Integrating the STREAM Disinfectant Generator into national health systems

Inadequate access to water, sanitation, and hygiene services in health facilities increases the risk of infectious diseases, particularly among vulnerable patient populations. This contributes to high levels of maternal and newborn morbidity and mortality, which can be prevented through improved infection prevention and control practices (IPC).

IPC is critical for reducing the spread of health care–associated infections, which affect an estimated 15 percent of patients in low- and middle-income countries. Water, sanitation, and hygiene (WASH) are an essential component of IPC and the delivery of 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.

These factors contribute to the spread of infections, particularly among vulnerable patient populations, such as mothers and infants. As a result, an estimated 15 percent of inpatients in low- and middle-income countries will develop health care–associated infections (HAIs), yet most HAIs are preventable.

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

The STREAM is an onsite, electrolytic chlorine generator designed specifically for low-resource settings. It produces a consistent flow of 0.5 percent milligram per liter chlorine solution using salt, water, and electricity. The chlorine solution can be used to disinfect surfaces and tools, which improves infection prevention and control practices and prevents the spread of HAIs.

A key success factor for the 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 various levels of the health system—national, regional, and district level.

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

In all three project countries, PATH maintains strong relationships with directors from 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’s 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 Disinfectant Generator into the public health system.

Together, the MOH/CSD and PATH jointly designed STREAM evaluations to generate evidence on the performance, acceptability, and cost impact of the STREAM 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 a strong working relationship with the MOH Acting Commissioner Health Services, Clinical Services, Dr. Rony Bahatungire, and the 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’s Institutional Care Division (GHS/ICD) team launched an observational study involving eight STREAM Disinfectant Generator units in the Eastern Region.

During the study, biomedical staff from the Eastern Region 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 operational and maintenance/repair of the STREAM to the Eastern Region health management team, health facilities, and biomedical staff.

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

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

Ethiopia

PATH used a similar roadmap as Uganda and Ghana, by identifying the Amhara Region and Addis Ababa City Administration for the launch of an evaluation of 14 STREAM Disinfectant Generator 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.

Overall

Strong partnerships with government health officials led to several key achievements in Uganda, Ghana, and Ethiopia. These include:

1. Developing and maintaining strong collaborative relationships with government actors at all levels
2. Landscaping required policy and regulatory approvals for each country and working closely with government officials to obtain them
3. Generating evidence on the performance and acceptability of the STREAM Disinfectant Generator to get local buy-in
4. Working with and training local staff to foster local ownership of the device
5. Maintaining flexibility to adapt to each unique situation
6. Partnerships in practice: Securing STREAM policy and regulatory approvals

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 health care facilities by 2025.

Health 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 health facilities with STREAM maintenance and repair needs.

These successes are built, in part, on the strong relationships developed between PATH and government champions. Together, we have 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 health system champions led to policy approvals and regulatory certifications that are expanding the reach of the STREAM across public health systems in Uganda, Ghana, and Ethiopia.

Going forward, PATH will continue to work together with government leaders, private-sector partners, and other WASH and health stakeholders by supporting technical innovation and shaping the market to expand the introduction and scale of the STREAM worldwide.