assessment of unrwa’s healthcare waste management in …...of the healthcare waste management...

Assessment of UNRWA’s

healthcare waste management

in the North of the West Bank

Nuria Botella Mestres

June 2019

This publication has been funded by the Italian Cooperation within the Project «Integrated approach for

an improved solid waste management, environmental awareness and education in healthy eating for

refugees in Nour Shams and Tulkarem camps» AID 11264/CESVI/UNRWA/16.

The views expressed in this publication are those of the authors and do not necessarily reflect the views

or policies of the Italian Agency for Development Cooperation and the Consulate General of Italy in

Jerusalem.

The Italian Agency for Development Cooperation and the Consulate General of Italy in Jerusalem are not

responsible for any inaccurate or libelous information, or for the erroneous use of information.

Cesvi Palestine

Ata Al-Zir Street nr 15

Beit Hanina, East Jerusalem

Ph. +972 (0)2 5836677

Email [email protected]

www.cesvi.eu

AICS – Agenzia Italiana

per la Cooperazione allo Sviluppo

Sede di Gerusalemme

Mujeer Eddin Street, 2

Sheikh Jarrah - Jerusalem

Ph. +972 (0)2 5327447

https://gerusalemme.aics.gov.it/

Assessment of UNRWA’s healthcare waste management system in the North of the West Bank i

Cesvi Palestine- June 2019

Content

INTRODUCTION ............................................................................................................................................. 1

Background ............................................................................................................................................... 1

Objectives and scope of the study ............................................................................................................ 2

Methodology ............................................................................................................................................. 2

Definitions ................................................................................................................................................. 3

PART ONE: SITUATION ANALYSIS .................................................................................................................. 4

Section 1: Legal and regulatory framework .............................................................................................. 4

1. Analysis of the Palestinian regulation on healthcare waste management .................................. 4

2. Appraisal of UNRWA internal regulation on HCWM .................................................................... 6

Section 2: UNRWA healthcare facilities in the North of the WB .............................................................. 9

1. Location and type of existing healthcare facilities ........................................................................ 9

Section 3: HCW generation in UNRWA healthcare facilities ................................................................... 10

1. Type of HCW generated .............................................................................................................. 10

2. Estimation of generated quantities ............................................................................................ 11

Section 4: Characterization of the HCW management ........................................................................... 11

1. Segregation, packaging and labelling .......................................................................................... 12

a) In UNRWA Healthcare facilities ............................................................................................... 12

b) In Palestinian public healthcare facilities ................................................................................ 13

2. Collection, on-site transportation and storage ........................................................................... 14

a) In UNRWA Healthcare facilities ............................................................................................... 14

b) In Palestinian public healthcare facilities ................................................................................ 15

3. Treatment and disposal .............................................................................................................. 15

Section 5: Analysis of UNRWA capacities ............................................................................................... 16

1. Financial resources ...................................................................................................................... 16

2. Training and awareness of staff .................................................................................................. 16

a) Awareness ................................................................................................................................... 16

b) Training ....................................................................................................................................... 17

Section 6: Synthesis of the findings ........................................................................................................ 17

PART TWO: RECOMMENDATIONS .............................................................................................................. 18

Recommendations R1 – Establishing specific UNRWA HCWM regulations ....................................... 18

Recommendations R2 - Standardizing the HCWM Practices within UNRWA HCFs ............................ 18

Recommendations R3 - Strengthening UNRWA institutional capacities ............................................ 19

BIBLIOGRAPHY ............................................................................................................................................ 21

ANNEXES ..................................................................................................................................................... 21

Assessment of UNRWA’s healthcare waste management system in the North of the West Bank ii


List of acronyms

AICS Italian Agency for Development Cooperation (Agenzia Italiana per la Cooperazione allo

Sviluppo)

EQA Environmental Quality Authority

HC Health Center

HCF Healthcare Facility

HCW Healthcare Waste

HCWM Healthcare waste management

HDPE High Density Polyethylene

HP Health Point

HWM Hazardous Waste Management

MoH Ministry of Health

MoLG Ministry of Local Government

NGO Non-Governmental Organization

PE Polyethylene

PLO Palestinian Liberation Organization

PNA Palestinian National Authority

PPE Personal Protective Equipment

RAT Rapid Assessment Tool

UNRWA United Nations Relief and Works Agency

WB West Bank

WHO World Health Organization

Assessment of UNRWA’s healthcare waste management system in the North of the West Bank Page 1


INTRODUCTION

Improper management of healthcare waste has serious implications for public health and the

environment. Insufficient internal regulations for healthcare waste management have resulted in

increasing exposure to health risks of patients and medical and support staff in UNRWA healthcare

centers. Moreover, the lack of appropriate technologies and infrastructures for healthcare waste

treatment in the northern West Bank is having serious implications for the environment as untreated

hazardous healthcare waste is collected mixed with municipal waste and sent to the transfer station and

to the landfill.

Cesvi, in the framework of the project "Integrated approach for an improved solid waste management,

environmental awareness and education in healthy eating for refugees in Nur Shams and Tulkarem

camps" funded by the Italian Agency for Development Cooperation (AICS), decided to conduct a study on

healthcare waste management in the West Bank northern area. The aim is to provide a realistic framework

of the healthcare waste management situation inside and outside UNRWA structures.

The tasks included a two-week assessment, which took place in April 2019, and the redaction of

recommendations based on the collected data. This report presents the findings of the two-week

assessment carried out in the North of the West Bank.

Background

The northern area of the West Bank comprises the governorates of Tulkarem, Nablus, Jenin, Qalqiylia,

Tubas and Salfit, and has a total land area of 2,141 km2and an estimated population of 1,175,104

Palestinians.

For over 60 years, the UNRWA Health program has been delivering comprehensive primary health care

services, both preventive and curative, to Palestine refugees, and helping them access secondary and

tertiary health care services.

In the West Bank the health system is composed by four major health service providers: the Ministry of

Health (MoH), the United Nations Relief and Works Agency (UNRWA), non-governmental organizations

(NGOs), and private healthcare providers (for profit).

MoH UNRWA NGOs Private HC providers

Provides primary, secondary

and tertiary health services1

(purchases unavailable tertiary

services from domestic and

foreign providers)

Provides primary care

services only for

refugees, and purchases

secondary care services

for hardship cases

Provide primary,

secondary and some

tertiary services

Provide all three levels of

care through a variety of

specialized hospitals and

investigation centers

Table 1: Health system service providers in the West Bank (WHO, 2012).

The legal institutional framework governing the health sector is embodied in the Palestinian Basic Law

(2003) and the Public Health Law (2004). Accordingly, the MoH is the steward of the health system and is

responsible by law for overseeing the system and ensuring equitable and affordable access to quality

health services for all Palestinians (WHO 2012).

1 See the Definitions point in page 3 for definition of the different types of healthcare services.



Objectives and scope of the study

The aim of the present assessment is to provide a realistic picture of healthcare waste management -

starting from quantities and typologies produced up to disposal methods - inside and outside UNRWA

facilities, analyzing widespread practices in public and private health facilities and various disposal

options.

The study focuses on UNRWA health-care facilities in the governorates of Tulkarem, Jenin, Nablus, Tubas,

Salfit and Qalqilia. A comprehensive assessment of healthcare waste management in UNRWA facilities

was carried on. Some Palestinian public healthcare centers in the North of the West Bank were briefly

assessed in order to identify waste management practices and available disposal facilities for identifying

possible synergies.

Methodology

The study includes the identification and collection of primary and secondary data, including an analysis

of the available literature and a waste measurement campaign in UNRWA health care centers. To carry

out the healthcare waste management assessment, the Rapid Assessment Tool2 (RAT) developed by the

World Health Organization (WHO) was used. In each selected healthcare facility, a walkthrough visit took

place in order to collect information through direct observation. The assessment phase, carried out over

a period of two weeks, consisted in:

- Discussions with officials of the healthcare facilities as well as representatives of public institutions;

- Review of the existing documents obtained from UNRWA, healthcare facilities and MoH; - Visits paid in selected healthcare centers in the North of the West Bank, with systematic

discussions initiated with the medical and administrative staff.

Out of the 20 UNRWA healthcare facilities in the North of the WB, the following 7 facilities of different

sizes and year of construction were selected and assessed during the study:

- Balata HC (Nablus);

- Qalqilia HC (Qalqilia);

- Qalqilia Hospital (Qalqilia);

- Askar HC (Nablus);

- Camp1 HC (Nablus);

- Nur Shams HC (Tulkarem);

- Silat adh Dhahr HP (Jenin);

Regarding the Palestinian public HCF, after discussion with representatives of MoH, it has been decided

to include in the study two clinics from Nablus and Tulkarem governorates respectively. It was as well

foreseen to interview the representatives of two hospitals in both governorates, but special

authorizations was required and this mission did not manage to get it on time.

2 See in Annex 1 the WHO RAT set of questions formulated during the assessment.



Definitions3

Hazardous waste4: waste generated by the various activities and operations or the ash thereof, which

preserve the characteristics of hazardous substance which have no usage, such as atomic waste, medical

waste, or refuse emanating from the manufacturing of pharmaceutical products, medicines, organic

solvents, dyes, paints, pesticides or any other similar hazardous substance.

Healthcare waste: all the waste, hazardous or not, generated within healthcare facilities, research centers

and laboratories related to medical procedures;

General healthcare waste: HCW that does not pose any particular biological, chemical, radioactive or

physical hazard. It includes paper, cardboard, non-contaminated plastic or metal, cans or glass, food rests,

etc.

Sharps: are all objects and materials, infected or not, that pose a potential risk of injury due to their

puncture or cutting properties (e.g. syringes with needles, scalpels, blades, broken glass…).

Infectious waste: waste that may contain pathogens or their toxins in concentrations sufficient to cause

disease in susceptible hosts, such as equipment and tools used in the treatment and diagnosis and

prevention of diseases, which come in contact with body fluids and secretions like feces, urine, blood and

sputum.

Highly infectious waste: waste from medical laboratories like cultures and stocks of bacterial pathogens,

including body fluids of patients with highly infectious diseases such as cholera or typhus.

Pathological and anatomical waste: organs (including placentas), tissues and body parts and fluids such

as blood, whether infectious or non-infectious. This category of waste should be considered as infectious

whether they may be infected or not.

Pharmaceutical waste: drugs, antibiotics and vaccines and raw materials for the production and

preparation of pharmaceutical products and ointments that are expired or discarded for other reasons.

Not all the pharmaceutical wastes are hazardous.

Chemical waste: chemical substances, whether solid, liquid or gaseous, used for diagnosis, treatment or

testing, or resulting from the work of cleaning and sterilizing, which are characterized by one of these

qualities: toxic, corrosive, flammable or explosive.

Primary healthcare services: basic first level of contact between individuals and the health system. The

general practitioners, the family physician, the physiotherapist are the usual primary health care

providers. Immunization, basic curative care services, maternal and child health services, prevention of

diseases are examples of primary healthcare services.

Secondary healthcare services: services provided by medical specialists. They may not have first contact

with patients. Patients access these services through physician referral.

Tertiary healthcare services: specialized consultative healthcare for inpatients. The patients are admitted

on a referral from primary or secondary health professionals. Tertiary health care is provided in a facility

that have personnel and facilities for advanced medical investigation and treatment.

3 Definitions from “Safe management of wastes from health-care activities” second edition (WHO, 2014). 4 Definition from the Palestinian Environmental Law No7 of 1999.



PART ONE: SITUATION ANALYSIS

Section 1: Legal and regulatory framework

This section analyses the current legal framework for HCWM in Palestine as well as the rules that are

applied within UNRWA healthcare institutions.

It is important to remind that the legal provisions constitute the backbone for improving the management

of healthcare waste since it enables to:

- Determine official standard procedures and guidelines for healthcare waste management, which any health worker must refer to;

- Define clearly the duties and responsibilities of each actor involved in the management of healthcare waste;

- Set-up legal control of the healthcare waste management systems within the healthcare facilities.

1. Analysis of the Palestinian regulation on healthcare waste management

Since 1994 with the establishment of the Palestinian National Authority, the management of hazardous

waste, which includes healthcare waste, has been addressed through different laws and regulations.

In September 1995, the Oslo-II agreement was signed between Israel and Palestine Liberation

Organization (PLO), including an environmental chapter, which addressed amongst others hazardous

waste management.

In July 1999 the Palestinian Environmental Law was issued stating that the producers of hazardous waste

must comply with orders and directives of the Ministry of Environmental Affairs (now Environment Quality

Authority) in coordination with specialized agencies. However, these norms and regulations for hazardous

waste are not issued yet. The Environmental law forbids the import of hazardous waste and indicates that

transport of hazardous waste through the country can only be conducted with a special permit from EQA.

In 2002 was issued the Palestinian Basic Law, meant to function as a temporary Constitution for the

Palestinian Authority. This law identifies the right to a clean and a balanced environment as basic right of

every Palestinian and the preservation of the environment as a national duty.

In 2004 was issued Public Health Law, assigning to the Ministry of Health (MoH) the responsibility to issue

licenses to waste facilities, determine the health hazards that negatively affect public health or the

environmental health and to develop specifications and instructions with regards to the transport,

storage, treatment or disposal of hazardous materials and wastes.

In 2012 the Bylaw on Medical Waste Management was published establishing a detailed regulation for

healthcare waste management. The bylaw defined a deadline in 2014 for compliance of all institutions

with the bylaw, but the reality is that until now it has been only partially implemented in Hebron and

Bethlehem Governorates.

In 2018 the Solid Waste Management Bylaw established the obligation not to mix hazardous and non-

hazardous waste and to submit import of hazardous waste to the approval of competent authorities. It

also describes the duties and responsibilities of the MoH, in monitoring the separation, collection and

transportation of healthcare waste and those of EQA in terms of hazardous waste treatment approval.



According to the definition of hazardous waste in the Environmental Law 1999, HCW is hazardous waste.

The absence of precise technical specifications or classification of hazardous waste or a list of its sources

and the lack of information on this type of waste make it more difficult to determine its size and

consequently identify appropriate ways for its management and disposal (National Strategy for Solid

Waste Management, 2010).

Weaknesses in the Palestinian legal and institutional framework with regards to hazardous waste

management can be summarized as:

- Incomplete legislation;

- Weak political will to enforce regulations on hazardous waste management;

- Unclear roles and responsibilities of stakeholders.

In Tables 2 and 3 is presented an overview of all regulations on HWM and HCWM, and a summary of the

Medical Waste Management Bylaw (2012) content.

Regulatory

dispositive Year

Competent

body Foundation

Important

articles Scope

Oslo-II

agreement 1995

PNA and

Israel

government

Transfer of environmental powers and responsibilities

to the PNA in the environment sphere, including

hazardous waste management.

Art. 12 National

Environmen

tal Law 1999

MEnA

(now EQA)

Establishes the general legal framework for solid

waste management in Palestine. Defines hazardous

waste, the need to comply with regulations on

hazardous materials and waste, forbids the

importation of hazardous waste and establishes the

need of a permit for the waste passing thought.

Art. 1, 11,

12, 13, 29,

30

National

Basic Law 2002

PNA –

Palestinian

Legislative

Council

Identifies the right to a clean and a balanced

environment as basic right of every Palestinian and

the preservation of the environment as a national

duty.

Art.33 National

Public

Health Law 2004 MoH

Assigns licensing responsibilities for waste facilities to

the MoH,

Art. 2, 39,

42 National

Medical

waste

bylaw

2012 MoH

Regulates the management of medical waste for all

institutions involved in any stage of medical waste

management or medical waste generation.

All National

SWM

Bylaw 2018

EQA and

MoLG

Establishes the obligation to segregate hazardous

waste from non-hazardous waste and defines the role

of MoH in segregation, collection and transport of

medical waste and the role of EQA in the approval of

hazardous waste treatment.

Art.25,

26, 33, 34 National

Table 2: Overview of Palestinian legal framework in regard of hazardous and healthcare waste.

Medical Waste Handling and Management System Bylaw (2012)



Chapter 1

Definitions and

general provisions

Article 1 –definitions.

Article 2 – scope of the system.

Article 3 – sources of waste.

Article 4 – defines the need to issue further regulations for HCWM in remote areas.

Article 5 – identifies the roles and responsibilities of medical waste generators.

Article 6 – topics relevant to occupational health and safety.

Article 7 –approval of manuals for management of medical waste within each institution.

Article 8 – identifies the responsibility of the director of the institution.

Chapter 2

Types of waste

Article 9 – 12 – description, classification and characteristic of medical waste.

Chapter 3

Separation and

collection of waste

Article 13 - identifies procedures for separation of waste.

Article 14 – implementation of color code system for waste segregation.

Article 15 to 22 – identifies procedures for the collection of the following types of waste:

sharps, infectious, highly infectious, chemical and pharmaceutical, pathological,

radioactive, mixed and other waste.

Chapter 4

Transport and

storage of waste

within the facility

Article 23 – specifies General HCW collection in medical facilities.

Article 24 – identifies transport procedures of HCW within the institution.

Article 25 to 27 - identifies means of storage of different medical waste within the facility.

Chapter 5

Transfer of medical

waste outside the

facility

Article 28to 29 – identifies procedures, and responsibilities of transport of waste outside the

medical waste generator institution.

Articles 30 to 34 - defines preventive measures to be taken during transport, waste tracking,

specifications of transport equipment, special conditions and reporting prior to transport

and export of medical waste.

Chapter 6

Medical waste

treatment

Article 35– establishes the obligation of medical waste treatment.

Article 36 – defines the conditions for waste treatment within the generator’s facility.

Article 37 to 44 – defines the acceptable methods for medical waste treatment and the

responsibilities for waste treatment units outside medical facilities, and how to obtain

permits, and requirements for environmental approvals. Establishes polluter pays principle,

and that waste treatment fees shall be set by the waste treatment facility. Identification of

allowed locations for medical waste treatment should be specified by EQA in cooperation

with the Local authority.

Chapter 7

Medical waste

disposal

Article 45 to 47 – discusses the disposal of waste and the requirements for treatment prior

to disposal in sanitary landfills. Article 48 - specifies how to dispose of treated medical waste

in the case of non-availability of sanitary landfills.

Article 49 to 54 - identifies the types of wastewater that should be separated from regular

wastewater, and that needs separate treatment. Specifies various preventive measures to

be taken, and considers random disposal of medical wastewater as illegal act.

Chapter 8

Supervision and

inspection

Article 55 to 63 - specifies the roles and responsibilities of the various institutions in

monitoring and inspection, including the MoH, EQA, local authorities and the director of the

various institutions.

Article 64 - discusses information exchange.

Chapter 9

Emergency cases

Article 65 to 67 - discusses emergencies, plans of actions during emergencies, and how to

prevent disasters.

Chapter 10

Final provisions

Article 68 to 70 - discusses the various options punishments in case of lack of compliance,

including revoking of environmental approvals.

Table 3: Summary of the chapters and articles of the Medical Waste Management Bylaw (2012).

2. Appraisal of UNRWA internal regulation on HCWM



In order to properly manage waste in HCFs, good adequate instructions consigned in a formal document

are crucial to make the medical and support staff fully aware of their duties and responsibilities. UNRWA’s

internal rules for HCWM in healthcare facilities are established in the Technical Instruction (Series No.

HD/NC/96 revision No. 1/2010) for Infection Control Procedures at Primary Health Care. In Annex 2 are

presented the indications that refer to HCWM.

During the interviews and field visits, it could be observed that these rules are mainly respected by

UNRWA’s medical and support staff. However, UNRWA internal rules on HCWM need further

development in order to comply with Palestinian national regulations and minimum requirements

internationally accepted on HCWM. In the table below a comparison is made between both regulations.

HCWM

component Medical Waste Management Bylaw (2012)

UNRWA HCWM internal

regulations

Waste

segregation

Segregation of hazardous and non-hazardous medical waste.

Segregates general waste, sharps, infectious waste, highly

infectious waste, anatomical waste and pharmaceutical and

chemical waste.

Use of color code for waste segregation (black for general

waste, yellow for infectious and highly infectious waste, red for

anatomical waste and brown for pharmaceutical and chemical

waste).May not fill bags with more than 75% of their capacity.

Segregation of sharps.

General waste is mixed with

infectious waste.

Use of plastic bin liners (no

specific color code) for

collection of contaminated

and non-contaminated waste.

Use of safety puncture

resistant container for sharps.

Waste

handling

Full waste containers and bags cannot be accumulated at the

place of production, nor in corridors and lounges.

Full waste bags or containers cannot be transferred by hand

through the corridors to the storage area or treatment unit.

Need to use special devices to transport waste within the HCF.

Need to develop a plan for transportation of waste within the

HCF and assign this task to trained staff using proper PPE.

Waste collection staff should have access to storage areas.

Temporary storage areas should be made available in the HCF

(establishes the characteristics of storage areas and procedure).

Sealing of plastic bin liners

(when full or at the end of the

day) and place them into a

black garbage bag.

Sealing of safety boxes for

sharps (when full) and place

them into a black garbage

bag. Sealing of the black

plastic bag and disposal into a

public waste container.

Waste

transport

Waste transport out of the HCF should be done by authorized

institutions (with license) using transport documents to ensure

waste traceability.

Characteristics of specific transport vehicles for medical waste.

Monitoring Should keep record of: staff handling waste (annual number of

injuries, training, health certificates and the results of periodic

medical examinations, vaccination), quantities of waste

generated and how were they disposed after treatment.

Treatment Obligation of treatment of medical waste (on-site or off-site).

Highly infectious waste (laboratory) should have a preliminary

treatment in the HCF (evaporation, chemical or cold

treatment).

Treatment methods: steam sterilization (autoclave), chemical

treatment, heat treatment, microwave and incineration.

Burning of waste not allowed

Final

disposal

Prohibition to dispose untreated medical waste. Need to use

landfill adapted for medical waste disposal.

In accordance with national

rules and regulations

Table 4: Comparison of UNRWA internal HCWM rules with Palestinian national regulation on healthcare waste

management.



Duties and responsibilities for HCWM are well defined in UNRWA’s internal regulation (see Table 5). In

the healthcare facilities the HCWM responsibility is shared between the (Senior) Medical Officer, who is

directly in charge of the overall implementation of HCWM rules and the Senior Staff Nurse, who has the

responsibility to supervise the auxiliary and nursing staff and ensures healthcare waste is properly

managed.

However, duties and responsibilities of UNRWA staff in regard of HCWM will have to be reviewed and

further developed once UNRWA internal regulation are updated to meet the minimum requirements

internationally accepted on HCWM and standards of the Palestinian regulations.

Although not mentioned in UNRWA´s internal procedures for HCWM, at area level UNRWA has specific

staff in charge of supervising HCWM, the Area Health Officer and the Area Nursing Officer.

Position Duties and responsibilities

Headquarter level

Chief Medical Care Services Coordinates the establishment of Field Infection Control Committee.

Coordinates the implementation of internal HCWM rules.

Field level

Chief Field Health Program Establishes the Field Infection Control Committee.

Field Infection Control Committee:

Deputy Chief Field Health Program

(chairperson)

Field Family Health Officer

Field Disease Control Officer

Field Nursing Officer

Field Laboratory Services Officer

Field Pharmaceutical Service Officer

Field Oral Health Services Officer

Assesses training needs of the staff and provide training;

Supervises, monitors and evaluates the implementation of infection

control procedures;

Ensures the quality of services provided for all general medical and

nursing procedures undertaken in the health centers;

Provides adequate supplies in their fields to ensure proper

implementation of effective infection control procedures;

Establishes the Infection Control Team at HC level.

Area level

Area Health Officer, Area Nursing

Officer

Supervises, monitors and evaluates the implementation of infection

control procedures;

Ensures the quality of services provided for all general medical and

nursing procedures undertaken in the health centers;

Provides adequate supplies in their Areas to ensure proper

implementation of effective infection control procedures;

Follow up the Infection Control Team at HC level

Camp level

(Senior) Medical Officer in charge of

the HCF (head of the HC Infection

Control Team)

Has the overall responsibility for the organization and management

of the services provided from Treatment Rooms.

Ensures that staff are adequately trained and effectively supervised.

Senior Staff Nurse (member of the HC

Infection Control Team)

Ensures the quality of care provided in the Treatment Rooms.

Supervises and provides on the job training to auxiliary and nursing

staff.

Ensures proper disposal of all waste, contaminated or not.

Dental surgeons and laboratory

technicians

Responsible for maintaining infection control procedures in their

respective units

Table 5: Current duties and responsibilities of UNRWA staff in regard of HCWM at different levels.



Section 2: UNRWA healthcare facilities in the North of the WB

1. Location and type of existing healthcare facilities

UNRWA has 20 HCF that provide services to a total population of 450,288 refugees registered in the North

of the West Bank: one hospital in Qalqiliya, 9 healthcare centers and 10 healthcare points distributed

among the different governorates. In 2018 a total of 483,302 consultations were delivered and 186,788

persons benefited from UNRWA healthcare services in the North of the WB. In Annex 3 is presented a list

of all UNRWA facilities providing healthcare services in the North of the WB.

Following healthcare primary services are provided in UNRWA health centers and points:

Curative Services Disease prevention and

control

Reproductive health

services

Community Mental

Health

- Outpatient care services

- Hospital referral

- Oral health (only in

HCs)

- Dispensing pharmacy

- Laboratory services

- Communicable and Non-Communicable

Disease services

- Immunization

- Child health services

- School health program

- Antenatal care

- Preconception care

- Postnatal care

- Family planning

- Family & child protection

- Psychosocial

counselling

Table 6: Healthcare services provided in UNRWA Health Centers and Health Points.



Section 3: HCW generation in UNRWA healthcare facilities

It’s important to have good estimations on the amounts of HCW generated and its typology in order to

develop efficient HCWM plans, take the appropriate technical decisions for waste segregation, collection,

treatment and disposal, and produce reliable cost estimations. For each HCF, the level of waste production

depends on its size and its level of activity. These two parameters can be estimated knowing the number

of beds, the average daily occupancy rate and the number of out-patients treated in the HCF.

1. Type of HCW generated

Following categories of HCW are

generated in the different types of

UNRWA Healthcare facilities:

- General waste: made of all wastes that are not contaminated with

infectious or pathogen agents

(food residues, paper, cardboard

and plastic wrapping);

- Sharps: manly auto-disable or disposal (single use) syringes, and

other sharp materials like broken glass from vaccine vials;

- Infectious waste: materials contaminated with body fluids (dressings, cotton, gloves contaminated with blood, urine, etc.);

- Highly infectious waste: culture kits from laboratory. Discarded after treatment within the laboratory.

- Pharmaceutical waste: consisting in outdated drugs. This is specifically managed and disposed of with strict control from UNRWA field level.

- Chemical waste: produced in very small quantities are mainly used as reagent in the laboratory and in the dental care service.

- Anatomical waste: made of body parts, tissues and fluids.

In UNRWA HCFs different types of waste are generated in the various healthcare units, as it is shown in

the table below.

Type of waste materials generated Lab Dental

services

Dressing

room

Vaccina-

tion

Family

Planning

Phar-

macy

X-Ray

unit

Human body tissues, parts and fluids

(blood, urine, sputum, stool, teeth) X X X

Sharps (syringes, opened vaccine vials) X X X X X

Culture kits X

Chemicals and reagents (mercury-

amalgam, silver, lead, etc.) X X X X X

Blood-soaked dressings, gloves, masks

and cotton X X X X X X

Drugs (emergency drugs, expired

vaccines) X X X

Table 8: Types of waste generated in UNRWA healthcare units.

Waste category Hospital Health Center Health Point

General waste X X X

Sharps X X X

Infectious waste X X X

Highly infectious waste X X

Pharmaceutical waste X X X

Chemical waste X X

Anatomical waste X

Table 7: Types of healthcare waste generated in UNRWA HCF.



2. Estimation of generated quantities5

UNRWA HCFs do not keep record of the amounts of HCW generated. However, a measurement campaign

was carried on during 7 consecutive days in 3 UNRWA HCs in order to estimate the amounts of healthcare

waste generated (see in Annex 4 the results obtained). Since in UNRWA facilities only sharps are properly

segregated from the rest of the waste, the measurement campaign could only estimate the generated

amounts of sharps and mixed waste. Further measurement campaigns are needed to assess the quantities

of all different types of waste generated in UNRWA HCFs.

According to the collected data, for each outpatient 0.0033 Kg of sharps and 0.0422 Kg of mixed

healthcare waste (hazardous and non-hazardous) is generated in average. Total average amount of HCW

generation per outpatient has been estimated in 0.0455 Kg. Taking into account this, if we only consider

the waste generated by outpatients (483,302 outpatients in 2018), in 2018 a total amount of 21.99 tons

of healthcare waste were generated in UNRWA HCF in the North of the West Bank.

For the estimation of waste generation in the only hospital that UNRWA has in the WB, with 63 beds and

an average bed occupancy of 55%, it has been considered as valid the estimation done by the HCWM

Master Plan (2005) that established a generation rate for hospitals in the WB of 1.29 Kg/bed*day. Taking

into account these data, the HCW generated in the hospital has been estimated in 16.31 ton/year.

Therefore, if we consider all UNRWA HCF in the North of the WB (Health Centers, Health Points and the

Hospital), the total amount of waste generated in a year is 38.30 ton/year.

According to the WHO6 between 75% and 90% of the waste generated in healthcare facilities is non-

hazardous waste. Therefore, out of the estimated 38.30 ton/year of waste generated in UNRWA HCF,

between 9.58 ton/year and 3.83 ton/year are hazardous healthcare waste that would need to be treated

before disposal.

Section 4: Characterization of the HCW

management

HCWM is an integral part of healthcare

facility’s hygiene and infection prevention

and control as infectious HCW contributes to

nosocomial infections, putting the health of

medical staff and patients at risk. Proper

HCWM practices should therefore be strictly

followed.

The HCW that is generated within a HCF

should always follow an appropriate and

well-defined flow from its generation until its

final disposal. This flow is composed of several

steps that include: generation, segregation, collection and on-site transportation, on-site storage, offsite

5 Further measurement campaigns should be carried on to confirm the results obtained, as some of the

measurement campaigns were done during Ramadan period, when the number of patients decreses (specially for

dental services, laboratory and family planning services). 6 “Safe management of wastes from health-care activities” second edition (WHO, 2014).

Figure 1: HCWM flow chart.



transportation (if needed) and finally on- or off-site treatment and disposal (Figure 1).

1. Segregation, packaging and labeling

Segregation at source of hazardous and non-hazardous waste is one of the most important steps in

HCWM. It consists in separating the different types of waste based on its hazardous properties and the

type of treatment and disposal methods that will be used.

Considering that only about 25 – 10 % of the HCW is hazardous, proper segregation will greatly contribute

to reduce treatment and disposal costs, once the treatment will mandatory, as well as reducing the risks

of infection for workers handling HCW.

a) In UNRWA Healthcare facilities

In the healthcare facilities visited during the assessment HCW is segregated at the source into only two

main categories, as it is established in UNRWA internal regulations, sharps and all the rest of waste

(hazardous and non-hazardous). Therefore, segregation is not carried out according to international

standards, as a part from sharps, other hazardous waste is mixed with non-hazardous waste in the medical

units. The three bin system recommended by the WHO is not implemented in UNRWA HCFs.

Another problem identified is that due to the absence of adequate treatment facilities in the North of the

West Bank, segregation fails to be maintained all along the waste stream and UNRWA sharps’ safety boxes

can be found in the domestic waste stream, as they are collected by municipal compactor trucks outside

the healthcare facilities or sent first to the MoH7 and finally disposed at the municipal transfer stations to

be transferred to the landfill.

The wastes produced within UNRWA healthcare facilities are generally segregated as follows:

- General waste, infectious waste and anatomical waste (in the hospital)are collected together into a variety of plastic rubbish bins of different sizes lined with PE black bags (Image 1 and 2), that may be

covered with a lid or not. These containers, located at strategic points inside or outside the medical

units, are not lined with adequate yellow leak proof bags.

- Sharps are collected using puncture-proofed single use safety boxes made out of plastic or cardboard (Image 4);

7 In Nablus governorate UNRWA has an agreement with the MoH for centralized collection of sharp safety boxes.

Image 1: Lidded waste bin for mixed waste collection

outside medical unit in UNRWA Balata HC. Image 2: Different types of unlidded waste bins in

medical unit in UNRWA Qalqilyia Hospital.



- Pharmaceutical waste follows a totally separate waste stream from the other categories of waste. Expired drugs are sent to UNRWA field level for disposal;

- Highly infectious waste produced in laboratories is set aside (Image 3) and pre-treated before

disposal. The pre-treatment consists in sterilizing (autoclaving) the material directly in the laboratory.

b) In Palestinian public healthcare facilities

In the Palestinian public healthcare facilities, HCW is segregated at the source into three main categories,

which is a very positive aspect. However, there is an obvious lack of equipment (color-coded waste

containers and PE bags), as it has been directly observed and reported by the interviewed persons, that

jeopardizes the attempts to apply the national HCWM regulation and the WHO recommended three-bins

system (Image 5 and 6). Consequently, segregation is not carried out according to international standards.

The absence of adequate treatment facilities in the North of the WB does not allow segregation efforts to

be maintained all along the waste stream.

Image 4: Cardboard and plastic sharp box used in

UNRWA HCF (UNRWA Nur Shams HC).

Image 3: Highly infectious waste from laboratory

collected in special bags for autoclaving in UNRWA

Qalqilyia Hospital.

Image 6: Three-bin system with color-code for HCW

segregation in MoH Tulkarem clinic.

Image 5: Sharp safety box used in MoH Balata al Balat

clinic in Nablus.



2. Collection, on-site transportation and storage

Waste should be collected on a regular basis to avoid its accumulation in the medical units. It should be

transported to a storage area within the HCF before it’s sent for treatment and disposal. Hazardous and

non-hazardous HCW should not be stored in the same area in order to avoid cross-contamination.

Collection routes within the HCF should be defined to minimize the passage of waste collection devices

through the medical units. When handling HCW, sanitary staff and cleaners should always wear protective

clothing including, as a minimum, overalls or industrial aprons, boots and heavy duty gloves.

a) In UNRWA Healthcare facilities

The way the collection and on-site transportation of HCW is organized depends on the type of HCF and

the available human resources. In UNRWA HCFs cleaners are in charge of this duty and one to two

collections per day are normally scheduled (morning and afternoon) depending on the size of the HCF.

The following has been noticed during the visits to UNRWA HCFs:

- Waste handling is performed in most of UNRWA HCF by hand without the use of any kind of device for on-site waste transportation. Cleaners use bigger and stronger black PE plastic bags to collect the

waste bins liners in each medical unit. Only in two HCFs barrels (Image 8) or plastic bins of 120 L are

used for transporting waste within the HCF.

- HCFs lack of proper onsite storage containers for HCW. Most of the HCF do not have a storage area for HCW (only Balata HC used the cleaner room as temporary storage). Waste is accumulated in

corridors or right outside the HCF before its disposal (Image 7) into municipal waste containers which

are located in the streets. Most of these containers have no protection against animals.

- Cleaners are not properly protected during waste handling. Personal protective equipment such as heavy duty-gloves, aprons or overalls and boots are not available. Cleaners use in some cases medical

gloves and perform their work dressed with street clothes.

- In some cases, there are not enough cleaners assigned to the HCF and sometimes when the only cleaner is on leave nurses have to transport and drop off the waste directly to the disposal points.

This practice should be avoided, as it could increase the risk of spreading infections once back in the

medical units.

- In UNRWA HCFs located in Nablus governorate sharp safety boxes follow a different path than the rest of HCW. Sharp boxes are first accumulated in the medical units and twice a week sent to the MoH

Balata al Balat Clinic, where they are collected in a special container outside the facility (Image 10).

These containers are served with municipal vehicles and the HCW sent to the municipal transfer

station and finally to the landfill.

- In most of the cases, HCW is disposed in municipal containers and mixed with general municipal waste (In Nur Shams HC and Tulkarem HC waste is disposed in UNRWA containers). HCFs do not have special

containers for off-site transportation.

- HCW is transported in the municipal waste vehicles that are not specially designed for HCW transport (open refuse vans or compactors) and do not engage in management practices suited for HCW.



b) In Palestinian public healthcare facilities

In Palestinian healthcare facilities the way the collection and on-site transportation of HCW is organized,

is basically the same as in UNRWA HCFs, presenting similar problems and difficulties.

In Tulkarem MoH clinics HCW is segregated in the medical units but hazardous and non-hazardous waste

is handled together during the collection and on-site transportation as HCW is disposed directly in

municipal containers (1,100 L) outside the HCF and mixed with municipal waste.

In Nablus MoH clinics efforts are done to keep waste segregation and a special waste container for

hazardous HCW is installed outside of MoH Balata al Balat Clinic (Image 10). This container was supposed

to be served by a skip-loader truck designated exclusively for HCW collection. However, the truck is out

of duty and the container is currently serviced by a municipal waste mini-compactor truck, that unable to

load the container’s content, forces the municipal workers to carry on this operation by hand. In both

cases, MoH clinics in Tulkarem and Nablus, hazardous HCW is stored in inappropriate places outside the

HCF where the general population has free access to hazardous HCW (Images 9 & 10).

3. Treatment and disposal

Image 7: HCW accumulated at the entrance of Balata HC

before disposal. Image 8: Barrel used for on-site handling of waste at

Balata HC.

Image 10: HCW container outside MoH Balata al Balat Clinic

in Nablus.

Image 9: HCW storage at the entrance of MoH

Tulkarem clinic.



In the past, UNRWA HCFs use to incinerate hazardous healthcare waste. However, the inappropriate

conditions in which this process took place generated a lot of inconveniences to camp population. To date,

burning of HCW is no longer allowed at UNRWA HCFs. Currently, landfilling of HCW without prior

treatment8 is the disposal method applied by UNRWA and Palestinian Public HCFs in the North of the WB.

Some of the technologies internationally recognized and accepted in Palestine for treating hazardous

HCW are:

- Incineration in rotary kilns or double chamber incinerators;

- Burning in single chamber incinerators;

- Wet thermal treatment (autoclaving);

- Chemical disinfection;

- Microwave irradiation;

- Sanitary landfill, including inertization and encapsulation.

In Hebron there is a HCW treatment facility operative since 2014 that provides services to the South

governorates and is based on microwave irradiation technology. The capacity of Hebron medical

treatment facility is 110 kg/hour, and it treats about 700 kg/day, giving service to 150 medical institutions.

However, in the North of the WB none of the above technologies for HCW treatment are applied due to

funding limitations. None of the HCFs visited has the necessary equipment for on-site treatment of

hazardous HCW. The current disposal of HCW in the absence of adequate financial means and treatment

facilities is problematic and will certainly remain so in the coming years as long as a proper treatment

facility is not set-up to provide services to the HCFs in the North of the WB.

The following specific practices have been observed:

- Highly infectious waste is pre-treated in the microbiological laboratories (autoclaving) before being disposed of together with general waste. The systematic pre-treatment of this category of waste in

most of the HCF that have a Laboratory is a good practice.

- Pharmaceutical waste is managed separately from the other categories of HCW.

Section 5: Analysis of UNRWA capacities

1. Financial resources

UNRWA funds expended for HCWM are managed at field level in a totally centralized manner. Although

not having a specific budget allocated for HCWM, UNRWA healthcare facilities are provided regularly with

the necessary materials to manage HCW according to UNRWA internal technical instructions. Some of the

provided materials are: safety boxes for sharps, waste bins and plastic liners, personal protective

equipment and materials for disinfection and sterilization. None of the assessed HCFs has reported having

shortages of sharps safety boxes.

2. Training and awareness of staff

a) Awareness

8 Except for highly infectious waste from laboratories that is treated through sterilization (autoclaving).



The level of awareness is a key element when introducing changes and improvements. All UNRWA staff

interviewed during the assessment is fully aware of the public health and environmental risks associated

with inappropriate HCWM. However, more attention should be given to the awareness level of the

workers directly handling the waste (cleaners and auxiliary staff). These workers are very much exposed

to the risks of HCW and often perform their work without the necessary hygienic measures. This is not

only due to their lack of awareness but also to the lack of improved and more detailed instructions in how

to organize and perform their work. Examples of it would be the poor organization of collection and on-

site transportation of HCW within the HCF (waste accumulated on HCF corridors and entrances before

disposal, lack of containers for on-site storage of HCW, work without using the minimum PPE, etc.).

b) Training

All UNRWA staff interviewed during the assessment had attended to an infection control training at least

once. Aside from the fact that the current technical instructions for infection control, where HCWM is

partially addressed, are insufficient and need to be reviewed and improved, the training based on those

instructions is not provided regularly to all the staff. Moreover, while in the UNRWA technical instructions

on infection control is define that the Senior Staff Nurse is in charge of providing on the job training to

auxiliary and nursing staff, it’s unclear who is in charge of providing this type of training to medical staff.

Section 6: Synthesis of the findings

UNRWA internal regulations on HCWM do not comply with the Palestinian National regulations. Currently,

the local authorities are being permissive with how HCW is being managed by HCFs in the northern

governorates, due to the lack of HCW treatment facilities. However, the construction of a HCW treatment

facility in the northern governorates is an objective of Palestinian competent authorities and the

enforcement of national regulations will be subsequently a priority. There is a need to review UNRWA

internal regulations in order to comply with Palestinian regulations, as the HCW of UNRWA institutions

needs of Palestinian facilities for treatment and disposal.

In the absence of treatment facilities in the north governorates of the WB, hazardous healthcare waste,

except for sharps, is mixed with non-hazardous waste systematically in UNRWA healthcare facilities and

all HCW is disposed of with the municipal waste. There is an urgent need to implement proper HCW

segregation measures and to build up adequate treatment and disposal facilities.

UNRWA medical staff received training on infection control and has a good perception of the degree of

hazard associated with HCW. However, more attention should be given to the training and awareness of

the staff handling directly the waste (cleaners). Furthermore, the current practices in UNRWAHCF result

in public health risks. The hygiene conditions linked to HCW handling and disposal cannot guarantee a

satisfactory control on the transmission of nosocomial infections throughout the HCFs.



PART TWO: RECOMMENDATIONS

The Palestinian Authority should take action to address the lack of a treatment facility for HCW. It is urgent

to establish a health care waste management facility in the North of the West Bank. However, this part of

the report presents the different actions that UNRWA should implement to establish HCWM procedures

that are more in accordance with the international standards.

Recommendations R1 – Establishing specific UNRWA HCWM regulations

R1.1 – Formulating in a separate document UNRWA HCWM regulations.

We recommend to formulate in a separate document clear UNRWA guidelines for the management of

HCW that could be sent to all HCFs as a guidance manual. They should be practical, applicable and include

the minimum obligatory procedures for the safe management of HCW. In addition, it could be worthwhile

editing the Technical Instructions for Infection Control, in which the management of HCW could be

specifically and comprehensively addressed.

R1.2–Developing HCWM basic plans for each UNRWA HCF.

Each UNRWA HCF should have a clear HCWM plan where it is established how UNRWA HCWM guidelines

will be implemented in that particular HCF. The plan should clearly define the duties and responsibilities

of all members of staff in respect of the handling of healthcare waste. In Annex 5 is presented a possible

structure for the content of such HCWM plans for HCF.

R1.3 – Monitoring and harmonizing the HCWM Plans established in each UNRWA HCF.

The HCWM plans to be established in each HCF should be systematically verified and amended by UNRWA

before its implementation. It would be necessary that UNRWA provides step-by-step Guidelines and

centralizes the HCWM plans of each HCF to monitor in a more efficient way their application.

Recommendations R2 - Standardizing the HCWM Practices within UNRWA HCFs

R2.1 - Setting-up a three-bin system

The segregation and the safe packaging of HCW is crucial to ensure safe manipulation and appropriate

disposal of HCW, optimize the treatment and disposal procedures for each category of waste and reduce

the costs linked to the treatment and the disposal of HCW.

We recommend to set-up standardized segregation procedures by introducing the three-bin system with

color coding, as it is currently in use in Palestinian public HCFs.

Hazardous HCW (yellow) Sharps (safety box) General HCW (black)

Gloves, masks, dressings, swabs, spatulas

contaminated with blood or body fluids.

Urine and blood bags, suction canisters,

intravenous lines.

Pre-treated highly infectious waste from

medical laboratories, isolation wards.

Are considered as potentially infectious

waste but are managed separately for

technical reasons: Human tissue placentas,

body parts.

Syringes, lancets,

scalpels, blades, scissors,

broken glass, ampoules,

intravenous catheter,

glass slides, cover slips

Gloves, masks, dressings, swabs,

spatulas non-contaminated with

blood nor body fluids.

Sanitary napkins, incontinence

pads (except in isolation wards).

Packages, boxes, wrappings,

newspapers, disposable food

utensils, food rests.



Table 9: Three-bin segregation system.

R2.2: Setting-up the Black – Yellow International Color Coding System

A standardized color coding system aims at ensuring an immediate and non-equivocal identification of

the hazards associated with the type of HCW that is handled or treated. The internationally recognized

colors already mentioned in the Palestinian national regulation should be applied in UNRWA HCF:

- Black: for all bins and bags filled with general HCW;

- Yellow: for all bins and bags filled with hazardous HCW.

R2.3: Preferring standardized bag-holders to waste bins

We recommend to progressively replace the various types of plastic bins used within the HCFs with bag-

holders using 50 to 80liters yellow PE bags (respectively black) for hazardous (respectively general waste)

HCW. The standardization of the different waste bags in all HCFs (size and color) should facilitate the

planning activities at UNRWA field level.

R2.4: Setting-up hygienic on-site collection and transportation procedures

In all UNRWA HCFs, we recommend to:

- Use wheeled 240L o 120 L HDPE containers of different colors (with a lid) for temporary storage of HCW and sharps inside the HCFs. These containers could also be used for off-site

transportation.

- Store temporarily filled-up yellow and black waste bags in separate containers so as to avoid mistakes, away from patient areas;

- Precise the schedule for the collection of waste and containers from each medical unit in order to ensure the regular removal of waste from each location, at least once a day. All waste should be

disposed of within a maximum of 48 hours.

- Set-up separate schedules and separate collection times for black and yellow bags (once a treatment facility for HCW will be available);

- Ensure that the cleaners and waste collectors wear protective clothes when they handle waste, at least, heavy-duty gloves, industrial boots and an overall.

We recommend to create when possible (e.g. construction of new HCFs or rehabilitation and upgrade

works of old HCFs) central storage points in the HCFs for the two types of waste (hazardous and non-

hazardous). They should be geographically separated within the HCF ground in order to: avoid

contamination of non-hazardous HCW waste and facilitate the collection of both wastes that will go to

different treatment/disposal facilities. Above all, the wastes should be stored in such a way that they are

protected from the effects of the weather and from the scavenging of animals and insects.

Recommendations R3 - Strengthening UNRWA institutional capacities

R3.1 - Setting-up adequate monitoring procedures

The following parameters should be monitored by the Senior Staff Nurse in charge of the HCWM within

HCFs and reported to UNRWA Field level for analysis of the data:

- Quantity of waste generated each month, by waste category (in each medical unit);

- Supplies and materials used for collection, transport and storage as well as decontamination and cleaning;

- Incidents resulting in injury or failures in the handling, separation, storage or transport system



(including spillages of HCW).

R3.2 – Improved capacity building

Training is a critical issue and its overall aim is to develop awareness of the health, safety and

environmental issues relating to HCWM. Once UNRWA HCWM Guidelines are established and appropriate

means are made available, a training package should be developed by UNRWA.

Training materials should focus on the health risks associated with HCW; the adequate management

systems, and the duties and responsibilities of healthcare workers. They should be well illustrated with

drawings and diagrams. All procedures should be carefully represented in diagrams and photographs.

Specific on the job training programs on HCWM should be organized for HCF staff including administration

services, nurses, medical doctors and technical services. Initial HCWM briefings should be systematically

organized for new healthcare workers recruited in the HCFs.



BIBLIOGRAPHY

Birzeit, 2006: Hazardous Waste Management in the West Bank and Gaza Strip.

EQA, 2005: Master Plan for Healthcare Waste Management West Bank/Gaza Strip.

MoH, 2017: Health Annual Report. Palestine 2016

UNRWA, 2010: Technical Instruction (Series No. HD/NC/96 revision No. 1/2010) for Infection Control

Procedures at Primary Health Care.

WHO, 2012: Health System Profile - Occupied Palestinian Territory.

WHO, 1999: Safe management from wastes of health-care activities.

WHO, 2017: Safe management of wastes from health‑care activities. A summary.

ANNEXES

Annex 1 – Set of questions from WHO RAT formulated during interviews at HCFs.

Annex 2 - UNRWA internal regulation on HCWM

Annex 3 - UNRWA healthcare facilities in the North of the West Bank

Annex 4 – Healthcare waste measurement campaign in UNRWA HCFs.

Annex 5 – Content structure of a HCWM Plan for HCF

Annex 6 – Images of HCWM current practices in UNRWA HCFs



Annex 1 – Set of questions from WHO RAT formulated during interviews at HCFs.

Healthcare waste management • data collection

Inventory of all B, C and D questions

n° topic question type data comments / multiple choice B1 B2 C D1 D2 D3 D4

2 healthcare facility (HCF)

200 HCF which category is it (are they) ? C

[1] small (ambulant service); [2] medium ((sub-)district hospital);

[3] large hospital x

201 HCF which type is it (are they) ? C [1] public; [2] private x

202 HCFs could I obtain a list of all HCFs in the country ? T if possible by category & type (Nbr. bed), by locality / district x

204 bed capacity how many beds do you have in total ? N x

205 occupancy what is the average bed occupancy ? N x

206 outpatients how many outpatients come each day on average? N x

3 staff

300 medical staff training is training of med. staff available regarding HCWM ? B if yes, what kind of training is given? x x

301 staff for HCWM

a responsible person for HCWM is identified and

operational C

[0] not identified; [1] planned; [2] identified but not operational; [3]

operational x x

302 training responsible of HCWM what kind of training has this person followed ? T x x

303 staff for HCW awareness awareness of risks of person(s) handling HCW ? Q x

304 hepatitis B and tetanus do you vaccinate your personnel against them ? B x

306 medical staff training Is the participation in the trainings documented? B Please provide participation sheets x

307 staff training on monitoring staff is trained on monitoring and supervising of HCWM B x

4 HCW generation

400 HCW kinds which kind of waste is generated in the HCF C

[1] general, [2] recyclables, [3] radioactive, [4] infectious, [5]

sharps; [6] chemicals (liquid and solid); [7] pharmaceutical

waste; [8] anatomic waste; x

401 domestic waste quantity produced/day (estimated, in kg) N x

402 sharps quantity prod/day (in kg or number of sharps boxes) N x

403 infectious (non-sharp) waste quantity produced/day (estimated, in kg) N x

404 anatomic waste quantity produced/day (estimated, in kg) N x

405 pharmaceutical waste quantity produced/day (estimated, in kg) N x

406 chemicals (liquid and solid) quantity produced/day (estimated, in litres) N x

407 radioactive waste quantity produced/day (estimated, in kg) N x

408 number of injections performed how many are done in average per day ? N x

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5 HCW segregation & handling ask to be allowed to take photos of the system !

500 segregation categories into which categories are HCW separated ? C

[0] no segregation, [1] general, [2] recyclables, [3] radioactive, [4]

infectious, [5] sharps; [6] chemicals (liquid and solid); [7]

pharmaceutical waste; [8] anatomic waste;

x

501 needle stick injuries how many cases reported in the past 12 months ? N if yes, what measure do you take when it happens? x

502 type of syringes used what type of syringes do you use? C [0] disposable; [1] sterilisable; [2] auto-disable; [3] safety syringe x

503 protective equipment

sufficient personal protective equipment for the handling of

waste is available B Yes / No x

504 segregation proper segregation of waste is: N

[0] non-existent; [1] bad (low); [2] insufficient; [3] satisfactory; [4]

good; [5] excellent (high) x

505 Handling safe handling of waste is: N



6 HCW handling equipment ask to be allowed to take photos of the system !

600 infectious waste containers what kind of specific containers do you use ? C[0] no specific container;

[1] plastic; [2] metallic; [3] cardboard; [4] bag; [5] box; [6] otherx

601 sharp containers what kind of specific containers do you use ? C

[0] no specific container; [1] puncture-proofed single use; [2]

puncture-proofed multiple use, [3] not puncture-proof single use;

[4] not puncture-proof multiple use

x

602 shortage of sharps containers for what reasons are there shortages, if any ? C [0] no shortages; [1] budget; [2] logistical; [3] other (specify) x

603 colour coding do you have a specific colour coding system ? B x x

604 infectious waste containers infectious waste container are lidded B x

605 Equipment

sufficient equipment for proper HCWM is available and

properly used C

[0] not available; [1] partly available; [2] widely available; [3]

available and properly used . x

7 HCW storage area ask to be allowed to take photos of the system !

700 storage area do you have a specific area for HCW ? B x

701 storage area access Is the area only accessible for authorised pers. B x

702 storage area organisation are different waste kinds stored in separated storage areas? B x

8 HCW collection & on-site transportask to be allowed to take photos of the system !

800 Collection and transport is hazardous and non-hazardous waste collected and transported separately?B x

801 HCW on-site transport what kind of means do you use ? C [0] open device; [1] closed device; [2] other (specify) x

802 HCW collection & on-site trans. do you think current practices offer enough security? B x

9 HCW off-site transport ask to be allowed to take photos of the system !

900 transport services are there any transport documents used? C [0] none; [1] transport form; [2] other (specify) x x x

901 type of transport who generally transports hazardous healthcare waste C [0] the HCF; [1] municipal service; [2] private company (name ?) x x



10 HCW treatment ask to be allowed to take photos of the system !

1000 type of on-site HCW treatment syst.which kind of system is used ? C [0] none; [1] open fire; [2] incinerator; [3] chem. disinf.; [4] other x

1001 capacity of HCW treatment syst. what is the current capacity of the system(s) ? N in kg/day x

1002 operation HCW treatment syst. any operation problems; if so for what reasons ? C [0] none; [1] money; [2] maintenance; [3] spare-parts; [4] other x

1003 failure of HCW treatment syst. what do you do when it doesn't function ? T x

1004 domestic waste is it treated on-site or off-site? C

[0] no treatment; [1] on-site; [2] off-site (which treatment

technology is used) x x x

1005 sharps is it treated on-site or off-site? C


technology is used) x x

1006 infectious (non-sharp) waste is it treated on-site or off-site? C



1007 anatomic waste is it treated on-site or off-site? C



1008 pharmaceutical waste is it treated on-site or off-site? C



1009 chemicals (liquid and solid) is it treated on-site or off-site? C



1010 waste recycling is it treated on-site or off-site? C



1011 on-site treatment is general waste treated on-site? B if yes, which treatment technologies are used? x

1012 on-site treatment is hazardous waste treated on-site? B if yes, which treatment technologies are used? x

1013 Treatment quality how is the quality of treatment technology N



1014 Maintenance

how is the maintenance status of the technology (Technical

level/Quality) N



11 HCW final disposal

1100 hazardous HCW final disposal siteis it on or off-site ? C [0] on-site; [1] off-site x

1101 type of hazardous waste disposal sitewhich kind of disposal site is used for the HCW ? C [0] open dump; [1] sanitary landfill; [2] small burial pit; [3] other x x

1102 protection of disposal site is the area secured ? B x

1103 domestic waste where is it disposed off? C

[0] at the HCF [1] off-site: open dump; [2] off-site: sanitary landfill;

[3] other x x

1104 off-site: hazardous waste what kind of hazardous disposal types are available? T x



12 HCWM regulations (code of conduct; management plan, policy…)

1200 hazardous waste regulations can we have copies of existing (draft) documents? B x

1201 national HCWM regulations can we have copies of existing (draft) documents? B x

1202 national HCWM regulations (HCF)are available and enforced C

[0] not available; [1] not enforced; [2] partly enforced; [3] available

and enforced x

1203 national HCWM regulations do their application cause any problems ? T x x

1204 HCF HCWM regulations internal guidelines and SOP are available and used C

[0] not available; [1] partly available; [2] widely available; [3]

available and used x

1205 national monitoring regulations are monitoring regulations available? B if yes, could I obtain the legal document and checklists? x x

1206 monitoring regulations is a monitoring system stipulated and established? B Please provide detailed information x x

1207 Incineration / waste treatment regulationcan we have copies of existing (draft) doc. ? T x

1208 Hazardous goods / waste Transport regulationcan we have copies of existing (draft) doc. ? T x

1209 monitoring regulations HCWM is monitored regularly by the relevant authorities B x

13 policy and budget

1301 budget allocation for HCWM is available and used C

[0] not identified; [1] planned; [2] available but not used; [3]

available and used x x

1302 budget allocation for HCWM budget per bed and year N US $ per bed and year x x

1303 purchase practises is there a national policy for items used in HCWM ? B x

1304 relations with other ministries with which ministry(ies) do you work on HCWM ? T x x

1305 annual report of activities could I obtain a copy of your annual report(s) regarding transport, treatment, disposal of hcw?T please obtain copies of the last 1-2 years x x x

14 sanitation & wastewater

1401 waste water drains to what is the waste water system connected? C [1] sewer; [2] septic tank; [3] open water source; [4] other x

1402 sewer connection where does the sewerage system lead to ? C [1] wastewater treatment plant; [2] open water source; [3] other x

15 personal opinion

1501 personal opinion

what kind of short-comings, weak points regarding HCWM

in your country can you point out? T x x x

1502 personal opinion do you think sufficient funds are allocated to HCWM ? Q x x

1503 personal opinion do you think HCWM is safely managed? Q x x x

1504 personal opinion do you think HCWM is environmental friendly managed? Q x x x

Explanations Legend for [Q]

Comments: enter any relevant comments made by the interviewee which can help better understand the problematic.

Type: data is either quantitative [N] (enter a number or percentage); qualitative [Q] (see legend); Boolean [B] (yes/no); multiple choice [C] (write down one or several numbers which

correspond to the answer) or text [T] (write essential relevant points told to you by the interviewee).

insufficient = 2

bad (low) = 1

All the information noted down corresponds to what the interviewee tells you. Your personal comments are to be put separately in the box below ! satisfactory = 3

good = 4

excellent (high) = 5



Annex 2 - UNRWA internal regulation on HCWM

UNRWA rules on HCWM are established in the Technical Instruction (Series No. HD/NC/96 revision No.

1/2010) for Infection Control Procedures at Primary Health Care. Following is indicated in the Infection

Control Procedures in regard of hazardous medical waste and sharps management in UNRWA healthcare

centers:

IX. Disposal of Contaminated Clinical Waste:

The disposal of contaminated clinical waste tends to be a controversial issue. There are only two

recommended methods, burying or burning (incineration). Burning however can prove

hazardous if a high temperature between 1100-1400ºC is not achieved because:

a) Insufficient heat may not destroy all organisms; and,

b) Burning plastic material at a low temperature releases toxic fumes.

An inadequate incineration process can therefore contribute to environmental pollution and

could prove to be a health hazard. Therefore burning in open air is not allowed.

The approach in many countries is to use a very large and sophisticated incinerator and

centralize the disposal of contaminated plastic and waste material. This is neither feasible nor

practical in UNRWA’s area of operations.

Burying is also not a practical option at the primary level. The only solution is to adopt a

pragmatic approach that utilizes the facilities that are available in the safest possible manner.

It is therefore important that the following instructions are adhered to strictly:

- Do not burn any waste from an UNRWA health facility, this includes: EPI Transport and Safety Combustion Boxes, Syringe Safety Boxes, non-contaminated and contaminated

waste;

- All waste bins must be lined with a plastic bin liner; - All waste material, contaminated and non-contaminated, must be collected in these

plastic bin liners;

- At no time should any sharp object (needles, scalpel blades) or syringes be put directly into a plastic bin liner or black garbage bag. These objects should be disposed in a safety

puncture resistant container;

- Either when the plastic bin liner is full, or at the end of the day, the plastic bin liner must be sealed and placed into a black garbage bag;

- The black garbage bag must be sealed and placed inside a Public Garbage Container. It is important that the garbage bags are not left beside the container but put inside it;

- Final disposal of medical waste should be in accordance with the national rules and regulations of the host authorities.

X. Disposal of Syringes, Needles and Sharps:

Injuries from needle-stick and sharp instruments may pose the greatest risk of transmission of

HIV, Hepatitis B and C and other blood borne pathogens. Following precautions must be taken

to prevent such injuries.

- Do not re-cap needles; - Used disposable sharp instruments such as syringes, needles, scalpel blades should be

placed in a Syringe Safety Box. This is a puncture resistant container that is kept close to

the area where injection and dressing procedures are undertaken;



- All dental clinics, laboratories, treatment rooms and MCH rooms should be equipped with a either an electrical needle destroyer or disposable sharp container with needle removal.

The electrical destroyer will render the needle harmless by disintegrating the needle either

wholly, or partially. The syringe must be put in the syringe safety box and not in a plastic

bin liner. The needle ends must be emptied directly from the needle box into the black

garbage bag;

- The needle terminator should also be used for EPI auto-disable syringes. The syringe should be disposed of in the Autodestruct Transport, Safety and Combustion Box. This box

must be used in accordance with the manufacturer’s instructions;

- Empty or partially empty vials and ampoules should be disposed of in the Syringe Safety Box and not put directly into the waste bin. Partially used vials/ampoules should not be

emptied and washed down the drain;

- When full, the puncture resistant Syringe Safety Box and EPI Transport, Safety and Combustion Box, must be sealed according to the instructions provided by the

manufacturer and placed in a black garbage bag. This black garbage bag is sealed and

immediately disposed of in the Public Garbage Containers;

- The Practice of using cardboard boxes or kidney dishes to store used syringes/needles must be discontinued;

- staff must not accumulate syringes and needles for destruction by the terminator at the end of the clinic session;

- Discontinue the practice of counting syringes used. The number of syringes used can be accounted for through the use of the Treatment Diary.



Annex 3 – UNRWA healthcare facilities in the North of the West Bank.

Healthcare

Facility Governorate

Number of work

days/week

Num. outpatients

per day

Number of

beds

Average bed

occupancy (%)

Balata HC Nablus 5 400 0 -/-

Old Askar HC Nablus 5 220 0 -/-

New Askar HC Nablus 5 100 0 -/-

Camp1 HC Nablus 5 200 0 -/-

Tulkarem H

assessment of unrwa’s healthcare waste management in …...of the healthcare waste management...

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