Design for Pour Flush Latrine - Pit Section 20Figure 5: Typical Septic Tank Design - Section 21Figure 6: Typical Septic Tank Design - Plan 21Figure 7: Typical Septic Tank Design – Slab 22Figure 8: Typical Soak away pit Design - Pit 23Figure 9: Typical Soak away pit Design - Plan 23Figure 10: Typical Laundry facility Design - Foundation Plan 24Figure 11: Typical Laundry facility Design - Left & Rear Elevation 24Figure 12: Typical Laundry facility Design - Floor Plan 25Figure 13: Typical Laundry facility Design - Front & Right Elevation 25Figure 14: Typical Laundry facility Design - Section A-A 26Figure 15: Typical Placenta Pit Design - Cross Section, Total Depth – 2m. 27Figure 16: Typical Placenta Pit Design - Plan Views 28Figure 17: Typical Placenta Pit Design - Strip Foundation and Beam 28Figure 18: Typical Sharps Pit Design - Cross Section, Total depth – 2m 29Figure 19: Typical Sharps Pit Design - Plan Views 30Figure 20: Typical Sharps Pit Design - Strip Foundation and Beam 30Incinerator Construction – De Montfort Mark 8a Incinerator. 31Figure 21: Typical Ash Pit Design - Cross Section, Total Depth – 2m. 36Figure 22: Typical Ash Pit Design - Plan Views 37Figure 23: Typical Ash Pit Design - Strip Foundation and Beam 37Figure 24: Typical Shower Block Design - Plan 38Figure 25: Typical Shower Block Design - Front and Side Elevations 38Figure 26: Typical Shower Block Design - Section A-A 39Figure 27: Typical Waste management area/facility size, Layout 40Figure 28: Typical Isolation Unit & Screening area design - Floor Plan 41Figure 29: Typical Isolation Unit & Screening area design - Section A-A 42Figure 30: Typical Isolation Unit & Screening area design - Right Elevation 42Figure 31: Typical Isolation Unit & Screening area design - Left Elevation 42Figure 32: Typical Isolation Unit & Screening area design - Front Elevation 43Figure 33: Typical Isolation Unit & Screening area design - Rear Elevation 43Figure 34: Typical Force lift Pump (CHPs & MCHPs) 44

TABLE OF FIGURES

STANDARDS & GUIDELINES FOR WASH SERVICES IN HEALTHCARE FACILITIES IN SIERRA LEONE v

LIST OF ACRONYMS

CMO Chief Medical OfficerCDC Centre for Diseases Control and prevention CNO Chief Nursing officerCMS Central Medical Store DSO Disease surveillance OfficerDMO District Medical Officer DPC Disease prevention and ControlHAI Healthcare Associated Infections HCW Healthcare care Workers IPC Infection Prevention and Control MOHS Ministry of Health and Sanitation NGO Non-Governmental Organizations NIPCU National Infection Prevention and ControlPHU Peripheral Health Units PPE Personal Protective Equipment SOP Standard Operating ProcedureUNICEF United Nation children’s FundsWHO World Health Organization

STANDARDS & GUIDELINES FOR WASH SERVICES IN HEALTHCARE FACILITIES IN SIERRA LEONEvi

STANDARDS & GUIDELINES FOR WASH SERVICES IN HEALTHCARE FACILITIES IN SIERRA LEONE 1

1 MINIMUM WASH PACKAGE FOR HEALTH CARE FACILITIES

TABLE 1.

WATER SUPPLY SUMMARY

WASH Facility Hospital Community Health Centres

Community Health Posts

Maternal Child Health Posts

1.1.1 Minimum Quantity (litres)/day

< 100 beds: 20,000 ltrs1

5000 ltrs2 5000 ltrs2 5000 ltrs2101–200 beds: 40,000ltrs> 200 beds: 60,000 ltrs

1.1.2 Source

Protected Source2

Protected Source

Protected Source

Protected Source

1.1.3 Abstraction Methods

Submersible pumps powered by solar/power grid and backup generator.

Submersible pumps powered by solar/power grid and backup generator.

Mechanical force-lift pumps. Submersible pumps powered by solar, solar power.

Mechanical force-lift pumps. Submersible pumps powered by solar, solar power.

1.1.44 Storage

Elevated tank for GFS; with 2 days back up storage.

Elevated tank GFS; with 2 days back up storage. Minimum (10,000 Ltrs2).

Elevated tank GFS; with 2 days back up storage. Minimum (10,000 Ltrs2).

Elevated Tank GFS; with 2 days back up Storage. Minimum (10,000 Ltrs2).

1.1.5 Distribution Systems

Yes. Labour room is a must.




1Minimum water demand have been based on 200 ltrs/bed capacity. Specific average water demand per facility will be determined based on average data available for OPD, IPD, staffing and various health services/procedures undertaken by the facility. Refer to Table under Water Supply for minimum per-capita consumption.

2Protected sources shall be pipe borne, bore holes, hand dug wells & spring catchments.3Pump type and specifications shall be as per the MoWR Guidelines and Recommendations.4Shall be informed by the specific water demand per facility based on footnote 1 above.

STANDARDS & GUIDELINES FOR WASH SERVICES IN HEALTHCARE FACILITIES IN SIERRA LEONE2

1.1.6 Quality (Water Quality Analysis at Source)5

Yes. (MoHS/MoWR)

Yes. (MoHS/MoWR)

Yes. (MoHS/MoWR)

Yes. (MoHS/MoWR)

1.1.7 Quality Monitoring and Treatment

Yes. (MoHS)

Yes. (MoHS)

Yes. (MoHS)

Yes. (MoHS)

1.1.8 Sustainability (O&M)

Yes. Facility management & maintenance structure: Provision of tool kits, start up spare parts & training.MoHS to make budgetary provisionstructure: Provision of tool kits, start up spare parts & training.MoHS to make budgetary provision.

Yes. District level/facility management & maintenance structure. Provision of tool kits, start up spare parts & training.District Council to make budgetary provision.

Yes. District level/facility management & maintenance structure. Provision of tool kits, start up spare parts & training.District/Chiefdom Administration to make budgetary provision.

Yes. District level/facility management & maintenance structure. Provision of tool kits, start up spare parts & training. District/Chiefdom Administration to make budgetary provision.

COMMENTS:

1.1.1 In the event that there are a number of beds exceeding 12, we revisit the amount of water required at the HCF. We need to take care of the outpatients as the calculation only caters to inpatients.

1.1.4 Elevated tanks should have lids.

1.1.7 All the necessary tools should be provided to MOHS for water quality monitoring and treatment

Regular frequency for physiochemical analysis of samples collected to be as per the MoHS, once every 6 months.


TABLE 2.

SANITATION SUMMARY




1.2.1 Toilets/Latrines/Urinals

Water borne toilets (flushable toilets, pour flush latrines) for labour room. Flushable toilet and VIP (ventilated improved) latrines for patients.

Waterborne toilets (flushable toilets, pour flush latrines for labour room. Flushable toilet and VIP latrines for patients).

Toilets (pour-flush latrines) for labour room. Flushable toilets and VIP latrines for patients.

Toilets (pour-flush latrines) for labour room. Flushable toilet and VIP latrines for patients.

1 toilet to 10 inpatients

1 toilet to 10 inpatients

1 SP to 10 inpatients6

1 SP to 10 inpatients

1 toilet to 20 outpatients

1 toilet to 20 outpatients

1 SP to 20 outpatients

1 SP to 20 outpatients

Total number of toilets and urinal length to be determined by designed capacity of hospital in terms of OPD/IPD and staff, ensuring gender concerns, with separate facilities for staff, 2 for staff in each main service delivery area.

Total number of toilets and urinal length to be determined by designed capacity of CHC with a minimum of 5 stances (1 for Isolation Unit, 2 for staff, 2 for patients).

Minimum of 4 stances (2 for staff, 2 for patients) complete with urinals.

Minimum of 4 stances (2 for staff, 2 for patients), complete with urinals.

6SP – squat pan / squat plate


1.2.2 Shower/Bathing Facilities

Yes. Privacy rooms for bathing/bathing cubicles (specify)




1 (2) in each inpatient ward.

1 in each inpatient ward.

2 for staff in each ward. 2 for staff. 2 for staff. 2 for staff.

1.2.3 Hand Washing Facilities

Yes Yes Yes Yes Hand washing basins, soap & veronica buckets.

Hand washing basins, soap & veronica buckets.



1.2.4 Black/Grey Water Disposal

Yes Yes Yes YesSeptic tank & soak away pits.

Septic tank & soak away pits.

Soak away pit & septic tank.

Soak away pit & septic tank.


Yes. Facility management & maintenance structure.MoHS to make budgetary provision.

Yes. Facility management & maintenance structure.District Council to make budgetary provision.

Yes. Facility management & maintenance structure.District/Chiefdom Administration to make budgetary provision.

Yes. Facility management & maintenance structure.District/Chiefdom Administration to make budgetary provision.


TABLE 3.

HEALTH WASTE MANAGEMENT SUMMARY




1.3.1 Healthcare waste Management Facility

Mechanical operated incinerator min. temp 1200oC, autoclave unit, electricity power incinerator, bottle, ash pit, placenta pit and or double chambered incinerator, sharps pit, placenta pit.

Double chambered incinerator, ash pit, sharps pit, placenta pit.

Single chambered incinerator, ash pit, sharps pit, placenta pit.

Single chambered incinerator, ash pit, sharps pit, placenta pit.

1.3.2 Other Solid Waste Management Facility - Collection Bins and Bin Liners

Colour coded bins with lids and bin liners in all required locations. Provide biohazard plastics where applicable and sharps boxes.(Covered wheelbarrow bin, cart bin).

Colour coded bins with lids and bin liners in all required locations. Provide biohazard plastics where applicable and sharps boxes. (Covered wheelbarrow bin).

Colour coded bins with lids and bin liners in all required locations. Provide biohazard plastics where applicable and sharps boxes. (Covered wheelbarrow bin).

Colour coded bins with lids and bin liners in all required locations. Provide biohazard plastics where applicable and sharps boxes. (Covered Wheelbarrow bin).

1.3.3 Desludging Septic Tank/Toilets/Latrines & Disposal

Yes. MoHS support on final disposal.

Yes. MoHS support on final disposal. Yes. MoHS support on final disposal.

Where needed. Yes. MoHS support on final disposal.

Where needed. Yes. MoHS support on final disposal.


Yes. Facility management & maintenance structure.





TABLE 4.

IPC SUMMARY




1.4.1 Isolation Unit

1 – Four Bed Capacity

1 – Two bed capacity



1.4.2 Triage/Screening Area

1 1 1 1

1.4.3 Laundry

Yes. Machine washing powered by national power grid, with generator back power back up and/or running water, provision of washing basin, well drained and roofed platform, including drying area.

Yes. Running water, provision of 4-6 washing basins, well drained and roofed platform, over welded galvanized wire mesh walls supported by structurally sound timber or concrete columns, with provision of drying area/lines.

Yes. Running water, provision of 2-4 washing basins, well drained and roofed platform over welded wire mesh walls, supported by structurally sound timber or concrete columns, with provision for drying area/lines.

Yes. Running water, provision of 2 washing basins, well drained and roofed platform over welded wire mesh walls, supported by structurally sound timber or concrete columns, with provision for drying area/lines.


1.1 Components of WASH Package in Health Care Facilities

WASH in the healthcare facility package includes both hardware and software components. Below are the key aims of hardware and software components of the WASH package in healthcare facilities.

1.2 Hardware

Hardware aims at improving the quality and quantity of WASH services in healthcare facilities. It includes the construction and rehabilitation of water points; sanitary toilets including urinals, showers, wastewater collection systems and hand washing facilities; storm water drainage system; laundry facilities; healthcare waste management facilities including collection, storage and disposal facilities, such as ash pits for the final disposal of incinerated ash, sharps pit for disposal of sharps, placenta pits for the disposal of placentas and other body tissues.

1.3 Software7

Software aims at improving and managing WASH services in healthcare facilities to prevent infections among healthcare workers, patients and the general community. It includes promoting key hygiene messages to enhance behavioural change as well as Infection Prevention and Control (IPC) measures, including effective use of Personal Protective Equipment (PPE), decontamination, processing linen and housekeeping; management of health care waste; wastewater treatment; analysis of water quality and quantity to ensure access to safe water, safe excreta disposal and other environmental health issues.

7This is covered under the IPC guidelines by the MoHS.


2 PROVISION OF HARDWARE COMPONENT

The hardware component of WASH in healthcare facilities shall be provided by constructing new or upgrading existing facilities and rehabilitating existing dilapidated WASH facilities based on the specifications and guidelines by MoHS8, MoWR9, SHPERE Standards and WHO guidelines. The minimum standards for WASH services are outlined herein.

2.1 Water Supply

Water for drinking, personal hygiene including hand washing, bathing and cleaning personal utensils, cooking, laundry, cleaning and medical activities is safely treated, reliable and sufficient. Ensure on-site water collection points that are functional at all times.

REQUIRED MINIMUM STANDARDS

2.1.1 Water QuantityThere should be 5-300 litres/person/day10 depending on the category/level of healthcare facility and nature/type of service delivery. Where applicable underground, surface and elevated water storage tanks with accompanying distribution network should be constructed and installed based on MoWR and MoHS guidelines to allow sufficient water supply in healthcare facilities.

INDICATORS

1. Sufficient water quantity (Table 5) is available to meet all the minimum daily requirements in the health facility.

2. Sufficient water storage volume is available onsite to provide the health facility with 48 hours11 of emergency backup supply.

8Sanitation technology options by the MoHS; technical WASH meeting 30th July 2015; Integrated National Waste Management Policy, October 2012.

9RWH Guidelines, October 2014; technical brief/guidelines for pipe laying and house connections, December 2014; Principles of Bore Hole Construction and Rehabilitation, October 2014; Technical Guidelines for the Construction and Maintenance of Hand Dug Wells, April 2014.

10WASH in Health Care Facilities in Emergencies, WHO 2012.11It is assumed that 48 hours would be the maximum downtime to fix water supply facilities in case of breakdowns interrupting water supply.


TABLE 5.

Source: WASH in Healthcare Facilities in Emergencies, WHO 2012

Activity Minimum Water Quantity RequirementStaff 5 litres/person/dayOutpatients 5 litres/consultation/day

Inpatients40–60 litres/patient/day15 litres/caregiver/day

Operating Theatre/Maternity Unit 100 litres/intervention

Dry or Supplementary Feeding Centre 0.5–5 litres/consultation (depending on waiting time)

Wet Supplementary Feeding Centre 15 litres/Consultation

Inpatient Therapeutic Feeding Centre30 litres/patient/day15 litres/caregiver/day

Cholera Treatment Centre60 litres/patient/day15 litres/caregiver/day

Acute Respiratory Diseases Isolation Ward

100 litres/patient/day15 litres/caregiver/day

Viral Haemorrhagic Fever Isolation Ward

300–400 litres/patient/day15 litres/caregiver/day

Table 5 above shows WHO/SPHERE recommended minimum water quantities for different stations in health care facilities. While these would be used to determine minimum water quantity needs, other factors including special days, e.g. antenatal clinics, should be taken into account.

2.1.2 Water Quality

Water for drinking, kitchen activities, personal hygiene, medical activities, cleaning and laundry is treated, disinfected and safe for the purpose intended. Water quality should adhere to MoWR/MoHS water quality standards and the WHO recommended guidelines for drinking on all chemical, microbial and physical parameters. Water Quality testing be conducted by MoWR/MoHS before commissioning water sources for use followed by regular/periodic sampling and testing of water samples, frequency and sampling to be as per the MoWR/MoHS guidelines. Results of water quality analysis should be made available to the respective healthcare facility. Health facilities should have chlorine disinfectants readily available for treating water, basic tools and reagents for monitoring water quality.

INDICATORS

1. Thermo-tolerant Coliform bacteria are not detectable in any 100ml sample of drinking water within the health facility.

2. There are no odours, tastes or colours that would discourage consumption or use of drinking water.


3. All water supplies in the healthcare facility are treated with disinfectant so that there is a free chlorine residual of between 0.3–0.5mg/l and turbidity is below 5 NTU (nephelolometric turbidity units) at the point of use. In the case of highly infectious disease epidemics, supplies should be disinfected to achieve free chlorine residual of above 1mg/l at the point of use.

2.1.3 Water Access

Functional running water access points are available in all health care service delivery points for outpatients, inpatients, staff and caregivers at all times 24 hours a day. For gravity flow systems, there should be adequate residual pressure to ensure running water at all access points with a minimum flow rate of 3 minutes to fill a 20 litre container.

2.2 Sanitation – Excreta Disposal, Showers/Bathrooms/Urinals, Wastewater disposal and Site Drainage

Toilets or latrines and showers/bathrooms/urinals should be accessible to all users including staff, patients and visitors. Urinals should be made available for male use in busy facilities to reduce usage of toilets. There should be sufficient numbers of suitable, reachable and proper toilets and showers/bathrooms/urinals in each healthcare facility. These facilities should be safe and segregated by gender for staff and patients. They must make provisions for people with disabilities and ease of use by children. Design of these facilities should also take into account guidelines from the MoHS12. Wastewater generated in healthcare facilities should be disposed of promptly and safely to avoid contamination. Wastewater collection facilities can be onsite or off-site depending on availability of such facilities.


2.2.1 Sanitation Facility Quantity

In each healthcare facility, there should be separate toilets or latrines and shower/bathrooms/urinals for patients and staff with clear symbols, signs and hygiene promotion messages on the proper use of such facilities. There should be sufficient toilets or latrines for staff, patients and visitors. Minimum requirements are 1 facility for every 10 inpatient users, 1 facility for every 20 outpatient users and facilities for female and male staff in every ward. In all CHCs/CHPs/MCHPs there should be at minimum 4 toilets with urinals; 2 for outpatients (male, female) and 2 for staff (male, female). At least one shower/bathroom facility should be available for 20 inpatient users including caregivers or at a minimum 1 facility per ward and at least

12Sanitation technology options by the MoHS, technical WASH meeting 30th July, 2015.


2 facilities for staff (1 for male, 1 for female) in each ward. In all CHCs/CHPs/MCHPs there will be at minimum 2 shower/bathroom facilities for staff (male, female). All toilets/shower/bathroom facilities for maternity wards/delivery rooms shall be indoor. There will be at minimum 1 toilet with urinal and shower facility at the Isolation Unit in all hospitals and CHCs.

Septic tanks and leach fields/pits should allow proper collection, on-site treatment and percolation of wastewater. Location of all infiltration disposal systems to take into account distance to water sources, depth of ground water table and soil formation. In areas where off-site waste treatment is available, septic and holding tanks should be desludged by MoHS when they are ¾ full.

2.2.2 Sanitation Quality

Toilets with urinals and wastewater collection facilities, including septic tanks, leach fields/pits and holding tanks should be constructed according to the specifications issued by MoHS/MoWR to ensure that excreta and wastewater are safely managed. These facilities should be located at least 30 meters downstream from water sources. Septic tanks and any leaching pits should be located at least 3 meters away from main buildings and minimum 1.5 meters above the maximum ground water table in all cases. In addition, sanitation facilities should be cleaned and maintained regularly to ensure that clean and functioning toilets, showers/bathrooms are readily usable.

2.2.3 Sanitation Access

Sanitation facilities should be accessible to female and male staff, patients and visitors, including children and people with reduced mobility. Toilets should be easily accessible within and no more than 30 meters from all users13.

INDICATORS

1. The healthcare facility grounds and environment is free from human faeces.

2. A sanitary survey of the wastewater disposal chain from point of origin to point of disposal indicates a low level of public health risk for staff, patients or the environment at every stage14.

3. Wastewater is removed rapidly and cleanly from the point where it is produced.

13Essential environmental health standards in health care, WHO 2008.14Use Sanitary Survey Risk Score Tool to measure level of risk, WASH in Health Care

Facilities in Emergencies, WHO 2012.


2.3 Hygiene – Hand Washing Facilities

There should be sufficient and well-designed hand washing facilities with soap and running water at critical areas such as within sanitation facilities, in patient care areas and in food preparation areas. Hand washing facilities are necessary in order to promote proper hygiene practice among staff, patients, caregivers and visitors. Information, education and communication (IEC) materials should be available in areas with hand washing facilities to promote safe hand washing practices at critical times.


2.3.1 Quantity of Hand Washing Facilities

Hand washing facilities should be conveniently located throughout the healthcare facility including consultation rooms and all areas where healthcare procedures are performed including delivery rooms in BEmONC facilities and in convenient locations within toilet peripheries15. Patient’s wards with more than 20 beds should be provided with at least two hand washing basins16. In case of absence of such facilities, waterless antiseptics should be readily available (wall-mounted) or other alcohol hand rub in small bottles depending on the availability.

2.3.2 Quality of Hand Washing Facilities

Hand washing facilities should be constructed according to the specifications issued by MoHS and provided with soap to ensure that facilities are user friendly and safely managed. Hand washing facilities should be cleaned, maintained and provided with good drainage. Clear signs, symbols and health and hygiene messages to encourage the use of hand washing facilities should be provided.

2.3.3 Access

Hand washing facilities should be accessible and easy to use by every person visiting a healthcare facility, especially children.

INDICATORS

1. A functional hand washing facility with soap is available in every area where healthcare procedures are performed.

2. Patients and caregivers are informed about essential hygiene behaviours necessary for limiting disease transmission in the CHC repeatedly, starting within 30 minutes of arrival.

3. Where appropriate (CHCs with inpatient facilities), food for patients, staff and caregivers is stored in a way that minimises the risk of disease transmission.

15No more than 5 meters within the toilets16Essential environmental health standards in health care, WHO 2008.


2.4 Storm Water Drainage Systems

There should be adequate and well-designed storm water drainage system in all healthcare facilities. The system should ensure that unblocked storm water channels exist and are properly sized and functional. It should also ensure that rainwater does not flood or carry potentially infectious agents to nearby residents/communities or pond within the facility to encourage mosquito breeding. Rainwater should not be directed into septic tanks to avoid overspill in case wastewater collection facilities cannot absorb it.


The quantity of storm water channels: There should be enough storm water canals to contain and direct movement of storm water runoff in each healthcare facility.

2.4.1 Quality

Storm water channels should be constructed according to the specifications issued by MoWR to ensure that rainwater is safely managed. Where RWH system is to be constructed for storm water management, design and construction should be as per the approved MoWR guidelines.

INDICATORS

1. Rainwater and surface runoff is safely disposed of and does not carry contamination from the healthcare facility to the outside surrounding environment.

2.5 Laundry Facilities

There should be at least one laundry facility in each hospital and healthcare centre. Laundry facilities should be well-designed with enough space to allow sorting, washing and temporary storage of clean linen. Good drainage system should be in place and all laundry facilities should be kept dry to avoid the accumulation of moisture. Proper electrical wiring should be done in case laundering is done by machines.


2.5.1 Quantity of Laundry Facilities

At minimum one laundry facility should be available in each hospitals and CHC. Where possible, machine laundering should be prioritized for the occupational safety of laundry workers.


2.5.2 Quality of Laundry Facilities

Laundry facilities should be constructed or rehabilitated in accordance with the specifications approved by MoHS to ensure that facilities are well-located, safe, user friendly, safely managed and with adequate drainage systems for grey water. Adequate water supply, soap or detergent, disinfectant and hand washing facilities should be made available in a laundry facility17. Where manual laundry is used, facility should have adequate access to water, at least three washing basins with waste water drainage system, appropriately drained on the surface, roofed and with a provision for drying of linen which is appropriately drained.

2.5.3 Access

The main entry to the laundry facility should allow smooth movement of handcarts or containers carrying both clean and soiled linen. Access limitation or control should apply to non-laundry staff and other unauthorized personnel.

INDICATORS

1. Laundry facilities, soap or detergent, water and a disinfectant (such as chlorine solution) are available in all patient settings.

2.6 Healthcare Waste Management Facilities

Healthcare waste (HCW) should be properly segregated at the point of generation, collected in leak proof and puncture-resistant containers, transported to treatment sites, stored safely prior to treatment, treated and disposed of safely. The healthcare facility surroundings should be free from uncontrolled healthcare waste. Waste handlers should strictly adhere to the MoHS IPC protocol and waste management guidelines18.


2.6.1 Segregation

Segregation of HCW should be done at the point of generation according to the types of waste generated, i.e. sharps, highly infectious, infectious and non-infectious. Color-coded HCW containers/bins and bin bags should be used with clear signs and symbols as per MoHS guidelines19. Recommended color-coding system is yellow cardboard boxes for infectious sharps and non-sharps infectious waste, red for highly infectious waste and black for general or domestic non-infectious waste. Hazardous waste (e.g. pharmaceutical waste, lab reagents,

17Essential environmental health standards in health care, WHO 200818Integrated National Waste Management Policy, October 2012.19Integrated National Waste Management Policy, October 2012, Page 27.


radioactive materials, insecticides, etc.) should be collected and stored in appropriate and labelled containers placed in a secure location. Further segregation may be done depending on the level of healthcare facility. Domestic or general waste can be segregated to facilitate the recycling of papers, cardboards, plastics, glass and metal waste depending on the availability of recycling opportunities.

2.6.2 Collection of Health Care Waste

Health care waste collection bins should be made of plastic with adequate strength (puncture resistant and leak proof) in accordance with the approved color-coded containers with clear labels indicating the contents for safe handling. Clearly marked and color-coded bins enhance the occupational health of waste handlers by providing understandable and easy-to-follow identification of types of HCW and should be maintained throughout the healthcare waste management chain, i.e. segregation, collection, transport, storage, treatment and final disposal.

• Sharps Containers – Shall be of cardboard, yellow safety boxes, where treatment and final disposal option is incineration or sharps pit. Sharps containers should be located within arm’s reach of generation points (injection rooms, laboratories and patients wards) and disposed when filled up to ¾ full levels. These shall also be within easy arm’s reach of all locations where these wastes are generated.

• Highly Infectious Waste Containers – Shall be of plastic with adequate strength (puncture resistant and leak proof), red coloured containers, and will be 20-40 litre capacity with bin covers/lids and bin liners of the same colour. This waste will be disposed immediately into the placenta/organic waste pit. These shall also be within easy arm’s reach of all locations where these wastes are generated.

• Infectious Waste Containers – Shall be of plastic with adequate strength (puncture resistant and leak proof), yellow coloured containers, and will be 20-40 litre capacity with bin covers/lids and bin liners of the same colour. This waste will be disposed when filled up to ¾ full level into the incinerator and the ash generated into the ash pit. These shall also be within easy arm’s reach of all locations where these wastes are generated.

• Non-Infectious Waste Containers - Shall be of plastic with adequate strength (puncture resistant and leak proof), black coloured containers, and will be of up to 60 litre capacity with bin covers/lids and bin liners of the same colour.

• Hazardous Waste – shall be collected and stored in appropriate and labelled containers stored in secured location for disposal, either through destruction and disposal in secured landfill as per MoHS guidelines.

• At least one set of black and yellow containers should be allocated per 20 beds in each ward, in patient’s waiting areas and consultation rooms.


• Once containers are ¾ full, waste handlers should remove waste bags and replace with new liner bags. Bags should be tied and handled carefully by the neck. In the event where there is leakage, the containers should be removed, cleaned and disinfected before replacing with a new liner bag. All healthcare waste bins should be removed for a thorough cleaning and disinfection on a weekly basis.

2.6.3 Transportation of Healthcare Waste

All movement of healthcare waste either on site or off site should be in line with the MoHS guidelines (Refer to INWM Policy 5.1.12, 5.1.13.2 & 5.1.13.4). On site transportation of HCW from the point of collection to storage, treatment or final disposal facility should be done by using leak proof waste collection trolleys or at minimum metal handcarts/wheelbarrows. Generally, both onsite and off-site transport equipment should allow easy loading and unloading of waste. Bags should be handled delicately by the neck so as not to tear or cause any leakage while transferring waste bags into trolleys, handcarts and trucks.

2.6.4 Healthcare Waste Storage

Where applicable all health care waste should be stored in designated storage facilities as per the guidelines by MoHS (Refer to INWM Policy 5.1.13.1 & 5.1.13.3) for any facility storing waste awaiting onsite treatment or off-site transportation. At a minimum, hospitals shall have healthcare waste storage facilities/provision within the incinerator facility. Waste generated from the other facilities should be treated and disposed daily at the respective disposal facilities located in demarcated waste disposal zones to minimize the need for storage. Waste disposal zones shall be situated at least 50 meters (preferably downhill and downwind) from any buildings or public areas, fenced off, locked and all pits adequately locked and covered. In all facilities organic wastes should be disposed daily.

2.6.5 Healthcare Waste Treatment and Disposal

Healthcare waste shall be treated prior to final disposal as per the MoHS guidelines (Refer to INWM Policy 5.1.14 & 5.1.15). On-site treatment methods such as incineration at temperatures not less than 1200 degrees centigrade for hospitals is recommended. At a minimum, double chambered De Montfort incinerators will be used in hospitals and CHCs. Treated HCW should be disposed of in a safe manner not to cause environmental contamination. Lined ash pits should be used for disposal of incinerated ash, which is normally 5-10 percent of incinerated waste. At a minimum, sharps waste shall be disposed into a sharps pit, where medium/low burning incinerators are used for incineration. In case incinerators will not be operational for a few days beyond the capacity of the storage facility, waste can then be disposed of by burning in primitive incinerators, barrels or pits under the MoHS supervision, and ash disposed of in an ash pit.


References1. Ministry of Health & Sanitation GoSL, Intergraded National Waste Management

Policy, October 20122. Ministry of Water Resources GoSL, Technical Brief/Guidelines for Pipe laying

and House Connections, December 20143. Ministry of Water Resources GoSL, Principles of Bore Hole Construction

and Rehabilitation, October 20144. Ministry of Water Resources GoSL, Technical Guidelines for the Construction

and Maintenance of Hand Dug Wells, April 20145. WHO (November 2014). Guideline on Hand hygiene in Health care in the context

of filovirus disease outbreak response.6. WHO. (2008). Essential environmental health standards in health care.7. Ministry of Health & Sanitation GoSL, Sanitation Technology options by the,

Technical WASH meeting 30th July 20158. WHO (2012) WASH in Health Care Facilities in Emergencies9. The Sphere Project, Humanitarian Charter and Minimum Standards in

Humanitarian Response (2011)

INDICATORS

1. Healthcare waste is segregated at the point of generation according to its type: Organic waste, sharps and non-sharps infectious waste, hazardous and general waste.

2. Colour-coded waste containers or containers bearing clearly understood signs and symbols are available in all places where healthcare waste is generated.

3. Each category of waste is treated and disposed of according to the safest feasible method available.

4. A specific waste-disposal zone exists, where wastes can be stored and disposed of safely and effectively.

5. The healthcare facility grounds and environment is free from uncontained healthcare waste.

6. Staff has sufficient and adequate waste handling equipment and personal protective equipment and are correctly trained to collect, handle and dispose of healthcare wastes safely.


ANNEXES: TYPICAL DESIGNSAPPENDIX 1: Typical Design for Pour Flush Latrine Block (with a provision for the disabled)

Figure 1: Typical Design for Pour Flush Latrine Block (with a provision for the disabled)


Figure 2: Typical Design for Pour Flush Latrine - Left Elevation

Figure 3: Typical Design for Pour Flush Latrine - Section


Figure 4: Typical Design for Pour Flush Latrine - Pit Section


APPENDIX 2: Typical Septic Tank Design (Low Capacity for CHCs)

Figure 5: Typical Septic Tank Design - Section

Figure 6: Typical Septic Tank Design - Plan


Figure 7: Typical Septic Tank Design – Slab


APPENDIX 3: Typical Soak away pit Design

Figure 8: Typical Soak away pit Design - Pit

Figure 9: Typical Soak away pit Design - Plan


APPENDIX 4: Typical Laundry facility Design (Hospitals to Complement Machine Laundry, CHCs)

Figure 10: Typical Laundry facility Design - Foundation Plan

Figure 11: Typical Laundry facility Design - Left & Rear Elevation


Figure 12: Typical Laundry facility Design - Floor Plan

Figure 13: Typical Laundry facility Design - Front & Right Elevation


Figure 14: Typical Laundry facility Design - Section A-A


APPENDIX 5: Typical Placenta Pit Design

Figure 15: Typical Placenta Pit Design - Cross Section, Total Depth – 2m.


Figure 16: Typical Placenta Pit Design - Plan Views

Figure 17: Typical Placenta Pit Design - Strip Foundation and Beam


APPENDIX 6: Typical Sharps Pit Design

Figure 18: Typical Sharps Pit Design - Cross Section, Total depth – 2m


Figure 19: Typical Sharps Pit Design - Plan Views

Figure 20: Typical Sharps Pit Design - Strip Foundation and Beam


APPENDIX 7: Incinerator Construction – De Montfort Mark 8a (CHCs)/9 Incinerator (Hospitals)


Double Healthcare Waste Management Treatment Incinerator

Pyroltyic Healthcare Waste Management Incinerator


II. WASTE TYPE:• Medical waste, disposable syringes, infusion sets processing, cotton yarn,

the operating room, the residual limb, waste rubber gloves, protective clothing and infectious and harm venereal hospital bed supplies, etc.

III. DESIGN BASIS:• Furnace body type: Vertical closed furnace combustion chamber;

• Burning capacity:100-120kg/time ( daily burn 3-6times,each time consume about 1 hour )

• Ignition manner: automatic

• Fuel type:0# or-10# diesel;

• Feeding mode: Solid waste manual feeding

• Take ash manner :manual

• Furnace inner pressure: adopt negative pressure design, no back-fire, —3~—10mmH2O

• Design heat value: waste mix 1500kcal/kg ~2500kcal/kg,0# diesel 10000kcal/kg

• Flue gas treatment manner: Gasification combustion chamber(first combustion chamber) + blower + mixed combustion chamber+high temperature secondary combustion chamber + flue gas purification room (calcium hydroxide filter brick) +exhaust fan + independent chimney

• Burning temperature: First combustion chamber: 600-800oC

• Secondary combustion chamber:1500oC

• Flue gas residence time≥2s

• Combustion efficiency: ≥99.99%,

• Incinerator during operation to ensure system is in negative pressure condition, avoid harmful gas escape;

• Glue gas discharge standard GB18484-2001<Hazardous waste incineration pollution control standards.


Notes:Chamber Capacity = 0.241m3

Jacket Capacity= 0.016m3

Minimum Safe

Low Speed Shredder

ElevationElevation

Autoclave Unite for Healthcare Waste Management


Cyclic Autoclave Unit for Healthcare Waste Management

Design Temperature = 0oCMaximum SafeDesign Pressure = 143oCChamber DesignPressure = 100/300 kpaJacket DesignPressure = 360 kpa

Notes:Chamber Capacity = 0.241m3

Jacket Capacity = 0.016m3

Minimum Safe

Design Temperature = 0oC Maximum safe Design Pressure = 143oC Chamber Design

Pressure = 100/300 kpa

Jacket Design

Pressure = 360 kpa

1. All waste management area must be covered to prevent rains and direct sun ray penetration.


APPENDIX 8: Typical Ash Pit Design

Figure 21: Typical Ash Pit Design - Cross Section, Total Depth – 2m.


Figure 22: Typical Ash Pit Design - Plan Views

Figure 23: Typical Ash Pit Design - Strip Foundation and Beam


APPENDIX 9: Typical Shower Block Design (PHUs)

Figure 25: Typical Shower Block Design - Front and Side Elevations

Figure 24: Typical Shower Block Design - Plan


Figure 26: Typical Shower Block Design - Section A-A


APPENDIX 10: Typical Waste management area/facility size, Layout (PHUs)

Figure 27: Typical Waste management area/facility size, Layout


APPENDIX 11: Typical Isolation Unit & Screening area design (CHCs)

Figure 28: Typical Isolation Unit & Screening area design - Floor Plan


Figure 29: Typical Isolation Unit & Screening area design - Section A-A

Figure 30: Typical Isolation Unit & Screening area design - Right Elevation

Figure 31: Typical Isolation Unit & Screening area design - Left Elevation


Figure 32: Typical Isolation Unit & Screening area design - Front Elevation

Figure 33: Typical Isolation Unit & Screening area design - Rear Elevation


APPENDIX 12: Typical Force lift Pump (CHPs & MCHPs)

Figure 34: Typical Force lift Pump (CHPs & MCHPs)


SPECIFICATION FOR SMALL-SCALE SOLAR WATER SUPPLY SYSTEMS FOR PHUSWater supply systems should be designed according to quantity and quality requirements. PHUs require smaller quantities of high quality water and need to be reliable and operate at minimal and affordable cost without recourse to complicated technology fixes.

New solar-powered pumping systems combined with boreholes have potential to meet this need, however, the systems must be designed properly and components selected carefully to achieve a robust system. The following offers recommendations to achieve a reliable water supply system for PHUs.

Borehole Specifications:

• Minimum safe yield of 0.3L/s (1,000 L/hour)

• Casing – uPVC, flush threads, outside diameter 125mm, wall thickness 6-6.5mm, from the ground surface to 1-2m into the aquifer (length to be determined from drilling profile)

• Screen – same diameter as above with slots of 0.75 to 1.0mm, sandwich between the casings on top and downwards, the bottom plug. Length to be determined by the aquifer characteristics

• Bottom plug and sump of 1m to 3m

• Gravel Pack – clean, rounder of river sand or alluvial origin with grains from 1.5mm to 4mm; placed between the hole and the outer face of the screen casing up to 2m above screen

• Lower sanitary seal – sand 1m then bentonite or cement for 1m; placed upon gravel pack

• Top screen – generally should not be higher than 20m below ground level, but this is flexible depending upon the water strikes and aquifer characteristics

• Backfill material – drill cuttings without organic matter of the topsoil; clay is best

• Grouting or sanitary seal – the protective seal shall be placed from 4-6 meters below ground level to 0.25 meters above ground and will occupy an annular space between the wall and the outer face of the casing

• Well cap – steel or uPVC cap or lid placed over the mouth of the borehole to prevent entrance of pollutants into the well, including surface water and insects

• Once the borehole has been completed and tested, it should be sterilized with a chlorine solution yielding at least 50 mg/l of active chlorine in all parts of the borehole


Storage Facility

• Elevated Tank GFS; with 2 days, back up Storage. Minimum 5,000 ltrs. While the government is advocating for the white coloured storage tanks, this allows light to enter, thus encourages the growth of algae which makes water unhygienic. So the black colour storage tanks are encouraged.

Distribution System

• Standard water supply network within PHU in accordance with Standards and Guidelines for WASH in Healthcare Facilities, 2016

Solar Pump Specifications

1. Submersible solar pump suitable to be used in boreholes with output capacity 1200L/hr (0.4L/s output) which meets the stated requirement (as average daylight is 5hrs in August and 9hrs in February, the extra output will be utilized by the users), with total dynamic head of 45m and shut off head of 90m

2. DC pump motor to run directly from solar panels (DC pumps are more efficient and do not require batteries).

3. 1 HP to 1.5 HP depending on depth of well (the smallest needed to achieve the minimum water requirement is best to reduce the number of solar panels and reduce costs.)

4. The pump is to be provided with compatible control panel which should consist of all type of automatic protection and measuring instrument such as voltmeter and ammeter all incorporated and assembled in lockable box

5. Soft-start feature to reduce torque upon pump start up

6. Dry-run protection (in case the water level drops below pump intake)

7. Over voltage protection

8. Control Unit with manual on-off switch

9. Control Unit protected from tampering, but should not be far from the borehole & tower because distance in wiring increases wiring diameter, cost and efficiency significantly.

10. Electrical cable should be waterproof and diameter to match pump power requirements and distances.

11. Straining cable – ideally should be stainless steel, but this is expensive. Nylon rope may be used if stainless steel is unavailable. Galvanized cable may be used only where the water pH is 6.9 or above.

12. Float switch in tank for automatic shut off of power when tank is full

13. Lightning arrestor & earthing

14. The operation and maintenance manual, installation manual, and circuit diagrams of the control panel and pump shall be supplied at the time of delivery of the goods


Panels Specifications

• Pump capable of pumping rate up to 10,000 l/day

• Solar panel Wattage and array layout to match pump electrical specifications. Procuring from a professional supplier is advised to ensure compatibility of all components.

• Fastened to sturdy steel or aluminum framework capable of withstanding wind speed of 90km/hr; best to use at least 1 security bolt per panel.

• Best placed above the tank to avoid theft and shade from trees and buildings. If the tower is used to carry the module, this must be consider in the layout of the tower allowing the orientation to be north-southwards

• Panel positioned on maximum of 30 to 45 degree angle to south facing for maximum power production or as per the manufacturer’s instructions (for grundfos - 9 degree tilt for Freetown).

Warranty

The PV Modules must be warranted for output wattage, which should not be less than 90% at the end of 10 years and 80% at the end of 25 years. The whole system including submersible/surface pumps shall be warranted as indicated by the manufacturer. Any spare parts provided by the manufacturer during the warranty period should be safely kept and accounted for by the DHMT solar focal point.

Operation and Maintenance Manual

An easy to use operation and maintenance manual, in simple English, should be provided with the solar PV pumping system. The manual should have information about solar energy, photovoltaic, modules, DC/AC motor pump set, tracking system (where applicable), mounting structures, electronics and switches. It should also have clear instructions about mounting of PV module, DO’s and DONT’s and on regular maintenance and trouble shooting of the pumping system. Name and address of the focal point from the DHMT (district level) to be contacted by other healthcare facilities in case of failure or complaint. Otherwise the details of the manufacturer should also be provided to the focal point for easy contact in case of difficulties within the warranty period.

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