The 1992 United Nations Development Conference on the environment in Rio, Brazil signaled a major turning point in the manner in which countries across the globe sought to collectively develop policies to improve stewardship of the natural environment. At the conference, the management of waste was included as one of the main agenda items.

In line with increasing global consumption levels and at current trends, the United Nations Centre for Human Settlement Infrastructure and Environmental Programme (UNCHS-SIEP) predicts that there will be a five-fold increase in world-wide waste generation. Domestic and industrial waste generation patterns are increasing across the globe with per capita rates in developed countries increasing nearly three fold over the past two decades. These increases are reaching levels of five to six times those in developing countries.

In 1999, the United Nations Environment Programme noted that one of the main challenges which the world faces today is the need for:

“A more life-cycle oriented approach to addressing production and consumption”

It goes on to argue that:

“Such an approach stimulates recycling and reuse of products, and reduces materials and energy use during production and consumption”

 

Figure 1. Common risks associated with managing healthcare waste. (Source: WHO (2000))

 

Therefore the effective management of waste plays a significant role in the environmental, social and economic constructs of a country. Indeed, according to a report in 2000 from the World Health Organization (WHO), a leading international organization with responsibility for healthcare waste (HCW) management, the incorrect management of this waste can have direct health impacts on the community, individuals working in healthcare facilities, and the natural environment. Risks to the community arise from both intentional and unintentional exposure. Intentional exposure includes ‘widespread’ reuse of disposable materials such as syringes which results in the main diseases causing burden of inadequately managed HCW such as human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) transmission. Risks to the healthcare worker arise primarily from needle stick injuries. Figure 1 details some of the major risks in the management of HCW, according to work by WHO in 2000.

HCW management practices in poorer developing countries often pose a serious threat to public health and the environment. Diaz notes that scavenging is common in most urban areas in developing countries, and even though playing a vital role in resource recovery, often uses inefficient methods of materials recovery, and disregards basic principles of occupational health.

This can be contrasted with practices generally in the developed world. For example, in 2006 the advisor and researcher in waste management Phillip Rushbrook, argued that current waste management operations in Europe are characterized by a number of measures. These factors included increasingly stringent regulations, direct wastes to prescribed treatment processes, higher standards on emission control, facility operation and waste tracking, and the imposition of a ‘duty of care’ on waste producers to ensure that their waste is managed in a safe and legal manner.
 

An examination of planning mechanisms for the effective management of HCW in the two types of countries is therefore vital. In 1997, WHO stated that at the national level waste management planning provides the relevant agency with the basis for identifying actions on a district and national level. While a study by Khairun Neesa in 2001 argues that waste management planning is concerned with the optimization of waste management options, and is concerned primarily with treatment, recycling, transport and disposal options.

According to a report from WHO in 2004, while there are no ‘perfect readily available solutions’, whether generated at rural clinics or large hospitals HCW can be managed through well-operated infrastructures.

Based on primary research undertaken by the author, and a review of the literature this paper will highlight some of the major issues involved in the management of this waste in both the ‘developed’ and ‘developing’ world. These classifications are based on the annual United Nations Development Programme (UNDP) Human Development Report’s ranking of countries. The article provides an overview of countries, with examples taken from various countries, rather than focusing on a specific country.

Healthcare waste (HCW)

Definitions

Healthcare wastes are produced primarily by hospitals, general practice and dental surgeries, pharmacies, research establishments and veterinary clinics. According to documentation by the WHO in 2000, HCW is considered to be:

“Waste hazardous or not, generated from medical facilities”.

More specifically it is comprised of: anatomo-pathological waste, infectious waste, chemicals, pharmaceutical waste, sharps and radioactive waste which would be considered to be hazardous. Alternatively, waste such as paper, cardboard and plastics which would be classified as domestic or municipal, and would be considered to be non-hazardous.

While the term that will be used through this article will be HCW it is worth briefly mentioning some of the other common terminology used (Table 1).

Healthcare waste management planning

Regulatory frameworks and policies

A number of waste management researchers including Annette Prüss in 1999, Philip Rushbrook in 2000, Nessa, Terry L. Tudor in 2005 and 2007, Anne Woolridge in 2005, and CE. Da Silva in 2005 have all posited the importance of having a structured plan in order to effectively manage HCW.
 

Table 2 outlines some of the main components in the development of a national waste management plan according to a WHO document in 2000.

Waste management legislation usually governs the management of risks to individuals as well as to the environment. At an international level key regulatory infrastructures governing the management of HCW include the Montreal Protocol, that is regulated by the United Nations Environmental Programme (UNEP), and bans chloroflurocarbons (CFCs), the Basel Convention on the Control of Transboundary Movements of Hazardous Wastes and Their Disposal, which was enacted in 1997 by the UNEP, and the Stockholm Declaration on reducing levels of persistent organic pollutants (POPs) in the atmosphere, that was enacted by the UNEP in 2001.

At a national level the management of HCW is usually covered under specific legislation in developed countries, however, legislation governing its management in developing countries is limited. For example, in the USA there exists the Medical Waste Tracking Act (MWTA), and in the European Union (EU), the Hazardous Waste Directive, the Landfill Directive, and the Waste Framework Directive. In 1999 Rushbrook noted that within developed countries there is an increasing adoption of a ‘precautionary principle’ with moves towards greater control of waste production and processing, as well as clearer definitions for wastes and a policy of avoidance or minimization of waste production. This control has primarily been through economic measures and legal penalties.

Research by the waste management academics Habibur Rahman and Mansoor Ali in 2000 found that many developing countries have only limited regulation, and knowledge about associated health hazards for individuals involved in handling HCW is often very poor. A report assessing 22 countries, published in 2004 by the WHO showed that 18% – 64% of healthcare facilities in developing countries did not use ‘correct’ waste disposal methods. According to Nessa, HCW management systems in Africa are limited, with some urban hospitals burning their waste in the open-air, and variation in levels of segregation and classification amongst the different countries. The authors also noted that while in Latin America and the Caribbean there has been attention paid to managing clinical waste, there should be a focus on reducing risks to healthcare workers. Two studies in Southeast Asia in 2000 by the WHO and another in 2005 by the academic Manilay Phengxay found that most healthcare facilities did not have any waste management plans, procedures or guidelines, and most of the countries also did not have legislation. As a result, in 2005 Holliday stated that in developing countries there are several barriers to effective HCW management, namely:

• Poor management of the wastes (e.g. waste being ocean dumped)
• Clinical waste being sent to open dumps
• Dumps being badly managed and insecure (e.g. lack of fencing)
• The presence of waste pickers who are prone to injury and infection and who can potentially spread diseases
• Reuse of scavenged needles that can spread diseases

Differences in regulatory practices therefore exist in HCW management between developed and developing countries.

Healthcare waste arisings and composition

Various writers including Rahman and Ali, as well as Da Silva have found several factors that affect HCW generation rates, including the:

• Size of the facility
• Proportion of in- and out-patients
• Type of facility and specialization
• Availability of waste segregation systems
• Proportion of use of reuse items
• Wealth of the facilities’ users
• Prosperity of the country

However, Rahman and Ali contend that information on quantities and composition of HCW is the most important data for its management. Based on work by Nessa, Table 3 demonstrates that quantities of HCW in developing countries are generally lower as compared to those for developed countries.

Figure 2. The average composition of hospital solid waste in the USA. (Source: Healthcare Without Harm (2001))

Research in both developed and developing countries has tended to suggest similar components in the waste streams. As illustrated in Figure 2 and Table 4 studies by Tudor and the medical association Healthcare Without Harm in the USA and by various researchers such as Terry L. Tudor, and Richard Olko and Peter Winch in the UK and Ashok Patil and AD. Shekdar in India have found that there are high quantities of paper, cardboard and plastics in the waste streams, while the clinical waste stream contains high percentages (>50%) of potentially ‘municipal/domestic like’ waste items such as plastics.

Research in the National Health Service (NHS) in Scotland by Wendy Rayner in 2003 showed that materials such as paper, cardboard and plastic accounted for as much as 25% of the mass and volume of waste produced, with organic waste being 29% of the overall mass.

A crucial point for consideration is that several studies from both developed and developing countries, including by Tudor in England, Ozbek and Sanin in Turkey, and both B-K. Lee and the U.S. EPA in the USA have all suggested that a large percentage of medical waste is not infectious. Indeed, research by medical association Healthcare Without Harm in 2001 in the USA and Mehrdad Askarian in Iran in 2004 indicate that as much as 50% of waste sent for incineration as clinical waste could potentially be classified as domestic.

Hence while there are differences in HCW quantities, there are similarities in composition between developed and developing countries.

Designating authority and commitment

Within developed countries responsibility for the effective implementation and regulation of policies usually involves a grouping of agencies. For example, in England and Wales development and implementation of HCW management policies is undertaken by a number of agencies including, the Department of Health (DoH), the Department for Environment, Food and Rural Affairs (DEFRA), and the National Health Service (NHS), with regulation from the Environment Agency (EA) and the Health and Safety Executive (HSE), while the U.S. EPA states that in the USA different federal agencies regulate various aspects of medical waste management (Table 5).

However, similar frameworks of responsibility and authority appear to be limited amongst many of the developing countries.

Training systems

Education and awareness are vitally important for improved waste management practices, with various writers such as Rushbrook, Tudor and Phengaxy arguing for the importance of staff training.

Healthcare waste minimization and technologies

Healthcare waste minimization

Studies have shown that hospitals that had implemented a segregation program could reduce clinical waste production by two thirds when compared with other hospitals. Healthcare Without Harm argued that disposal costs could be reduced by 40-70% through the implementation of a waste reduction program.

Through a greater understanding of waste arisings, several countries both in the developing and developed world have sought to implement segregation and waste minimization programs to reduce quantities of HCW. These include but are not limited to: in the USA by Healthcare Without Harm, and Lee; in the United Kingdom by NHS Estates, Olko and Winch, Woolridge and Phillips, and Tudor; in Finland by Antti Ponka; in India by Patil and Shekdar; in Tanzania by Rubhera R.R.M. Mato and Mengiseny E. Kaseva; in Iran by Askarian; and in Brazil by Da Silva.

Technologies: incineration

Incineration remains the main treatment employed to manage healthcare waste in developed countries. In 2004 it was also the method recommended by the WHO as the most appropriate option for developing countries, provided that attention is paid to effective waste reduction and segregation, placement away from populated areas, satisfactorily engineered and constructed, periodic maintenance and staff are properly trained and managed.

However, due to more stringent regulations on incinerating waste in many developed countries, there has been a significant reduction in the number of incinerators in operation. For example, according to the U.S. EPA some 50-80% of the existing 2400 medical waste incinerators in the USA are expected to be decommissioned as a result of the Medical Waste Incineration Regulations in 1997, with a shift towards alternative treatment technologies. Similarly in the UK the loss of Crown Immunity in 1992 (which meant all waste from healthcare facilities had to be segregated), resulted in the closure of many hospital-based incinerators.

Studies by the healthcare waste management researchers Adrian Coad in 1994 and by Kristoff Bosteon in 1997 found that in developing countries some 57%-92% of incinerators were either functioning poorly or not at all as a result of limited attention being paid to local conditions. A report by the WHO also notes that problems related to the health impacts of emissions and difficulties in transporting the waste to these sites can be a major barrier in developing countries.

The microbiologists and developers Malcolm Holliday and Sahil Chopra state that in many developing countries there are several barriers which make large-scale technologies, such as incineration, inappropriate for use, namely:

• The inappropriateness of mainstream technologies
• Small quantities of waste arisings
• Widespread sources of waste, while technologies require large quantities of waste concentrated in a particular area, such as a city or large town
• High capital and operating costs
• Complexity in maintenance and operation

However, while incineration remains the main technology in use both in developed and developing countries, it is not without limitations. Therefore, particularly in developing countries, alternative options are becoming popular.

Technologies: alternatives

There are a number of alternative treatments to incineration. These technologies have been seen as cleaner technology, easier to install, easier to gain planning permission to build and more cost effective to operate. They can also treat low-risk HCW waste such as packaging. However, Holliday states that while overall operating costs are generally lower, there is a limit to the types of waste that can be processed, and there will always be streams such as human tissue that must be incinerated. In addition, there are still doubts regarding the effectiveness of many of these technologies to efficiently treat HCW.

Table 6 lists some of the most common alternative technologies in the developed countries, while Table 7 lists those for developing countries, according to work by Healthcare Without Harm in 2004 and Holliday in 2005. It can be seen that differences in costs and waste generation patterns often results in a difference in the types of technologies employed between the two types of countries.

According to European Union landfill regulations, in Europe all healthcare wastes must be treated and made safe before they are landfilled at a licensed site, however, as noted earlier in many developing countries such restrictions do not exist.

Discussion

Differences in practice

This study has shown that at the national level while there were some evident differences there are also several similarities in the management of HCW from both developing and developed countries. These included differences in the quantities of HCW, with developing countries generally producing less, and in the stringency of the regulatory processes, with developed countries tending to have much more rigid legislative arrangements in place. However, while there were limited regulations in place it could perhaps be argued that the ‘lower’ stringency served to create a form of ‘self-regulation’ or ‘unwritten rules’ between the various stakeholders, such as between the healthcare facilities and the scavengers with respect to resource recovery. Indeed, academics such as Jenny Appleton and Mansoor Ali have argued that the adoption of overly stringent legislation is extreme and unnecessary. Hence there may well be a case for the fact that even though in line with international standards there should be improvement of standards in many of the developing countries, HCW regulations should be set to meet specific national needs and peculiarities.

Evidently, there is need amongst many developing countries for assistance in the development of and effective implementation of HCW management plans. In 2000 Rahman contended that effective HCW management in developing countries requires:

• Procurement strategies to reduce the quantities of hazardous wastes
• Mandatory staff education in waste segregation
• Mandatory hygiene education for healthcare employees and waste pickers
• Treatment of selected hazardous materials for safe reuse and recycling
• Effective surveillance to ensure hygienic practices

These issues could be realized through the development of greater partnerships at all levels between and within institutions in developing and developed countries, and the sharing of best practice between countries. This best practice should be in a number of areas including training and awareness, assistance in developing frameworks of responsibility, as well as waste treatment systems that are ‘fit for purpose’. Hence partnerships should be multi-disciplinary in nature involving a team approach that includes social scientists, engineers, behavioral scientists, urban planners, infection specialists, waste management experts, and importantly, the local population. The sharing of best practice should focus on sharing strategies and skills for the minimization of HCW similarly to the very successful voluntary partnership between the U.S. EPA and the American Hospital Association (AHA) (and its member hospitals) in 1998. However, there should be a balance struck between need for stringent approaches and peculiarities of local conditions. As indicated by Coad, implementation of technologies without sound knowledge of local conditions will often result in failure.

Similarities in practice

Despite differences, there were also fundamental similarities in the management of the waste, as well as individuals that should be addressed in both developed and developing countries:

There should be a greater focus on the management of the HCW at source. This would ensure both improved efficiency of treatment systems, as well as reduced risks to those handling the waste, as well as the technologies that have to manage it (e.g. reducing incidences of artificial hip joints breaking machines). Rahman and Ali note that there should be greater provision of education as a means of increasing awareness about the risks of handling the waste for waste pickers. WHO is of the view that particular emphasis should be placed on sharps, especially needles due to their highly infectious nature, and the particular threat their reuse poses to individuals in the community both in developed countries, as well as amongst the urban poor in developing countries.

While in both types of countries there were examples of programs to segregate the waste (both at source and further along the production chain), and there are also some markets for the recyclates (through scavenging or otherwise), there should be greater links made between waste generation and procurement. Studies by the researchers Anne Woolridge and Paul S. Phillips in 2004 showed that improved segregation can generate substantial savings. Research by Ozbek and Sanin in 2004 and by Tudor in 2007 demonstrated that greater linkages of product and service usage with ‘green’ procurement strategies could realize significant financial benefits. Such linkages could also lead to the development of materials and products that will produce less harmful waste to be disposed of.

A crucial component in achieving enhanced waste management efficiency is the behavior of the individual. Individuals should understand the need for segregation and be aware of what happens to the waste they generate. Hence there is a need for enhanced training and awareness of staff, as well as the general public. Training and awareness should focus on effective waste minimization and segregation for healthcare staff, as well as improving health and safety, and hygiene practices (in the handling, segregation, storage, transport and treatment of the waste) for both healthcare providers and the general public. This training should involve the full commitment of both management and employees. Staff should be included from the inception of the program, and throughout the process if any policies and programs are to be successfully developed and implemented.

Finally, there is a need for further evidence-based research in a number of areas to guide policy development. These areas should include, but not be limited to:

• Development of ‘fit for purpose’ regulatory policies and programs;
• Improving the efficiency of low-cost treatment technologies;
• Improving behavioral change amongst both staff and individuals in the community;
• Strategies for improving awareness and knowledge about effective HCW management;
• Greater partnerships between producers and research communities;
• Improving health and safety for workers and individuals in the community (e.g. scavengers);
• Understanding waste arisings and patterns from the community sector.

Thus, areas of research should cover both management of the waste itself, as well as the waste producer.

Future trends and implications

• Globally, the management of HCW is likely to undergo several changes primarily due to the changes in legislation and policies. For example, in Europe there will be greater ‘producer responsibility’ through legislation such the WEEE Directive 2005 and the Hazardous Waste Regulations 2005 acting as drivers for producers minimize the quantity of waste they produce, and to implement more ‘sustainable’ management practices such as recycling.
• The treatment and disposal of the waste will be more tightly regulated, in line with both international and national environmental management conventions and policies. Full compliance with and enforcement of these policies will, however, depend heavily on the level of control that exists within the country and its agencies.
• As a result of these more stringent restrictions, costs for managing HCW are likely to increase, and the required training of the individuals involved will have to be higher.
• In summary, it is likely therefore that the management of healthcare waste will become more heavily regulated, there will be more emphasis on producer responsibility, the regulatory framework will evolve, and costs will increase.

This study has demonstrated that there are both similarities and differences in the manner in which HCW is managed in both developed and developing countries. It is only through enhanced understanding and awareness of the issues, and greater partnerships that progress in the effective management of this waste can be achieved. With vast differences in access to resources such as finance and skills there will continue for some time to be variation in the manner in which HCW is managed between developed and developing countries. The crucial element will be to ensure that the gap does not become untenable, because within an increasingly global society the effects of damage in one geographical area will most certainly be felt in others.

Further Reading

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• California Department of Health Services (CDHS), 2007. Medical Waste Management Act. California: USA.
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• European Union (EU), 1999. Landfill Directive 99/31/EC. Office of European Communities.
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• Health Care Without Harm, 2001. Waste minimization, segregation and recycling in hospitals.
• Healthcare Without Harm, 2004. Non-incineration medical waste treatment technologies in Europe.
• Holliday, M.G., 2005. New and alternative technologies for treatment of hospital waste in developed and developing countries. Paper presented at ‘Tackling Waste’. July 13th – 14th, 2005. University of Nottingham. UK.
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