International governance structures for health-care waste management: a systematic review of scientific literature.

Journal of Environmental Management 153 (2015) 93e107

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Journal of Environmental Management journal homepage: www.elsevier.com/locate/jenvman

Review

International governance structures for health-care waste management: A systematic review of scientific literature M. Caniato a, *, T. Tudor b, M. Vaccari a a Research Laboratory on Appropriate Technologies for Environmental Management in Resource-Limited Countries (CeTAmb LAB), University of Brescia, Brescia, Italy b Centre for Sustainable Waste Management, School of Science and Technology, University of Northampton, Northampton, UK

a r t i c l e i n f o

a b s t r a c t

Article history: Received 2 October 2014 Received in revised form 19 January 2015 Accepted 24 January 2015 Available online

Significant differences exist in the management of health-care waste management, globally. This is particularly so between low, middle and high-income countries. A systematic review of scientific literature on global healthcare waste management spanning the period 2000 e current was undertaken, in order to identify key policies, practices, challenges and best practice. The findings were analysed considering the Gross National Income and the Human Development Index of each country. Effective regulation and operative definitions of waste categories are key-factors requiring improvement at the national level. The economic conditions in the country are an important factor, especially regarding treatment and disposal. Areas for improvement (e.g. the need for improved governance structures, the development of regional clusters, as well as sharps waste segregation) are suggested. © 2015 Elsevier Ltd. All rights reserved.

Keywords: Health-care waste management Medical waste Infectious waste Challenges Best practices Treatment and disposal

1. Introduction During the last 15 years several efforts have been dedicated to improving the governance structures and policies for health-care waste management (HCWM), and to identify and disseminate appropriate practices at the local, national and international levels (Pruss-Ustun et al., 2013; de Titto et al., 2012; UNEP/SBC and WHO, 2004). Policy and regulatory issues are often key weaknesses in the governance structures, particularly in low- and middle-income countries (LMICs), and require support for institutional strengthening and capacity building (Tudor, 2012; Shannon and Woolridge, 2011; Wilson, 2007). Several health-care facilities (HCFs) in LMICs do not properly manage their HCW, and in particular, infectious and hazardous waste are frequently not effectively segregated (de Titto et al., 2012). Indeed, a legal and regulatory framework, which sets the standards to apply and, in particular, gives operative definitions,

Abbreviations: GNI, gross national income; HCF, health-care facility; HCWM, health-care waste management; HDI, human development index; LMIC, low- and middle-income country. * Corresponding author. Via Branze 43, 25123 Brescia, Italy. E-mail address: [email protected] (M. Caniato). http://dx.doi.org/10.1016/j.jenvman.2015.01.039 0301-4797/© 2015 Elsevier Ltd. All rights reserved.

including of the different HCW categories, is the first step of a national strategy to improve HCWM (UNEP/SBC and WHO, 2004). This framework is extremely important because the appropriateness of HCWM can be evaluated only according to its compliance with regulation. HCWM practices vary greatly from country to country, according to various factors such as socio-economic conditions, regulation, level of education, available resources, treatment technologies, and the capacity to monitor and best manage inadequate practices (Shannon and Woolridge, 2011). A key aspect is that HCWM terminology at the international level varies greatly. For example, the waste generated by all the HCFs, research centres, laboratories, and scattered sources is defined ‘health-care waste’ by WHO (Pruss-Ustun et al., 2013, p. 3). The U.S. EPA (2012) uses the term ‘hospital waste’, with ‘medical waste’ indicating only the hazardous component. In addition, ‘regulated medical waste’ is used instead of ‘infectious waste’, to underline both the possibility of infection transmission, and the application of a specific regulation. The International Committee of the Red Cross (ICRC) uses the term ‘medical waste’ with a definition similar to HCW (ICRC, 2011, p. 12). Meanwhile the Secretariat of the Basel Convention employs the term ‘biomedical and health-care waste’ (SBC and UNEP, 2003, p. 4). ‘Clinical waste’ is used in United Kingdom (UK) to indicate

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hazardous health-care waste (DH, 2013). EU directives use none of the previous definitions, but list wastes with a short description including either their characteristics or origin (European Commision, 2000). This variation in terminology leads to significant issues and often confusion (Hossain et al., 2011). For example, the WHO's definition of ‘infectious waste’ is subjective, as it refers to the potential to be infectious (Pruss-Ustun et al., 2013, p. 4), which could be interpreted differently according to national circumstances, policies and regulations (SBC and UNEP, 2003). International guidelines and manuals can be applied to develop local structures and standards (Rushbrook and Zghondi, 2005). The WHO's ‘Blue Book’ represents an important guidance document, particularly for LMICs (Pruss-Ustun et al., 2013). It introduces standards accepted worldwide and integrates the approaches suggested by key international agencies, such as the Secretariats of the Basel, the Stockholm, and the Aarhus Conventions (SBC and UNEP, 2011; SSC and UNEP, 2009; SSC and UNEP, 2007; SBC and UNEP, 2003; UNECE, 1998), WHO and the World Bank (e.g. WHO and UNEP/SBC, 2011; WHO, 2007; Rushbrook and Zghondi, 2005; WHO, 2005; WHO, 2004; Zghondi, 2002; Johannessen et al., 2000; Rushbrook et al., 2000; Pruss and Townend, 1998). However, a holistic understanding of HCWM practices at the global and indeed in some cases national level is often limited (Hossain et al., 2011; Tudor, 2012; Pruss-Ustun et al., 2013). Thus a determination of how best to enhance governance structures for HCWM, particularly at the global level requires a stronger evidence-base upon which to develop strategies. This paper aims to systematically review the scientific literature of the last 15 years, in order to assess HCWM worldwide, and identify gaps, best practice and opportunities for improvement, particularly within LMICs.

2. Methodology The systematic review (Jesson and Lacey, 2006) identified articles in English on Scopus database with the terms ‘hospital/medical/clinical/healthcare waste management’, in the title or key words, published since 2000. This period of 15 years was chosen in order to any trends to be identified, as well as to have an acceptable number of papers, in particular about countries where publications in international scientific journals are limited. Moreover, 2000 is the first year after the publication of the first edition of the ‘Blue Book’, considered a milestone for the HCWM improvement worldwide (Pruss-Ustun et al., 2013). Articles of limited specific reference to the topic (e.g. dealing with wastewater, very specific waste categories, only treatment technologies, or providing little contribution because they were too generic) were eliminated. Papers focussing on countries that are generally poorly represented in the literature, especially LMICs, were a key focus. Thus the review analysed in particular papers from Africa, Asia, Middle East, and Latin America, with some papers about Europe, North America and Oceania. A total of 150 papers were reviewed. All the papers considered are reported in Appendix 1, divided according to the country they refer to, and the coverage of the studies analysed. Papers dealing with the topic worldwide were limited and often not very recent. 2.1. Evaluation of health-care waste management in a specific country Each country was first attributed a score according to the World Bank classification of national economies (The World Bank, 2014b). Taiwan and Somaliland that were not present in the World Bank classification, were considered high- and low-income countries respectively. Generally LMICs (i.e. countries with low, lower middle

Table 1 Description of all the HCWM aspects taken into consideration, and the classes adopted for the evaluation. HCWM aspect

Description

Classes

Country income group

Indicates the country's economy in 2012, in terms of gross national income (GNI), according to The World Bank (2014a).

Country coverage by studies

Indicates if the papers considered give a representative picture of the whole country, or only a part of it.

Level of national regulation

Indicates the completeness of the legislative framework against international standards.

4 2 4

Level of procedures at the HCF level

Level of awareness/training of HCF staff Level of personal protective equipment Level of segregation of sharps Level of segregation of other HCW Level of HCW storage at the HCF level Level of treatment and disposal

Indicates the quality of procedures in terms of completeness (covering all the possible cases), clearness to the staff (including being in written form), and applicability (customised to the HCF). Indicates what HCF staff know about hazards related to HCWM, internal procedures, and any other eventual indication. Indicates the use of appropriate equipment, in particular for waste collection, internal transport, and handling in general. Indicates if the sharps are safely and completely segregated, following all the precautions required. Indicates if the other HCW categories are segregated according to the standards. Indicates if the wastes are safely stored (appropriate location in an appropriate way) for a suitable time. Indicates if the waste produced by HCFs is safely treated for both human health and the environment, including the final disposal of by-products or residues.

5

classes: 1 e High-income: GNI $ 12,616; 2 e Upper middle-income: GNI ¼ $ 4,086e$ 12,615; 3 e Lower middle-income: GNI ¼ $ 1,036e$ 4,085; 4 e Low-income: GNI $ 1,035. classes: Total; Partial. classes: 1: Complete and detailed, in accordance with international standards; 2: Present, but improvements are required to meet international standards; 3: Completely or almost completely missing; N.A.: Information is not available or not clear. classes: 1: HCWM practices comply with national/international standards in all the HCFs across the country; 2: HCWM practices comply with national/international standards in almost all the HCFs, apart few cases; 3: HCWM practices comply with national/international standards in few HCFs, while in the majority they do not; 4: HCWM practices do not comply with national/international standards in almost all the HCFs; N.A.: information is not available or not clear.


and upper middle economies), were considered developing countries (The World Bank, 2014a). The country's regulatory framework was next evaluated against national regulations and best practice as suggested by WHO (Pruss-Ustun et al., 2013). In those countries where regulation was incomplete or completely absent, international guidelines were used. Compliance was evaluated for HCWM aspects within health-care facilities (HCFs), and offsite. For each country the papers considered are indicated, as well as if they either gave a complete picture of the situation, or described only some areas. All the parameters were evaluated according to the classes defined in Table 1. The classes are qualitative, but each one was attributed a number in relation to the efforts required to meet national/international standards. If it was deemed in compliance with the standards, it was assigned a 1. The explanation for the scores is given in the table. The classes were attributed considering all the papers dealing with a specific country. While the evaluation process is to an extent subjective, it is consistent across all of the papers and as noted, crucially is based on the presence or absence of established guidelines. 2.2. Aggregation of results and comparisons Data were grouped considering both the geographic disposition and the economy of the country. Data were aggregated with an arithmetic mean. Thus the average aggregated result of some factors within a grouping (e.g. “level of national regulation” for Asia) was a number between 1 and 4. Similarly, grouping was done according to the human development index (HDI) of each country (UNDP, 2014). The countries were then aggregated forming the ‘bottom billion’ of the world population (Collier, 2009, p. 239). Collier (2007, p. 5) defines these as countries characterised by one or more of the following four issues, leading to ‘development traps’: (i) conflict; (ii) limited natural resources; (iii) being landlocked with ‘bad’ neighbours; and (iv) bad governance in a small country. Such a classification was based on economic and political criteria, and this was then employed to determine a link between HCWM and the country's condition. The arithmetic mean was used because it is simple, and takes into consideration potential outliers. This approach also enabled groups with limited values to be included in the overall analyses. One country per geographic area with a level of national regulation below the mean was then selected. For the chosen country, the areas of improvement as outlined in the papers, were identified (Table 2). In the case of non-explicit but evident needs, these were reported as well. Data were aggregated per country and expressed as a percentage in order to enable comparison. The percentage expresses the number of papers reporting a specific need, on the papers evaluated regarding the same need. While this analysis evidently cannot capture all of the HCWM needs of each country, it aims to point out the most important challenges.

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Finally, examples of best practice in LMICs were identified. These could be either the results of a specific project/program, or a consolidated practice developed in a certain number of years. A brief critical review is provided in order to highlight the most significant issues, as well as the novelty for the local context. 3. Results There were a number of key overarching global issues raised. First, while much attention has been given to providing good health-care services, HCWM has been neglected, in particular in LMICs (de Titto et al., 2012; Townend and Vallini, 2008; Diaz, 2005). Moreover, there is a serious lack of reliable data, on factors such as waste generation and characteristics, thus making it very difficult to identify appropriate management solutions and to make them more sustainable. Second, many countries lack national legislation and even simple segregation and treatment techniques, while others aim to achieve more sustainability in HCWM. Third, waste generation and resource consumption have greatly increased in health-care, with rising production of hazardous by-products including dioxins, furans, and mercury (de Titto et al., 2012). For example mercury-containing instruments, banned in several countries, are redirected to developing countries by producers, or donated, when retired, by HCFs of industrialised countries. Fourth, in LMICs, several health professionals have a limited knowledge of the consequences of toxic contamination of the environment, and regulations, guidelines and implementation plans are generally lacking or even absent. Also enforcement is poor, and training programs are ineffective at both local and national level. Fifth, poor attention is dedicated to waste minimisation and pollution prevention in health-care. Harhay et al. (2009) note that a poor HCWM is generally attributed to scarce funding and confusion in duty and responsibility attribution. Sixth, several cities and areas of Africa, Asia and Middle East show clear evidence of public health hazards due to HCW (few studies are available for Caribbean, Latin America and Francophone Africa, and some are either unpublished or not translated). Indeed, the authors conclude that at least 50% of the World population is threatened by environmental, occupational and public health risks due to poor HCWM. 3.1. Analysis based on geography Data about HCWM aspects in single countries are reported in Appendix 2. In African countries, the situation is evidently problematic. At the national level, regulation is in place in some countries, but it is incomplete and not enforced in HCFs. Only sharps are partially segregated, and effective treatment is either missing or inappropriate, with evident risks. Similarly, in Asian countries the situation is not good, but improvements are reported, due to efforts in terms of regulation development and some pilot projects. Great

Table 2 Description of the needs/areas for HCWM improvement identified. Need of

Definition

Managerial training

The HCF management requires training in order to increase both their awareness about HCWM and their capacity to address it (e.g. development of procedures, organisation, identification of appropriate processes, green procurement) The HCF operative staff, especially waste collectors, cleaners, and nurses, should be trained about waste handling practices, safety procedures (including use of PPE), and identification and reporting of non-compliance New containers should be provided to enable effective management of the waste. For example: they contain all the waste without spillage or leakage; sharps are segregated in a safety box or equivalent rigid container; and a lid is present for infectious waste Waste segregation should be improved, according to the waste categories. At least a three-bin system (general, infectious, sharps) should be in place The HCF should have at least an option for treatment and/or disposal of hazardous waste (at least infectious and sharp) in compliance with WHO minimum requirements (Pruss-Ustun et al., 2013, p. 136)

Operational training Containers fit for waste collection

Effective segregation Appropriate treatment option

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Fig. 1. Mean values of the countries in Africa (left) and in Asia (right); values represent the aspects described in Table 1.

attention is dedicated to sharps waste, while all the other aspects present challenges (Fig. 1). Few papers give any indication about regulation in Latin America, thus this factor could not be adequately evaluated. However, all the HCWM aspects meet international standards in almost all the HCFs, with few exceptions. Only treatment technologies and the disposal of residues are not adequate, in particular in rural areas. In the Middle East, the situation is very similar to Asia, with some countries having very high standards, and others with evident challenges. However treatment and disposal are again the aspects requiring most attention (Fig. 2). Europe has high standards regarding HCWM, but not all the countries and HCFs are able to meet them. For example, countries in the Balkans still have to improve regulation, with cases of lack of risk awareness in the HCF staff. In general the treatment should be improved, in particular where small-scale incinerators are employed. Few papers describe the situation in North America and Oceania, and some aspects are not reported. However, no specific challenges are identified, while attention is focused on greening healthcare practices, including HCWM, and on the achievement of economical sustainability (Fig. 3). 3.2. Analysis based on economy and human development The country's economic level is evidently linked to all aspects of HCWM. Indeed, improved policies and practices are evident moving from lower-middle to upperemiddle income countries. Nevertheless, further improvements are still required. The key difference between low- and lower-middle income countries is the introduction of procedures in more HCFs, with improvements in

hazardous waste management. Considering the HDI, the differences between the groups are evident for all the aspects. National regulations and segregation of sharps have made similar progress, while treatment and disposal are the most challenging aspects (Fig. 4). Finally, a comparison of the mean values of the countries in the lowest groups in terms of GNI and HDI with those forming the ‘bottom billion’ was conducted. Only 11 out of the 58 countries of this last group were included in the analysis, as no papers dealing with the other 47 were identified. The countries analysed were part of the last two groups both in terms of both GNI and HDI, thus these three methodologies of aggregation considered different countries in the ‘lowest’ group. However the mean values were very similar, without any appreciable difference (Fig. 5). 3.3. Analysis of needs Table 3 synthesises the key factors requiring improvement. This analysis is based on a selected sample of countries from various geographical regions, including Africa, Southeast Asia, the Middle East, South America and Eastern Europe. The choice of countries is based primarily on the availability of papers. HCFs in Nigeria require urgent improvement in HCWM, with crucial issues being limited training and governance (Bassey et al., 2006), as well as a lack of knowledge and waste collectors (Chima et al., 2011; Coker et al., 2009). In Bangladesh, segregation is not carried out (Syed et al., 2012; Patwary et al., 2011; Akter et al., 2002). Hassan et al. (2008) reported the availability of an appropriate treatment technology in Dhaka, albeit used by few HCFs. In recent times, new treatment plants were under construction in the same city (Syed

Fig. 2. Mean values of the countries in Latin America (left) and in Middle East (right); values represent the aspects described in Table 1.


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Fig. 3. Mean values of the countries in Europe (left) and in North America and Oceania (right); values represent the aspects described in Table 1; ‘0’ represents ‘N.A.’.

Fig. 4. Mean values of countries aggregated per GNI (left) and HDI (right); values represent the aspects described in Table 1.

et al., 2012). In Brazil, sharps and infectious waste are generally effectively segregated (Da Silva et al., 2005). Some confusion due to the application of new regulation, including infectious waste definition, was reported (Moreira and Günther, 2013). In addition, training is needed, in particular to improve segregation of other hazardous waste, like chemicals (Moreira and Günther, 2013). HCWM in dental clinics is lacking in terms of segregation and staff training (Moreira and Jesus, 2013; Vieira et al., 2009). Finally, hazardous waste treatment, for both infectious and chemical waste, is still an issue, especially in small- and medium-size municipalities (Ferreira et al., 2012). In Serbia, the situation radically improved in

2009, with the implementation of the national waste management strategy (Gavrancic et al., 2012). Several autoclaves were installed in HCFs, giving an appropriate treatment option. However, despite these efforts, regular staff training and monitoring will be required to achieve a generally high and efficient level in HCWM (Ratkovic et al., 2012). Generally, the most common treatment technology available was incineration. However, several problems were reported for both single chamber brick-made (Haylamicheal et al., 2011; Manga et al., 2011; Mugambe et al., 2011; Manyele and Lyasenga, 2010; Nemathaga et al., 2008), and commercial incinerators, with two or three chambers (Njagi et al., 2012; Coker et al., 2009; Yang et al., 2009; Aristiz abal et al., 2008; Tsakona et al., 2007). The de Montfort incinerators, with different low-cost and locally made models, are suggested for LMICs, but only as an interim solution (Di Bella et al. 2012). Indeed, pollutant emission and the related impact on the public health are key concerns. Finally the development of new and more stringent regulation increases the interest in finding

Table 3 HCWM needs, in accordance with Table 2, reported by authors for a sample of countries.

Fig. 5. Comparison between mean values of countries with low income, low HDI, and forming the ‘bottom billion’; values represent the aspects described in Table 1.

Country

Managerial Operational training training

Nigeria Bangladesh Iran Brazil Serbia

33% 0% 70% 33% 50%

Appropriate Containers Effective fit for waste segregation treatment option collection

(1/3) 100% (4/4) 100% (2/2) (0/2) 100% (3/3) 100% (1/1) (7/10) 100% (10/10) 13% (1/8) (1/3) 33% (1/3) 0% (0/4) (1/2) 66% (2/3) 33% (1/3)

100% 100% 70% 25% 66%

(4/4) 100% (4/4) (4/4) 75% (3/4) (7/10) 100% (8/8) (1/4) 66% (2/3) (2/3) 50% (1/2)

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4. Discussion

regional programs and agreements supported the improvement of a certain area, but other factors (e.g. waste segregation and regulations, and the management of sharps) are particularly crucial (Figs. 1e3). Some countries achieved international standards several years ago, and in recent times few papers report HCWM in general terms. Indeed more attention is dedicated to specific aspects, like treatment technologies or transmission mechanisms of a certain infection, or the improvement of environmental and economic sustainability of the health-care system. The GNI had a good link with HCWM practices, and indicates the importance of financial, technological and human resources in order to achieve significant improvement at the country level. In particular, the clear gap between lower-middle and upperemiddle income countries suggests that a certain minimum economic threshold should be exceeded in order to get effective results. This is particularly true for waste treatment and disposal, which require technologies that often are too expensive to purchase, operate and maintain for LMICs, especially in rural areas. The aggregation through the HDI shows even clearer differences between the groups. It suggests that also other factors included in such an indicator, like education and population health, can affect HCWM (Fig. 4). The countries with either the lowest GNI or HDI shared similar challenges, but it is peculiar that it is the same also for the ‘bottom billion’, despite the different grouping methodology (Fig. 5). This finding suggests that the ‘development traps’ described by Collier (2007, p. 5) affect also HCWM, despite the level of GNI and HDI. Moreover scientific literature describes only few of the ‘bottom billion’ countries, thus the situation in the others could be even worse, especially for those involved in a conflict. The analyses provide empirical evidence of the direct correlation between investments/costs, and the effectiveness of HCWM. When standards are met in health-care, including for HCWM, this leads to reduced risks for public and occupational health, and the environment, and to look for new ways to increased efficiency and sustainability (Blenkharn 2006a; Podein and Hernke, 2010), especially economic sustainability (Bennett, 2013).

4.1. HCWM situation and factors

4.2. HCWM needs and best practice

The findings indicate that a national strategy, with appropriate regulation and policy, are the first factors to improve the governance structures for HCWM in any country (Townend et al., 2009; UNEP/SBC and WHO, 2004). Safe segregation of sharps is a key priority due to their classification as highly hazardous waste (PrussUstun et al., 2013). Indeed their segregation leads to a dramatic reduction in the rate of sharp-related injuries (Perry et al., 2012). Effective treatment and disposal are also critical aspects in all the countries. Indeed even where HCWM international standards are being met, improvements are still possible in order to reduce the impact on public health and the environment. This is particularly true in LMICs where treatment and disposal will become more tightly regulated in future (Tudor, 2012). HCF staff awareness and attention is another critical aspect, and concerted efforts are required to ensure that good standards are realised, including in those countries where ‘high’ standards are already in place. Any initiatives should take account not only risks for public and occupation health, but also the impact on the environment, and the generated pollution. Moreover improved knowledge of the overall HCWM system should be supported, with a clear understanding of how all the steps are linked and depend on each other (Caniato et al., 2014, 2015). Countries of the same geographical area share similar situations, apart from some clear exceptions, like South Africa in Africa, Japan and South Korea in Asia, and Saudi Arabia in the Middle East. Some

A generalised need for training is required, especially to clarify definitions and waste segregation. Although attention is usually focused on operative staff, like cleaners and waste collectors, and sometimes doctors and nurses, it is evident that all the HCF personnel should be involved. The commitment and direct involvement of the HCF's senior management should be the first priority, in order to provide adequate resources and guidance, and also to ensure that HCWM is a central topic for the HCF. If appropriate containers are present and correctly used, then the introduction of waste segregation is easier, faster and effective (Gavrancic et al., 2012). The identification and availability of appropriate treatment options are clearly issues, in particular in LMICs. The establishment of an effective monitoring system is a pivotal step to both ensure that procedures are effectively implemented and staff are kept focused. It is evident that there is a need for appropriate systems to be put in place that are fit for purpose, sustainable over the short, medium and long-term and which are managed by competent individuals. Thus it is important to ensure that adequate financial and human resources are made available to those countries most in need, particularly LMICs. At the national level, government involvement and commitment is fundamental, as well as regular inspections and an effective monitoring system, as for example is undertaken in Vietnam (Kühling and Pieper, 2012). At the HCF level, all the personnel should be involved, and training programs often achieve very

alternative solutions, like microwave disinfection in South Korea (Jang et al., 2006), and autoclaving in LAO PDR (Kühling and Pieper, 2012). Various writers (e.g. Stringer et al., 2010; Debere et al., 2013) suggest the importance of developing and introducing locallymade autoclaves in LMICs. 3.4. Best practice Few best practice examples are available in the literature and some are difficult to apply to other cases in LMICs, due to: (i) the high cost of implementation (Hagen et al., 2001); (ii) the need of a good regulation already in place to be in compliance with (Moreira and Günther, 2013); (iii) the need of a certain level of segregation and specific technologies (Anastasiadou et al., 2012; Ferreira et al., 2012); or (iv) a strong international support, also in terms of economic resources (Kühling and Pieper, 2012). However a HCF can be inspired by quite simple and low-cost approaches to improving HCWM, starting from awareness raising, education, and involvement (Moreira and Günther, 2013; Askarian et al., 2010; Beghdadli et al., 2010). A systemic approach is always suggested, aiming at the integration of different tools and actions, like the development of policy or procedures, the supply of material specifically dedicated to HCWM (e.g. with colour coding), posters and informative material, and training programs. These cases are evidence of the effectiveness of international guidelines, and their applicability in different countries. In Table 4 some best practice examples are described. They are various practical cases of how HCWM for both hazard and nonhazardous wastes were improved in a range of countries. In some cases packaging material was reused for HCWM, with an improvement of staff safety and a reduction of occupational risks (Mattoso and Schalch, 2001), in others, waste segregation and procedures were effectively introduced with low investment (Moreira and Günther, 2013; Beghdadli et al., 2010; Askarian et al., 2010).


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Table 4 Selected best practices for HCWM reported in scientific literature. Topic

Country

Inputs

Results

Management at the HCF level

Algeria (Beghdadli et al., 2010)

In a local hospital, the three-bin system was introduced, following the WHO approach. A hygiene and security commission was formed, and assessed current conditions and the needs of improvement. The bin system was part of a three-year plan, including education, material supply, regular inspections, written and standard recommendations, and injury surveillance system. Rigid plastic packaging was used for segregation of sharps, and was located at the point of use. It was motivated by the scarcity of safety boxes, and their high cost. A new approach was tested in a pilot hospital, with the following 5 steps: (i) diagnosis of the initial situation; (ii) development of a medical waste management plan; (iii) implementation of the plan; (iv) monitoring; and (v) evaluation of the plan. The intervention did not require a high investment, and the plan included only compliance with the regulation, some changes of procedures, training and monitoring activities. New guidelines were introduced in a pilot hospital, clear definitions of waste categories were given, and a new management system was developed. A team was appointed to follow the project, and a dedicated training program was put in place. The approach was “find-organizeclarify-understand-select-plan-do-checkact (FOCUS-PDCA)”. A hospital benefitted from both the implementation of segregation programs (e.g. in-service training, definition clarification, discussion of the survey results, supply of waste segregation material, development of posters) and regular audits for several years (4 surveys from 1991 to 1999). After every survey, recommendations were provided, and corrective actions were undertaken. Development of provincial level guidelines and strategy to fill the national regulative gap. Development of a network of treatment plants: (i) one centralised plant for the most complex waste; (ii) autoclaves for large district HCFs; and (iii) biomassfuelled incinerators for primary HCFs in rural areas. The chemical waste, both solid and liquid, produced in a public hospital and some primary HCFs was encapsulated: waste was mixed with the same volume of concrete (1:1:3 ratio of cement, aggregate, and sand respectively), and put in a metallic drum (diameter 100 mm, height 150 mm). The safety of disposal in a non-hazardous waste landfill was evaluated. Fly and bottom ash produced by a medical waste incineration facility (two rotary kiln systems) was characterized, and mixed with different ratios of cement for both stabilization and reuse purposes. The new material was tested for hazardousness with leaching test, and compressive strength test.

Waste segregation was introduced, and all performances related to waste management were monitored for three years. Quantitative improvements were not reported, but several non-compliances and injuries caused by misconduct were identified.

Brazil (Mattoso and Schalch, 2001)

Brazil (Moreira and Günther, 2013)

Iran (Askarian et al., 2010)

Saudi Arabia (Hagen et al., 2001)

Management at the provincial level

Indonesia (Kühling and Pieper, 2012)

Waste treatment and disposal of residues

Brazil (Ferreira et al., 2012)

Greece (Anastasiadou et al., 2012)

Improvement in sharps management without any extra cost related to special container procurement. Waste generation reduction, increase of recycling (new recyclables including organics were segregated), reduction of infectious waste generation per procedure. Compliance with national regulation largely improved, as well as worker safety.

In a few months after the first activity was implemented, waste production decreased (from 6.67 to 5.92 kg/occupied bed/day), as well as the percentage of waste considered infectious (from 73% to 61%). The high content of infectious waste was motivated by the definition adopted by Iranian HCFs.

After the first survey and consequent corrective actions, waste production decreased by 65%. In 8 years infectious waste production was reduced by 70%. The results were clearly and quantitatively monitored, and room for improvement identified. Findings addressed training activities and change of procedures. Staff safety was improved, and high-value items, wrongly discarded, were identified. Some HCFs improved HCWM, while some hospitals operated as collection and treatment hubs for HCFs of the area, with additional income to support economic costs.

Leaching and ecotoxicity tests showed a dramatic reduction of hazardousness, and levels were very low considering the new concrete blocks. 200 l drums were suggested, and these could serve as a disposal method for small- and middle-size municipalities.

The heavy metals were made stable and safe for disposal in a non-hazardous waste landfill. Physical characteristics changed according to the cement ratio, and the use of either fly or bottom ash. Use of the waste in construction works was acceptable. However, the authors suggested further tests about the long-term behaviour, and according to the composition of medical waste incinerated.

100


positive results (e.g. Johnson et al., 2013; Subero et al., 2004). Waste collection systems can be optimised by minimising transportation €z and Kocasoy, 2008b). Treatment technology should be (Alago identified according to local conditions, stakeholder opinions and €z and Kocasoy, technical inputs (Kühling and Pieper, 2012; Alago 2008a), and should build local capacity (e.g. Patil and Pokhrel, 2005). If the private sector manages waste treatment, it is better to avoid monopolies, by having more than one company involved (Siru et al., 2006). A systemic approach was utilised in England, with good results in terms of waste minimisation, and organisation performance and staff training and awareness (Tudor et al., 2008). Thus it is a potential approach for HCFs already meeting international HCWM standards. This study was able to identify some examples of best practice taken from a range of countries. Key results/outcomes related to improved waste segregation and reduction in impacts on public and the environment. While it is true that it would be difficult or, in some cases, impossible to translate these to other countries, the important lessons to be learnt relate to the areas of focus (e.g. effective segregation), as well as the approaches employed (e.g. involvement of staff). If these concepts and principles can be utilised in the development of policy and practice, then improvements should follow. 4.3. Methodological approach The use of standards and definitions suggested by international guidelines (e.g. Pruss-Ustun et al., 2013) is a common practice for countries where regulation is incomplete, unclear, or completely missing (e.g. Saad, 2013; Al-Khatib and Sato, 2009). Unfortunately the definitions, and their applicability vary. This confirms a problem highlighted for some time (Rutala and Mayhall, 1992). Differences in reporting make standardisation and areas of focus, especially where several needs are required, difficult. Indeed, in general, several countries still require improvement in their regulation. The number and characteristics of containers and bins are also not well described, with limited information on required costs and investment provided. Few papers described HCWM in countries where international standards have been achieved for some time. Some articles try to investigate staff risk awareness and commitment (Ferreira and Teixeira, 2010), but it would be interesting to have further studies about the impact of this behaviour on HCWM in LMICs, and how to deal with it, as was done in the UK (Tudor et al., 2007, 2008). Several papers simply report research activities, giving interesting, but generic indications at the HCF or the regional/national level. Unfortunately it is not always possible to establish to what extent they might have supported the development of HCWM. Indeed, there are several papers that highlight the potential benefits on policies and practice of for example, stakeholder involvement before and after the research activity (e.g. Kühling and Pieper, €z and Kocasoy, 2008a; Hagen et al., 2001). Few papers 2012; Alago report best practice, in particular at the HCF level, and it is a clear gap of knowledge. Indeed good examples could be provided to address HCFs willing to improve their performances, despite financial constraints and limited support from the government, as happens in some LMICs. Some papers are referred to high-income countries, and could not be easily applied to LMICs (e.g. Tudor et al., 2008; Hagen et al., 2001). Strategies for effective waste segregation, collection, handling and storage are often not discussed in enough detail. Also economic considerations are quite general, while some detailed evaluation of the economic impacts of different options could be particularly useful, due to the fact that some costing analysis tools are freely available on the web (WHO, 2013). Also the public health impacts, especially in LMICs, are not

rigorously investigated, while the correlation between HCWM and patients', occupational and public health, not only incinerator- and landfilling-related, would be particularly interesting. These kinds of studies are particularly challenging, due to privacy implication and the potential impact on HCF reliability, but some papers can be used as reference for new research activities (Cruz et al., 2011; de Moura et al. 2011; Tudor et al., 2010). Moreover, given that infection control can often be the first priority for HCFs in LMICs (Pittet et al., 2008), it is important to clarify the link with HCWM (Townend and Vallini, 2008). 4.4. Representativeness of the analyses Apart from the methodological limitations already declared, the paper considered a database dealing with peer-reviewed literature, only. Several development projects and national programmes, especially in LMICs, do not produce these kinds of papers, or they do, but some years after. Thus the analyses are not exhaustive. However, the intention was not to cover every document on the issue. Indeed, this would be impossible. Rather the aim was to use the same set criteria to examine a snap shot of countries from across a range of factors (e.g. geography and economic development). Use of databases such as PubMed and the inclusion of factors such as wastewater while useful, would have introduced further complications, in that while the breath of topics may have increased, their evaluation would have had to be compromised in keeping with the word count of the journal. 5. Conclusions The effective management of HCW has significant environmental and socio-economic impacts. This study systematically reviewed scientific literature from the last 15 years and identified key practices and challenges, as well as potential areas for improvement. The findings demonstrated that there are a number of challenges that have to be overcome (e.g. standardised definitions, appropriate segregation), at both the national and international level, before effective governance systems can be implemented. However, two key points are important to note here: first, while there was a link identified between GNI and HDI, and HCWM, there is variation within and across countries in selected geographical regions. Second, and relatedly, there are good examples of best practice in a range of countries. It is important therefore for there to be greater sharing of best practice and provision of support to enable more effective governance systems to be put in place. This support and sharing does not necessarily have to come from ‘developed’ countries, but rather could be through regional groupings. Indeed, the development of regional clusters should be encouraged and facilitated. In addition, while a single reporting system covering all countries would be difficult, given national policies, there is an urgent need for greater harmonisation of reporting, for example, with regard to definitions and waste arisings. It is only in this more holistic way, that there can be greater sharing of expertise, and more effective strategies and governance structures developed. A global effort should be dedicated to decouple economic resources and HCWM, through the development of new and sustainable HCWM systems. There should be the development of innovative technologies for a simpler and more effective waste segregation, sterilisation and reuse. Finally, international treaties to standardise processes and equipment, and to phase out hazardous materials like the Minata Convention on Mercury, and the courage to propose and test trailblazing management system are just few of the innovations that would enable further improvements in HCWM, particularly amongst LMICs.


101

Appendix 1. Papers analysed according to the country, and the corresponding research coverage

Acknowledgements Marco Caniato was a PhD student in “Appropriate Methods and Technologies for International Development Co-operation” at the University of Brescia, supported by the Alberto Archetti Fund.

Country

Coverage

Country

References

Coverage

Partial

Latin America Argentina

(Bassi and Moretton, 2003)

Partial

Partial

Brazil

Partial

Partial

Colombia

Partial

El Salvador

Partial

Partial Total Partial Partial

Venezuela Middle East Bahrain Egypt

(Subero et al., 2004)

Partial

(Mohamed et al., 2009) (Mohamed Soliman and Ibrahim Ahmed, 2007; Abd El-Salam, 2010)

Total Partial

Senegal

(Ngounou, 2004; Manga et al., 2011) (Haylamicheal et al., 2011; Debere et al., 2013; Muluken et al., 2013) (Nkonge Njagi et al., 2012) (Muluken et al., 2013) (Mohee, 2005) (Bassey et al., 2006; Coker et al., 2009; Adedigba et al., 2010; Chima et al., 2011) (Ndiaye et al., 2012)

(Mattoso and Schalch, 2001; Da Silva et al., 2005; Sales et al., 2009; Vieira et al., 2009; Ferreira et al., 2012; Severo et al., 2012; Moreira and Jesus, 2013; Reis et al., 2013; Moreira and Günther, 2013) bal et al., 2008; Hoyos et al., (Aristiza 2008) (Johnson et al., 2013)

Partial

Iran

Partial

Somaliland

(Di Bella et al. 2012)

Partial

Jordan

South Africa

(Nemathaga et al., 2008; Abor and Bouwer, 2008) (Saad, 2013)

Partial

Kuwait

(Askarian et al., 2004; Karamouz et al., 2007; Arab et al., 2008; Taghipour and Mosaferi, 2009; Farzadkia et al., 2009; Fazili et al., 2010; Askarian et al., 2010; Bazrafshan and Mostafapoor, 2011; Askarian et al., 2012; Koolivand et al., 2012; Aghapour et al., 2013; Damani et al., 2013) (Bdour et al., 2007; AlMomani et al., 2013) (Alhumoud and Alhumoud, 2007)

Partial

Palestine (West Bank only)

(Manyele and Anicetus, 2006; Manyele and Lyasenga, 2010; Manyele and Mujuni, 2010) (Mugambe et al., 2011)

Total

Saudi Arabia

Partial

Turkey

(Akter et al., 2002; Hassan et al., 2008; Patwary et al., 2009; Akter et al., 2010; Patwary et al., 2011; Syed et al., 2012) (Chung and Lo, 2003; Yang et al., 2009; Gai et al., 2009; Yong et al., 2009; Ruoyan et al., 2010; Geng et al., 2013; Zhang et al., 2013) (Kishore et al., 2000; Patil and Shekdar, 2001; Singh et al., 2001; Khan et al., 2004; Singh et al., 2004; Rao et al., 2004; Pandit et al., 2005; Patil and Pokhrel, 2005; Verma and Srivastava, 2006; Gupta and Boojh, 2006; Sharma and Chauhan, 2008; Hanumantha Rao, 2008; Boss et al., 2009; Gupta et al., 2009; Hanumantha Rao, 2009; Khajuria, 2009; Nema et al., 2011; Basu et al., 2012; Pant, 2012; Dohare et al., 2013; Sharma et al., 2013; Chethana et al., 2013)

Partial

Yemen Europe

Partial

Partial

Africa Algeria Botswana

Cameroon Ethiopia Kenya Libya Mauritius Nigeria

Sudan

Tanzania

Uganda

Asia Bangladesh

China

India

References (Bendjoudi et al., 2009; Beghdadli et al., 2010) (Mbongwe et al., 2008)

Partial

Partial Total

(Al-Khatib and Khatib, 2006; AlKhatib, 2006; Darwish and AlKhatib, 2006; Al-khatib et al., 2007; Al-Khatib, 2008; Al-Khatib and Sato, 2009; Al-Khatib et al., 2010; Eleyan et al., 2013) (Hagen et al., 2001; Almuneef, 2003)

Total (West Bank only)

€z and Kocasoy, 2008a; Alago €z (Alago and Kocasoy, 2008b; Birpinar et al., 2009; Eker et al., 2010; Ciplak and Barton, 2012) (Al-Emad, 2011)

Partial

Croatia

(Marinkovi c et al., 2008)

Partial

France

(Mühlich, 2003)

Partial

Partial

Partial

(continued on next page)

102


(continued ) Country

References

Coverage

Country

References

Coverage

Indonesia Japan

(Kühling and Pieper, 2012) (Miyazaki and Une, 2005)

Partial Total

Germany Greece

Partial Partial

Korea Lao PDR

(Jang et al., 2006) (Phengxay, 2005; Kühling and Pieper, 2012) (Siru et al., 2006; Ambali and Bakar, 2012)

Total Partial

Italy Macedonia

(Mühlich, 2003) (Tsakona et al., 2007; Gidarakos et al., 2009; Kougemitrou et al., 2011; Komilis et al., 2012; Anastasiadou et al., 2012) (Mühlich, 2003) (Kochubovski, 2011)

Total

Serbia

Partial

Spain

Partial

UK

Partial

Oceania and North America

Partial

Australia

Partial

Canada USA

Malaysia

Mongolia Pakistan

Taiwan Thailand Vietnam

(Shinee et al., 2008; Ali and Kuroiwa, 2009) (Hashmi et al., 2000; Majid and Umrani, 2006; Ali and Kuroiwa, 2009; Mustafa and Anjum, 2009; Kumar et al., 2010) (Chiang et al., 2006; Cheng et al., 2009) (Suwannee, 2002; Danchaivijitrmd et al., 2005; Ali and Kuroiwa, 2009) (Kühling and Pieper, 2012)

Partial Partial

(Jovic-Vranes et al., 2006; Stankovic et al., 2008; Gavrancic et al., 2012; Ratkovic et al., 2012) (Mühlich, 2003; Insa et al., 2010) (Mühlich, 2003; Tudor et al., 2005; Blenkharn, 2006b; Tudor et al., 2008; Nichols et al., 2012)

(Peng et al., 2008; Blundell et al., 2011; Bennett, 2013) (Stall et al., 2013) (Reinhart and Mccreanor, 2000; Podein and Hernke, 2010; Perry et al., 2012)

Partial

Partial Partial

Partial Partial Partial

Appendix 2. Synthesis of HCWM situation in the countries analysed in the different continents/regions

Country

Africa Algeria Botswana Cameroona Ethiopiaa Kenyaa Libya Mauritius Nigeriaa Senegala Somalilanda South Africa Sudana Tanzaniaa Ugandaa Asia Bangladesh China India Indonesia Japan South Korea Lao PDRa Malaysia Mongoliaa Pakistan Taiwan Thailand Vietnam Middle East Bahrain Egypt Iran Jordan Kuwait




Level of awareness/ training of HCF staff

Level of personal protective equipment

Level of segregation of sharps

Level of segregation of other HCW categories

Level of HCW storage at the HCF level

Level of treatment and disposal

2 2 3 4 4 2 2 3 3 4b 2 3 4 4

N.A. 2 2 N.A. N.A. 3 2 3 2 N.A. 1 3 2 N.A.

3 4 3 4 N.A. 4 N.A. 3 3 4 2 4 3 2

3 3 4 3 2 4 N.A. 3 2 3 2 4 3 2

3 3 3 4 2 3 N.A. 4 3 N.A. 2 4 3 2

3 3 3 3 N.A. 3 N.A. 3 3 3 1 3 3 2

4 4 4 4 N.A. 4 N.A. 3 3 4 2 4 3 3

4 3 4 4 N.A. 3 N.A. 3 3 4 2 3 3 3

4 4 4 4 3 4 N.A. 3 4 4 2 4 4 3

4 2 3 3 1 1 3 2 3 3 1b 2 3

3 1 1 2 1 1 2 2 2 2 1 2 2

4 2 3 3 1 N.A. 3 2 3 3 1 2 3

4 2 3 N.A. 1 N.A. 3 2 3 3 1 2 N.A.

4 1 2 N.A. 1 N.A. 3 N.A. 3 3 N.A. 2 N.A.

3 2 2 N.A. 1 1 2 2 3 3 1 1 N.A.

4 2 3 N.A. 1 N.A. 3 2 3 3 1 2 N.A.

3 2 3 N.A. 1 1 N.A. N.A. 4 4 N.A. 2 N.A.

3 2 2 3 1 2 3 3 4 4 N.A. 2 3

1 3 2 2 1

1 2 2 2 N.A.

2 3 3 3 1

2 3 3 3 2

2 3 2 3 1

1 2 2 2 1

1 3 3 3 1

2 3 3 3 1

1 4 3 3 1


103

(continued ) Country


Palestine (West Bank) 3 Saudi Arabia 1 Turkey 2 Yemen 3 Latin America Argentina 2 Brazil 2 Colombia 2 El Salvador 3 Venezuela 2 Europe Croatia 1 France 1 Germany 1 Greece 1 Italy 1 FYROM 2 Serbia 2 Spain 1 UK 1 North America and Oceania Australia 1 Canada 1 USA 1 a b c



Level of awareness/ training of HCF staff

Level of personal protective equipment

Level of segregation of sharps

Level of segregation of other HCW categories

Level of HCW storage at the HCF level

Level of treatment and disposal

3 1 1 N.A.

3 1 1 4

3 1 1 4

3 1 1 4

2 1 1 N.A.

3 1 1 4

3 1 2 4

4 2 2 4

N.A. 1 N.A. 1 N.A.

N.A. 2 N.A. 1 2

N.A. 2 N.A. 1 1

N.A. 2 N.A. 1 N.A.

N.A. 1 N.A. 1 1

N.A. 2 N.A. 1 2

N.A. 2 N.A. 1 2

1 3 3 N.A. N.A.

1 1 1 1 1c 2 1 2 1

2 1 1 1 1 2 2 1 1

3 1 1 2 1 N.A. 2 1 1

N.A. 1 1 2 1 N.A. 3 1 1

1 1 1 1 1 1 1 1 1

1 1 1 1 1 2 2 1 1

2 1 1 1 1 N.A. 3 1 1

3 1 1 2 1 3 3 1 1

1 1 1

1 1 1

1 1 1

N.A. N.A. N.A.

1 1 1

1 1 1

N.A. N.A. N.A.

N.A. 1 1

Countries forming the ‘bottom billion’ (Collier, 2009, p. 239). Class attributed by the authors according to The World Bank (2014a) classification. Mühlich (2003) reports a lacking regulation in Italy, but it was recently improved in compliance with EU directives.

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