Integrating the STREAM Disinfectant Generator into national health systems

Inadequate access to water, sanitation, and hygiene (WASH) services in health facilities increases the risk of infectious disease transmission, particularly among vulnerable patient populations, including high rates of maternal and newborn morbidity and mortality. An estimated 15 percent of inpatients in low- and middle-income countries will develop a health care–associated infection (HAI)—most of which are preventable.

Effective infection prevention and control (IPC) practices are critical for reducing the spread of HAIs. Further, safe water, sanitation, and hygiene are essential components of IPC and the delivery of high-quality health services, and are directly linked to achieving Sustainable Development Goal 3 (good health and well-being) and Goal 6 (clean water and sanitation).

Yet, data show that nearly 25 percent of all health care facilities worldwide lack basic water services, and 36 percent are not able to provide basic environmental hygiene services.

PATH is collaborating with the Ghana, Uganda, and Ethiopia ministries of health to strengthen IPC practices and WASH service delivery in health facilities through national introduction and scale up of the Aqua Research STREAM™ Disinfectant Generator (STREAM).

The STREAM is an on-site, electrolytic chlorine generator designed specifically for low-resource settings. It produces a consistent flow of 0.5 percent (5,000 milligrams per liter) chlorine solution using salt, water, and electricity. The chlorine solution can be used to disinfect surfaces and tools, which improves IPC and prevents the spread of HAIs.

A key success factor in national introduction and integration of the STREAM is direct government involvement and ownership. In Uganda, Ghana, and Ethiopia, PATH has cultivated strong relationships with government actors responsible for WASH services across national, regional, and district levels of each health system.

Our collaborative approach has enabled us to achieve key milestones in these countries, where the successful integration of the STREAM into national health systems contributes to ensuring access to safe and effective WASH services in health facilities.

In all three project countries, PATH maintains strong relationships with the directors of various regulatory departments, ensuring sustainability even during government and staff transitions, which has helped inform and drive project objectives, generate ownership and buy-in for the project, and further integrate the device into national health systems.

Uganda

PATH teams work closely with the Uganda Ministry of Health Clinical Services Department (MOH/CSD). Through this relationship, PATH and the MOH/CSD regularly engage to ensure programmatic alignment, discuss and review activities and progress, and jointly develop strategies for improving WASH services in health facilities.

The MOH/CSD and PATH co-developed a policy and regulatory roadmap that identified key governmental policy approval processes and bodies along with regulatory requirements for introduction of the STREAM into the public health system.

Together, the MOH/CSD and PATH designed evaluations of the STREAM to generate evidence on its performance, acceptability, and cost impact in health facilities and prepared and presented results to technical and ministerial-level governmental policy approval bodies (see Figure 1).

In October 2022, the National Advisory Committee on Medical Equipment issued a report concluding, “The device is recommended for Health Centres III and IV to the General Hospital Level.”

PATH spent years building strong working relationships with Dr. Henry G. Mwebesa, Director General of Health Services at the Uganda MOH, and MOH staff. Their expertise helped us to traverse regulatory hurdles and lent us additional credibility with regulatory approval bodies.

Ghana

PATH and the Ghana Health Service Institutional Care Division team launched an observational study involving eight STREAM units in Eastern Region.

During the study, regional biomedical staff accompanied PATH on trips to oversee functionality and understand usability. This partnership helped to strengthen the biomedical staff’s understanding of the device and allowed PATH to transfer operation and maintenance/repair of the STREAM to the Eastern Region health management team, health facilities, and biomedical staff.

In parallel, PATH and Aqua Research (based in New Mexico, United States) worked with Bureau Veritas to assess the STREAM’s compliance with the Ghana Standards Authority’s safety measures for electrical equipment (IEC 61010-1:2010).

PATH also worked with several Ghanaian governmental authorities to help issue classification of the STREAM—a significant milestone for the project as it simplified the registration, import, and market introduction of the STREAM in Ghana.

Ethiopia

In Ethiopia, PATH used a roadmap similar to those for Uganda and Ghana, identifying Amhara Region and Addis Ababa City Administration for the launch of an evaluation of 14 STREAM devices. In March 2023, we received Amhara Regional Health Bureau approval to submit a protocol to the ethics review committee.

While PATH was securing approvals from regional health authorities, confirming staff participation, and preparing the study protocol, an armed conflict erupted in the region, halting this work.

PATH is now continuing to work with leaders at the woreda level (woredas are equivalent to the district level in Ghana and Uganda) to continue progress on the study even as the level of instability in the region has slowed progress.

Our work in Uganda, Ghana, and Ethiopia yielded key achievements, including:

• Strong, ongoing collaborative relationships with government actors at all levels.
• A landscape of required policy and regulatory approvals for each country, and working closely with government officials to obtain them.
• Evidence on the performance and acceptability of the STREAM to attain local buy-in.
• Working with and training local staff to foster local ownership of the device.
• Flexibility to adapt to each unique situation.

To date, PATH and its government partners have installed 36+ STREAM devices across 30 health facilities, with plans to expand the use of the STREAM to up to 100 facilities by 2025.

The facilities are using their own budgets to procure STREAM consumables (for example, salt and vinegar) for chlorine production, and regionally based biomedical engineers are supporting facilities with maintenance and repair of the devices.

These successes are built, in part, on the strong relationships developed between PATH and government champions. Together, we helped inform and drive project objectives, generate ownership and buy-in for the project, and further integrate the STREAM into national health systems.

Collaborating with government actors at all levels led to policy approvals and regulatory certifications that are expanding the reach of the STREAM across the public health systems in Uganda, Ghana, and Ethiopia.

Going forward, PATH will continue to work with government leaders, private-sector partners, and other WASH and health stakeholders to support technical innovation and shape the market to expand introduction and scale-up of the STREAM Disinfectant Generator worldwide.