15. ENVIRONMENTAL COMPLIANCE IN HEALTH ACTIVITIES

Maputo, Mozambique • 7th – 11th May 2018

• Review the different types of healthcare waste

• Sensitize to the risks of improper disposal

• Understand healthcare waste management procedures

• Discuss environmental compliance and safeguards for effective healthcare waste management

• Examine novel ways to address healthcare waste issues

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SESSION OBJECTIVES

• PEPFAR

• PMI

• Bilateral health programming

• Supply chain management

• Education programs (e.g., HIV testing services for teachers or students)

• G2G support

• Agricultural programs

WHERE IN USAID PROGRAMS DO WE ENCOUNTER HEALTHCARE WASTES?

If there is waste (direct or indirect)

1) Negative Determination with Conditions

2) Positive Determination

Threshold Decision

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THE WORLD OF HEALTHCAREWASTE

Cytotoxic Blood/fluid contaminated

AnatomicalSharps

E-wastes Laboratory

Incinerator ash

General/ non-toxic solid waste

Construction

Pharmaceutical

Liquid/ sewage and gray water

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75-90% of healthcare waste is non-hazardous

Remaining 10-25% is hazardous:

• Liquid

• Heavy metals

• Pharmaceuticals

• Radioactive

• Sharps

Importance of waste quantification and segregation

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WASTE CHARACTERIZATION

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Environmental Impacts• Water supply contamination

‒ Infectious stools or bodily fluids

‒ Chemical and pharmaceutical waste• Toxic air pollution

‒ Burning or incineration of wastes Health Impacts• Physical injury

‒ Cuts, punctures (e.g., from sharps)• Disease transmission

‒ Greatest and most immediate threat

‒ HIV/AIDS, Hepatitis B & C

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WHAT ARE THE RISKS?

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Direct generation of waste:

- Supply chain management- Provision of testing services- Commodities distribution

Indirect generation of waste:

- Strengthening health services- Training of practitioners- G2G purchases

HEALTHCARE WASTE CONDITIONS (AN EXAMPLE)Where USAID support is direct, USAID bears full responsibility for adverse impacts when its support fails to address waste management or to consider the capacity of healthcare facilities to properly handle, label, treat, store, transport, and properly dispose of healthcare waste.

Where USAID indirectly contributes to waste generation, USAID generally has far less control over service delivery on the ground. Reduced control means that USAID’s responsibility for adverse impacts is shared—but not eliminated. For example, proper waste management requires that the systems and structures governing health care delivery address and require appropriate management. Where USAID’s support means that USAID has substantial influence over these systems and structures, USAID and IPs must work to best assure that these systems and structures support appropriate health care waste management.

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APPROACHES THAT RESPOND TO BOTH INDIRECT AND DIRECT MANAGEMENT OF WASTE?

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WASTE MANAGEMENT PLAN

1. Assess present situation and carry out a waste survey

2. Identify opportunities for minimization, reuse and recycling

3. Identify handling, treatment and disposal options

4. Evaluate options

5. Prepare a management plan

6. Establish a record keeping system

7. Estimate related costs

8. Prepare training program

9. Prepare implementation strategy

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WASTE MANAGEMENT PLANSample Waste Survey

Type of solid waste produced and estimated quantity(Mark X where waste is produced and note approximate quantity generated per day.)

Source Type of Waste

General Radioactive Chemical Infectious Sharps Pharmaceutical Estimate(Kg/day)

Patient

Pharmacy

Laboratory

Kitchen

Laundry

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WASTE MANAGEMENT PLAN

http://iwmp.environment.gov.za

Ongoing process throughout project lifecycle

WASTE MANAGEMENT PLANASSESSING THE SITUATION AND FINDING OPPORTUNITIES

Outside hospital(Total system)

Same car different time

Disposal siteProtected Landfill

Treatment

Centralincineration

Municipality

Private firms/NGOs

Big Hosp.Public/private

Management

Collection

Transport

Gen. Waste

Infect. Waste

Ash

Institutional Cooperation

Optimum & proper resource utilization

Public Participation

Public-Private Partnership

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Treat same as “domestic waste”

Reduces waste quantity, cost, risk from and to scavengers and workers

Manage as close to point of generation as possible

Disposal options include landfilling and incineration

Do not incinerate plastic, PVC or packaging— produces dioxins, furans, etc.

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WASTE MANAGEMENT PLANIDENTIFYING OPTIONS/MITIGATION MEASURES

NON-HAZARDOUS SOLID WASTE

Double-bagged

Marked

Hard exterior container (e.g., plastic bucket) with a lid

Yellow/red packaging (as appropriate), if possible

Comply with holding time requirements (commonly must be disposed once a week or when ¾ full)

Lock and store in area separate from other waste until destruction or disposal

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WASTE MANAGEMENT PLANIDENTIFYING OPTIONS/MITIGATION MEASURES

HAZARDOUS WASTE

Segregate and pretreat liquid hazardous waste

Disinfect infectious and highly infectious liquid waste with bleach, lime oxide, or other disinfectant

Non-hazardous chemicals (e.g., syrups, vitamins or eye drops) can be discharged to the sewer without pretreatment

Budget for development and operation of efficient wastewater-management system (low-cost options include anaerobic treatment and reed bed systems)

Consider onsite wastewater treatment if inadequate local/municipal system in place

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WASTE MANAGEMENT PLANIDENTIFYING OPTIONS/MITIGATION MEASURES

LIQUID WASTE

Emphasize waste reduction and segregation to reduce volume and toxicity of materials for incineration

Implement air pollution controls or site incinerators to minimize ambient air concentrations and depositing of pollutants to soil, plants, etc.

Use appropriate PPE when handling incinerator ash and residues from burning (e.g., may contain sharps)

Bury incinerator ash/residues in pit using safe burial methods

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WASTE MANAGEMENT PLANIDENTIFYING OPTIONS/MITIGATION MEASURES

INCINERATOR WASTE

Comply with host country requirements and/or international agreements if exporting waste (e.g., Basel Convention or regional treaties)

Ensure drivers and other staff involved with transport are adequately trained and qualified

Vehicles and containers should be appropriate (e.g., closed and labelled) for waste transported

Regularly clean and maintain vehicles and containers used for transport

Maintain waste transportation and disposal records (i.e. consignment note)

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WASTE MANAGEMENT PLANIDENTIFYING OPTIONS/MITIGATION MEASURES

TRANSPORTING WASTE OFFSITE

Appropriate management and disposal techniques and costs

Transportation needs

Human capacity

Environmental monitoring and reporting

Record keeping on disposal quantity and types ensure appropriate fuel for incinerators and disposal receptacles

Use of SIMS as a reporting structure and to capture needs

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WASTE MANAGEMENT PLANBUDGETING FOR COSTS AND REPORTING

Use of protective gear (PPE); gloves, masks, gumboots, etc.

Waste management requirements (reference host country national standards when available or international standards if national standards are not available)

Standard Operating Procedures (SOPs)

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WASTE MANAGEMENT PLANTRAINING

Lack of understanding of the conditions in

the IEE

Need for SIEE or country IEE

Resistance to the conditions specified

Confusion over application of

CatEx

Lack of time Lack of waste quantity data

Lack of accountability

Shared responsibility*

Waste generation as in indirect

impact

Lack of performance indicators for health wastes

Lack of infrastructure

(functioning and funding)

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WHAT CHALLENGES DO YOU FACE IN EFFECTIVE MANAGEMENT AND MONITORING OF HEALTHCAREWASTES?

* For example: Working through host country governments or partner facility being responsible for waste

Guest Speaker: Wilkister Magangi

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DETAILED WASTE ASSESSMENTSKENYA CASE STUDY

POTENTIAL APPROACHES TO WASTE MANAGEMENT CHALLENGES

A. Gain participant buy in: meetings and workshops around HCWM to express knowledge and needs and facilitate a collaborative effort

B. Raise awareness: Assess quantity and type of wastes as well as treatment and disposal practices; share with partner facilities

C. Improve knowledge and skills: reduce, segregate, proper use of sharps, consider environmental friendliness of disposal, alternatives when necessary, record keeping and monitoring of temps

D. Ensure appropriate budget and supplies (when possible): budget lines, bundle safety boxes to immunization/syringe purchases; locally sources bins; ensure PPE is in place

E. Strengthen disposal systems: conduct pilots where USAID/partner has more control over the disposal management; provide TA to facilities, particularly those where final disposal takes place; ensure a trained disposal staff 23