MAHWISH IRFAN, KAFFAYATULLAH KHAN, BASHIR ALAM, MUHAMMAD ZEESHAN AHAD, FAREEHA MALAHAT

Transcription

1 International Journal Applied Sciences, Engineering and Technology Vol. 02, No. 01, Jan-Dec 2013 Critical evaluation hospital waste management system in Pakistan and how it could be improved; recommendation for Pakistan environmental protection agency MAHWISH IRFAN, KAFFAYATULLAH KHAN, BASHIR ALAM, Department Civil Engineering, University Engineering & Technology, Peshawar, Pakistan Abstract: This paper critically examines and investigates the existing hospital waste management system in Pakistan and ascertains the perspective role Pakistan Environmental Protection Agency (Pak-EPA) in regulating hospital waste disposal system. Based on a qualitative research method survey 16 major hospitals and other healthcare establishments in the country were carried out and the results which indicate poor management hospital waste and lack use proper method waste disposal. The paper suggested multiprong strategy involving correctly identifying, segregating and handling clinical waste to avoid risks to staff and patients subject to proper risk assessment and disposing appropriately using modern techniques and stressing finally on maximizing the benefits recycling. Keywords: Pak EPA, PEPA 1. Research Methodology The project is mainly focused on the qualitative research study hospital waste management in Pakistan by carrying out an extensive survey major hospitals including government, private and other health care establishments in Pakistan. The purpose the survey was to critically analyze existing waste management system and its impact human health and environment and the role formal and informal actors involved in the waste management. It further ascertains the role Pakistan environmental protection agency, a prime regulator environmental sector in Pakistan. Primary data was collected by gathering responses employees engaged in hospital waste management and disposal through especially design questionnaire followed by personal observatory visits and informal interviews with health pressionals and concerned personnel s related to waste management in the hospitals and other health care establishments. The objective personal visits was to cross check the validity data collected through survey questionnaire regarding waste disposal system, storage system, waste segregation methods used, collection waste, conveying methods from source to final disposal sites, waste management policies hospitals, guidelines and information regarding onsite incinerator. Secondary data was collected by exploring various published reports the Government Pakistan, scholarly articles, reference books, various literatures and published reports Pak EPA, other concerned bodies and World Wide Web. 2. Literature Reviewed As compared to domestic and commercial waste, hospital waste is a special type waste produced in relatively small quantities but has the potential high risk infection. It mainly comprises infectious, radioactive, and toxic substances from hospitals including sharps (syringes and needles), blood products, human tissues, body parts, pharmaceuticals and heavy metals and also general use items i.e. paper, food, plastics etc ( Javied et al., 2008) [1]. Weak and inappropriate management may create serious repercussions on the public health and a significant impact on the environment (Pescod and Saw, 1998) [2]. It causes environmental pollution and health problems causing proliferation disease by viruses and micro-organism and contamination ground water by untreated medical waste in landfills (Patil and Pokhrel 2005, in Javied et al., 2008) [3]. Apart from few exceptions i.e. Agha Khan Hospital in Karachi and Shaukat Khanam Cancer Hospital in Lahore, waste management practices hospitals in Pakistan are not adequate. Hospital waste is ten disposed along with other municipal waste components by the municipal and local government authorities without giving proper attention to its diverse components and potentially infective constituents. Batterman (2004, in Javied et al., 2008)[4] argued that careless disposal sharps that are reused may lead the induction hepatitis B, hepatitis C, HIV and other possible infectious diseases to the exposed population. According to Visvanathan, (2006) [5] around 1.06 kg hospital waste is produced per day per bed estimating 0.25 million tons per year. IJASET Copyright 2013 BASHA RESEARCH CENTRE. All rights reserved.

2 MAHWISH IRFAN, KAFFAYATULLAH KHAN, BASHIR ALAM, Most the government as well as private hospitals in Pakistan do not ten give proper attention to the waste produced on site in terms storage, segregation, collection, transportation, treatment and disposal. Hospital staffs are also not properly trained in the handling hospital wastes which leads to weak or no segregation different types hospital waste. In government and private hospitals general and infectious wastes are ten mixed in the same primary container at source and such approaches result in a greater threat to the environment (Ahmed, 1997) [6]. One the common treatment methods hospital waste in Pakistan is the use incinerator. Rajput and Johri, (2003)[7] argued that although the use incinerator has an advantage destroying all microorganisms, melt needles and other metallic objects but it also produce large quantity combustion gases and incinerators are used without proper guidelines and legislative control. They further indicated that in Pakistan out 25 hospitals, 10 possess incinerator for incinerating hazardous waste. Javied et al., (2008) [8] stated that incineration hospital waste results in polluting the environment with fly ash and toxic metals in the incinerated ash. He further added that lack proper care in handling and disposing the newly generated incinerated waste gases, fly ash, bottom ashes and absence or ineffective local legislative limits or standards concerning levels heavy metals in bottom ash incinerators further exacerbate the situation. Constitution Pakistan does not contain statements principle or policy relating to the environment. The Pakistan Environmental Protection Ordinance (PEPO) 1983 was the first piece legislation that focused exclusively on the environment. Prior to its promulgation Pakistan had laws that contained provisions for environmental protection dealing only with certain issues (Hassan, 2006) [9]. These laws were piecemeal and ineffective, and punishments for violations were easy to avoid. Eventually Pakistan Environmental Protection Act (PEPA) 1997 replaced (PEPO) 1983 which is the most significant environmental legislation to date and a milestone in the environmental regulatory framework Pakistan. (PEPA) 1997 provides for comprehensive legislation encompassing hospital waste and handling hazardous substances. The Act also provides for the establishment Pakistan Environmental Protection Agency (Pak- EPA) charged with the mandate to regulate the implementation and enforcement laws and regulations on environmental issues. At a provincial level Environmental Protection Agencies (EPA s) were also established in all four provinces Pakistan i.e. Sindh, Baluchistan, Punjab and North West Frontier Province for the effective implementation and regulation environmental issues throughout the country. With regard to hospital waste, Hospital Waste Management Rules 2005 (Rules 2005) provides for detail legislation regarding the management and disposal hospital waste. According the Rules 2005, hospitals includes a clinic, laboratory, dispensary, pharmacy, nursing home, health unit, maternity center, blood bank, autopsy center, mortuary, research institute and veterinary institutions, including any other facility involved in health care and biomedical activities [Rule 2(1) (f)]. In spite these legislative measures the implementation and compliance with existing legislation is yet to be achieved and this ultimately gives rise to serious concerns about the environmental and public health impacts due to improper handling hospital waste. There is gap between theory and practice and such noncompliance by most the hospitals Pakistan denotes the symptoms weakness Pak EPA as a sole organization responsible for regulating environmental issues in the country. 3. Data Analysis and Findings The data collected through questionnaire survey and observational visit to the hospitals Pakistan reveals that the common practice, especially in government hospitals, are that plastic boxes were used for the disposal the sharps and other highly infectious waste and they were not being separated from other kind waste at source. The finding further reveals that in-spite existence legislation most the staff concerned with the handling waste the hospitals and other healthcare establishments are not aware it. Further, no proper waste management plans are in existence at the facilities. Management responsible for hospital waste does acknowledge that they were trying to implement waste management policies but were not effective. Waste generated by patients and their visitors in the hospitals are kept in small baskets and pots placed under each bed. The waste is later on collected by floor sweepers and ward cleaners at the end each shift and stored in a drum provided in each ward. Color coding is absent in many government hospitals and some other healthcare establishments. The only exceptions were blood products and placentas, which were stored separately and were later taken away by a governmental agency for disposal. However, some best private hospitals like Shoukat Khanum Cancer hospital in Lahore, Aga Khan Hospital in Karachi, Shifa International hospitals in Islamabad and Rehman Medical Complex and North West Hospital and research center in N-W-F-P, most legal obligations are followed and their waste management team are better trained in handling and disposing waste, further, some them also had ISO certification.

3 Critical evaluation hospital waste management system in Pakistan and how it could be improved; recommendation for Pakistan environmental protection agency In most the hospitals and other healthcare establishment waste are not formally separated at source and plastic containers or dustbins were used for collection such waste. Within wards the hospitals, the general and hazardous waste were kept together at temporary storage areas which are then shifted to the empty rooms on the premises the healthcare facility to be stored in cartons. Visit the hospitals shows that many places were inappropriate capacity due to which the waste spilled out from the facility, causing filth, dirt, and a proliferation rodents and insects, which might contribute to the spread disease. Table 1 Techniques used in the hospitals for waste collection Name Province No hospital Segregation at source Colour coding NWFP Islamabad Lahore Karachi Sharp segregation The storage facilities at hospitals and healthcare establishments were found to be made unsuitable materials and were not regularly cleaned, cleared, or disinfected. On-site treatment was not available and most prevalent type treatment is either improper incineration or open burning the waste, chemical disinfection is almost non-existent. The use gloves was not common during blood taking procedures and ward cleaners wore hardly any protective gear. The instructions were not strictly followed due to a lack effective monitoring in the hospitals. Although, the situation in the private health care establishments are comparatively better than the government hospitals. The result the survey also confirms incineration as prevalent method disposing f hospital waste in the hospitals Pakistan. Further the operator responsible for the use incinerator in hospitals is also not aware any emission level specified by Pak-EPA. Besides, no local legislative limits or standards are available regarding the emission into the air resulting from incineration. However, some standards regarding certain aspects environmental protection are available in literature. Ashes resulting from incineration are transported fsite in bags, using open municipality vehicles as a final disposal option. These bags were either buried along with the municipal waste or thrown away over the municipal waste dumps. Sometimes such open dumping places are put on fire which creates further waste and pollutes the local environment. Other waste is also transported to the storage site located outside, but adjacent to the hospitals. It was also observed that collection and transportation healthcare waste for final disposal is done along with other general waste without any segregation and finally it is disposed together with general waste at the open disposal site. Waste management teams in most the hospitals in the country, apart from ShaukatKhanum Cancer hospital in Lahore, Agha Khan Hospital in Karachi and Sheikh Zaid hospital in Lahore, are not properly trained according to international standards, especially cleaning hospital floors which are conducted by local labour class people who are not aware any safety measures. Scenarios at the private hospitals are comparatively better then government hospitals. Those waste management staff who are handling hazardous waste or infectious waste are ten lacks protective gears to facilitate safe handling such waste. As far as the awareness regarding the hospitals rules and other legal standards are concern, none staff members shows any awareness. Name Provinc e Table 2 Safety measures for waste handlings No hospita ls Existence waste managem ent team Trainin gs Table 3 Health care waste management team in hospitals Pakistan 4. Conclusion and Suggestions To address the problem hospital waste management in Pakistan a multi-prong approach need to be adopted on priority basis followed by awareness campaign and trainings to provide basic protection measures to those who are responsible for handling and disposing healthcare waste. As evident from this research studies all type wastes, including infectious, general, food and hazardous chemical materials are all mixed together and are collected, transported and finally Knowledge their legal Standards/rules/regu lations NWFP Islamab ad Lahore Karach i Name No hospit Province al Protecti ve gear for Waste handler s Appropri ate Transpor t vehicles Appropri ate Storage facility before disposal Use incinera tor NWFP Islamab ad Lahore Karachi

4 MAHWISH IRFAN, KAFFAYATULLAH KHAN, BASHIR ALAM, disposed collectively. The risk indicators include accidental exposure from contact with wastes at municipal disposal bins; exposure to chemical or biological contaminants in water and exposure to chemical pollutants from incineration the wastes. Firstly, separation waste at source is the most important and fundamental step in the effective waste management system and it must be ensured that all hospital waste is secured from areas public access. It is critical that waste is segregated prior to treatment and disposal which ultimately safeguards the health health care workers and other person responsible healthcare waste management. Imposing segregation policy in the hospitals will result in a clean solid waste which can be easily and cost-effectively managed through recycling, composting and landfilling. Further, the resulting waste will be having high proportion organic wastes (food items) and recyclable wastes (paper, plastic, metal) and very little will be left for disposal. For the effectiveness and success this process, training staff involved in healthcare waste management should be conducted and separate colored containers with visible signs should be used, and protective gear for workers should be provided. By ensuring all these measures proper segregation waste at source will be achieved which is the first and important step in hospital waste management system. Secondly, effective intervention Pak-EPA, who has successfully drafted and approved hospital waste management rules in But this is very unfortunate that apart from these guidelines nothing has been done by Pak-EPA to monitor and enforce these guidelines in the hospitals in Pakistan. Every hospital follows its own policy and most them are not following proper disposal procedures. The only method which is prevalent in hospitals is incineration which is not monitored to ensure this process does not lead to environmental contamination and harm. Pak-EPA should take proper steps to ensure that such rules have to be observed, followed by viable enforcement policy and all those hospitals who are in contravention such rules should be punished with heavy fine which will also enables Pak-EPA to generate its own revenue. This will result in following strict observance rules and effective management hospital waste. Development separate segregation policy by Pak EPA and its implementation in the hospitals will full vigor followed by effective monitoring and enforcement will serve this purpose. Thirdly, use incinerator at the hospitals should be strictly observed by Pak-EPA and directives regulating emission into the air should be prescribed by Pak-EPA and should be closely monitored. Many hospitals in Pakistan is using incinerator to reduce waste which leads to the generation ash as argued by Javied et al., (2008), that the use incinerator in the hospital to dispose f waste not only releases toxic gases (CO, CO 2, NO 2, SO 2 etc.) into the atmosphere but also leaves solid material which increases the level heavy metals, inorganic salts and organic compounds in the environment. However, all the above suggestion may not be implemented unless Pak-EPA should be made more autonomous. This can only be done by small intervention by Asian Development Bank (ADB) or World Bank. These institutions may sign loan agreements or grants on specific compulsory conditions attached to it which will create obligations that needs to be fulfilled by the government. These kinds interventions are not new in Pakistan and Corporate Sector in Pakistan has already witnessed the same. If ADB or World Bank provide loans or grant in few tranches to Pak EPA through Ministry Environment on the conditions that they should; amend the PEPA 1997 to make Pak EPA more strong and autonomous; strengthen the role environmental tribunals by enhancing its power to take cognizance the environmental fence, specially mishandling hospitals waste management; specifically provides power to Pak EPA to levy heavy penalties on environmental fenders which will enables them to generate their own revenue as well as create deterrence in the market on environmental fenders; specifically provides powers to Pak EPA to regulate hospital waste management regime in Pakistan with continuing legislation and effective monitoring; Add in establishing a regulatory body in Pakistan to regulate the licensing regime and other affairs the hospitals including waste management. There is lack such regulatory body in Pakistan to regulate the affairs the health sector including hospitals and other health care establishments. This led to irregular practices in every hospital. It is highly recommended that National Health Services Commission Pakistan should be established on the line National Health Services Scotland and UK. This regulating body will effectively regulate all the affairs the hospitals including health care waste management and the licensing regime new hospitals and health care establishment. Again ADB or World Bank can initiate such projects with the support Govt. Pakistan. Although NGO s culture do exist in Pakistan and they are working in various sectors. Millions dollars has been poured into by foreign donors through NGO s to bring about reforms in various sectors including education and health. However, this sector is also heavily affected by corruption and the objectives such type non-formal organization are not much fruitful. Since Afghan war, various foreign donor agencies has been providing money to support the government through NGO s and, as per the record, if all that money has been properly invested in an effective ways half Pakistan may represent the picture Hong Kong. Unfortunately the culture corruption has affected this country since long and this trend has been on the

5 Critical evaluation hospital waste management system in Pakistan and how it could be improved; recommendation for Pakistan environmental protection agency increase due to high inflation rates and low income per capita. Therefore, involvement NGO s in healthcare waste management may not deliver as required. Proper legislation and enabling Pak-EPA to perform its functions effectively without any political pressure would be a viable solution to address this problem. References: [1] Javied S., Tufial M. and Khalid S. (2008), Heavy metal pollution from medical incineration at Islamabad and Rawalpindi, Pakistan. Microchemical Journal, (90): [2] Pescod, M.B. and Saw, C.B. (1998), Hospital waste management in four major cities; a synthesis report. UWEP Working Document 8, WASTE advertisers on urban environment and development, Netherlands, available on: file/wd08%20ebook.pdf [3] Patil, G.V. and Pokhrel, K. (2005), Biomedical waste management in an Indian hospital: a case study. Waste Management 25 (6): Cited in Javiedet al., (2008). [4] Batterman, S. (2004), Findings an assessment small-scale incinerators for health-care waste, Report WHO, World Health Organization, Geneva. Cited in Javiedet al., (2008) [5] Visvanathan, C. (2006), Medical Waste Management Issues in Asia, Asian Institute Technology Thailand. Available on [6] Ahmed R. (1997), Hospital waste management in Pakistan, case study report by WASTE advisers on Urban Environment and Development, Netherlands, available on file/cs_hosp_pak.pdf [7] Rajput, A.M. and Johri, A.E. (2003), Assessment health care waste management in Pakistan. WHO and Govt. Pakistan joint collaborative Environmental health programme publication No WHO Islamabad, Pakistan, available on: BLICATION%20201%20- %20ASSESSMENT%20OF%20HELATH%20C ARE%20WASTE%20MANAGEMENT%20IN %20PAKISTAN%20- %20DR%20A%20MAJID%20RAJPUT%20&% 20DR%20AMIR%20ELLAHI%20JOHRI.pdf [8] Javied S., Tufial M. and Khalid S. (2008), Heavy metal pollution from medical incineration at Islamabad and Rawalpindi, Pakistan. Microchemical Journal, (90): [9] Hassan, J. (2006), Environmental Laws Pakistan. Lahore: Bookbiz.