SUBMISSION Ref.: 16/11/3 TO: ALL HEADS OF INTITUTIONS/HOSPITALS SUBJECT: SECOND DRAFT DISCUSSION DOCUMENT ON MEDICAL WASTE MANAGMENT 19 June 2001 The second draft discussion document on medical waste management is being circulated for comments. It is intended that the final draft document will be submitted for final approval by the Department before 29 June 2001. Mr W.D. Khanyile DIRECTOR : ENVIRONMENTAL HEALTH
1 SECOND DRAFT DISCUSSION DOCUMENT MEDICAL WASTE MANAGEMENT STRATEGY FOR KWAZULU-NATAL DEPARTMENT OF HEALTH 1. INTRODUCTION 1.1. The Strategy takes cognisance of the fact that it will not be possible for all Provincial Health Care facilities to achieve the highest possible standards in a short time. In many ways it is better to adopt the incremental approach, in which any improvement is better than none, even if the standards are not yet what would be desired. 1.2. Absolute elimination of all risks is impossible. A realistic goal is the attainment of a reasonable degree of safety at all times without needlessly compromising efficiency. 1.3. The purpose of the strategy is to assist health care facilities in the Province in establishing and implementing a uniform programme for the effective medical waste management control, to meet minimum standards. 1.4. Such programme when enthusiastically supported by management of all health care facilities will largely contribute to improved patient care, provide health and safety of health workers and also enhance the image of these facilities as professional health organisations totally committed, not only to quality patients care, but to public and environmental health as well. 1.5. The strategy further seeks to strengthen the institutional aspects of medical waste management rather than imposing rigid and unrealistic requirements on disposal methods. 1.6. The strategy therefore advocates promotion of procedures and practices which will reduce the risk of the spread of disease and occurrence of accidents associated with medical waste, while it does not signify that it is suitable for all situations and neither does it indicate that it is the ideal strategy. 1.7. The medical waste management is not a question of a single method, but the combination of various measures resulting in a waste management system as part of an overall hygiene concept. The system should be supported and monitored by the Provincial Department of Health management and backed by a National policy and guidelines on medical waste management and become part of local supervision systems. 1.8. The polluter pays principle holds the generator of the medical waste responsible for the safe handling and sound management of the medical waste, from the time it is generated until its final disposal, in a manner designed to protect health and the environment. The attachment of
2 1.9. responsibility attempts to assign liability to the generator to ensure that health and safety requirements are met and an acceptable level of hazard protection is achieved. 1.10. Appropriate planning to meet the challenges of medical waste management control requires the definition of a strategy that will facilitate careful implementation of the necessary measures and the appropriate allocation of resources according to the identified priorities. 2. THE CURRENT SITUATION 2.1. When reviewing the situation in the province it is important to consider the degree of awareness of health issues as well as practices and technology. 2.2. The degree of health education and hygiene awareness among the public is another crucial factor in deciding the risks posed by medical wastes. In our societies, there is a significant proportion of the population that is illiterate and unaware of the dangers, and it is these people who are most at risk. Barriers between such people and hazardous medical waste generally involve strict control of access and close supervision by responsible professionals. 2.3. There is very little control over how medical waste is stored, handled and disposed of. Very frequently medical wastes are dumped together with municipal garbage in municipal landfill sites. Hospital/Clinic incinerators, where provided, do not operate satisfactorily. Whether there is adequate classification and segregation of the different types of hazardous waste at source seems to vary from facility to facility. Whether there is adequate classification and segregation of the different types of medical waste at source seems to vary from facility to facility. 2.4. It seems that the worst problem arises in small rural hospitals and clinics, which are unable to give the required special care in handling medical waste because of being constrained by the lack of resources. 2.5. There is also acute need for training on hospital hygiene for all nonprofessional hospital staff and training about risks of infectious injuries from sharps and proper handling and secure storage of medical waste. 2.6. The main concern of infectious medical waste is the transmission of HIV/AIDS virus and more often, of Hepatitis B virus through injuries caused by syringe needles contaminated by human blood. 2.7. At present, the KZN Department of Health does not have one incinerator that meets with the legal requirements for the disposal of medical waste nor does it
3 have the financial capacity to upgrade the incinerators. (A Departmental situational analysis of the incinerators is attached as Annexure A). In view of this problem, steps have been taken to arrange a comprehensive Waste Management Contract, which is now available as Contract No.ZNT5027 effective from 1 st June 2000. Every health care facility should then be encouraged to make use of this contract in the disposal of medical waste. The situational analysis of the Institutions that are not participating in the contract has revealed medical waste problems that need the urgent attention of the Department. Annexure B shows the prioritization of these Institutions and it is recommended that they be considered as matter of priority for the coming financial year. 2.8. The participation in the contract results in the costs of separate collection, appropriate packaging and on site handling of medical waste being internal to each health care facility and paid as labour and supplies costs while the costs of off-site transport, treatment and final disposal are external and paid to the contractors who provide the service. 2.9. The baseline study, to establish current levels of medical waste production and specific medical waste management practices, is being initiated and the baseline survey report will inform the process of updating the strategy to incorporate essential changes. 3. MEDICAL WASTE MANAGEMENT CONTROL 3.1. Medical waste management is part of health care facility hygiene and maintenance activities. General facility hygiene is a prerequisite for good medical waste management. 3.2. For the prevention of the spread of infection outside health care facilities, careful management of wastes from the point of generation is of paramount importance. 3.3. Minimizing risks involves ensuring that the disposal methods employed are sustainable in the long term and at the same time, do not present long-term ecological hazards. 3.4. The medical waste management is a process with a chain of critical steps, namely, prevention and minimization, segregation, identification, handling, treatment and disposal. The procedure followed requires organisation and coordination, which is best expressed by the term medical waste management.
4 3.4.1. WASTE PREVENTION AND MINIMISATION Health Care facilities should seek to reduce the overall amount of waste generated, in particular medical waste. The following are the various ways of reducing the quantity of waste; 3.4.1.1. Careful and comprehensive management of stores to substantially reduce the quantities of chemical and or pharmaceutical waste produced by health care facilities will also give rise to financial savings. 3.4.1.2. Many undamaged pressurized gas containers which may be easily recycled should be returned to their original supplier for refilling. 3.4.1.3. Encourage use of items that can withstand the sterilization process and designed for reuse or recycling. 3.4.2 WASTE IDENTIFICATION The use of colour- coding and labeling of hazardous waste containers provides for effective waste separation, in addition to identifying its source of generation and person responsible. If a health care facility does not have an adopted colour code, then that of WHO is recommended: Yellow for infectious waste, red for sharps and highly infectious wastes, brown for chemical and pharmaceutical wastes and black for non-infectious non-hazardous waste. 3.4.3 WASTE SEGREGATION/SEPARATION The effective separation of hazardous medical waste from nonhazardous wastes is the key element in promoting waste management. Segregation of waste allows special attention to be given to the relatively small quantities of waste that need it. Separation is most effective when done prior to a procedure that generates the hazardous waste. For example, after use, a syringe becomes hazardous waste, but its original package does not. When separated from the syringe before use, the packaging can be placed into a non-hazardous waste container, avoiding potential contamination and subsequent classification as hazardous waste. It is important that containers used for the separation of hazardous wastes be leak-proof and kept in a secured area. All sharps should be put into suitable containers that are resistant to puncture and, these should be disposed of in such a way that they are not accessible to drug addicts, children and scavengers.
5 3.4.4 WASTE HANDLING Waste handling within the health care facility includes collection, transport and storage. The waste handlers or porters carrying waste should wear sensible protective clothing, such as gowns and gloves, both for hygiene reasons and to prevent skin puncture. They should also follow a decontamination procedure for the waste cart after each collection. The medical waste storage facility should be secure so that unauthorized people cannot gain access to the waste. 3.4.5 WASTE TREATMENT treatment is a process that changes the character of hazardous wastes to render them harmless to the public. The main purpose of waste treatment is to disinfect or sterilize the waste so that it is no longer the source of pathogenic organisms. There is no ideal or perfect treatment method and all technologies have both advantages and disadvantages. The decision to select an on-site treatment method should be based on treatment effectiveness, investment, maintenance, service costs, hazardousness of post-treatment residues and environmental pollution. The other alternative to take is a co-operative approach by co-sharing ownership and operation of an off-site treatment technology, which could also provide for the waste treatment needs of other health care facilities. Incinerators operate at their maximal efficiency when their capacity is large, and when the wastes they burn have a sufficiently high calorific value. In order to ensure complete combustion so that odours and smoke are kept to a minimum, the temperature must be high, and the wastes must be held at this high temperature for a sufficient time, and agitated or turned sufficiently to ensure that all the mass is burnt. Incineration or burning is not a disposal option for pressurized containers or aerosol cans because of the risk of explosion. The best disposal options are recycling and reuse. Wastes with high heavy metal content such as wastes containing mercury or cadmium should never be burned or incinerated because of the risk of atmospheric pollution with toxic vapours and should never be disposed of in municipal landfills as they may pollute the ground water. The safe management of radio active waste should ideally be the subject of a proper national strategy with an infrastructure that includes appropriate legislation competent regulatory and operational organizations and adequately trained personnel
6 3.5 MANAGEMENT ISSUES 3.5.1 The human element is more important than the technology used. Almost any system of treatment and disposal that is operated by well- trained, motivated staff can provide more protection for staff, patients and the community than an expensive or sophisticated system that is managed by staff who do not understand the risks and importance of their contribution. 3.5.2 The medical waste management strategy requires diligence and care from nursing and medical staff who use the equipment and supplies that become waste, through porters and labourers who provide clean sacks or containers and carry away waste, to incinerator operators and persons responsible for ensuring that residues are disposed of in the correct way. 3.5.3 All staff whatever the position in the above -mentioned chain, need to know what is expected of them, and why it is important. Regular refresher courses are helpful and monitoring should be carried out to expose the needs for further training. In order to achieve acceptable practices in the medical waste management, it is essential for all managers and other personnel to receive appropriate training. 3.5.4 Motivation should start with health care facility management who must show by word and example that they believe in the importance of correct waste management procedures. Full discussion with staff, should take place, of the hazards posed by medical waste for them to understand the significance of the steps they are being asked to take. 3.5.5 The above measures should be backed up by supervision to identify needs for further training, to investigate carelessness and deception and to punish any deliberate failure to comply with prescribed practices. 3.5.6 The health care facility management should also create an environment conducive to encourage a feeling of team spirit and shared responsibility for medical waste management control. 3.5.7 The contract of service between the private waste contractor and the Department of Health should, among other terms, include the following: 3.5.7.1 minimum level of service, especially with regard to reliability, safety or public health risks. 3.5.7.2 environmental concerns 3.5.7.3 regular inspections and regulatory control 3.5.7.4 a breach provision which specifies under what circumstances either party will be entitled to terminate the contract.
7 3.5.8 The proper management of medical waste depends largely on good administration and organization but also requires adequate financing as well as active participation by trained and informed staff. 3.6 RECOMMENDED MEASURES FOR COST REDUCTION ARE AS HEREUNDER: 3.6.1 Careful and comprehensive management of chemicals and pharmaceuticals stores. 3.6.2 Substitution of disposable medical care items by recyclable items. 3.6.3 Adequate segregation of waste to avoid costly or inadequate treatment of waste that does not require it. 3.6.4 Improved waste identification to simplify segregation, treatment and recycling. 3.6.5 Waste management and cost documentation will result in assessment of true costs to make it easier to identify priorities for cost reduction and to monitor progress in the achievement of objectives. 3.6.6 Establishment of training programmes for workers to improve the quality and quantity of work. 3.6.7 Protection of workers against occupational risks. 3.7 HEALTH AND PRACTICES FOR HEALTH CARE PERSONNEL AND WASTE WORKERS. 3.7.1 The medical waste management control should include provision for continuous monitoring of workers health and safety to ensure that correct handling, treatment, storage and disposal procedures are being followed. Essential occupational health and safety measures should include the following: 3.7.1.1 Proper training of workers. 3.7.1.2 Provision of appropriate equipment and clothing for personal protection. 3.7.1.3 Establishment of an effective occupational health programme that includes immunization, post exposure prophylactic treatment and medical surveillance. 3.7.2 Training in health and safety should ensure that workers know of and understand the potential risks associated with medical waste, the value of immunization against viral hepatitis B and the importance of consistent use of personal protective clothing and equipment. 3.7.3 Workers at risk include health care providers, health care facility cleaners, maintenance workers, operators of waste treatment equipment and all operators involved in waste handling and disposal within and outside health care facilities.
8 3.7.4 A comprehensive risk assessment of all activities involved in medical waste management plan, carried out during preparation of health care facility medical waste management plan, should allow the identification of necessary protection measures. These measures should be designed to prevent exposure to hazardous materials or other risks or at least to keep exposure within safe limits. 3.8 TRAINING 3.8.1 The overall aim of training is to develop awareness of the health, safety and environmental issues relating to medical waste and how these can affect employees in their daily work. Health and safety at the work place and environmental awareness are the responsibility of all and in the interests of all. 3.8.2 The personnel training programme on medical waste management control should include the following: 3.8.2.1 information on, justification for, all aspects of the medical waste management strategy. 3.8.2.2 information on, the role and responsibilities of health care facility staff members in implementing the strategy. 3.8.2.3 Technical instructions, relevant to the target group, on the application of waste management practices. 3.8.3 Periodic repetition of courses is essential to provide refreshment training as well as orientation for new employees and for existing employees with new responsibilities and to also update knowledge in line with policy or strategy changes. 3.8.4 The Infection Control Officer should be given responsibility for all training related to minimization, identification segregation, collection, storage and disposal of medical waste. The officer should ensure that staff at all levels are aware both of the Departmental medical waste management strategy and health care facility waste management plan and of their own responsibilities and obligations in this regard. 3.8.5 The training package should be suitable for various types of health care facilities and should be illustrated with drawings, diagrams, photographs, slides or overhead transparencies. These should reflect the environments in which trainees work and provide examples of measures, if any, that have been implemented. Where it is likely that waste handlers and other workers are illiterate, all procedures should be carefully represented in diagrams and photographs.
9 4. PLAN OF ACTION The Medical Waste Management strategy has been developed to ensure that reasonable steps are taken to improve medical waste management control and ensure responsible and sustainable management. The undermentioned action plans are aimed at assisting Provincial Public Health care facilities in establishing and implementing a better programe for more effective management of hazardous medical waste. When the programme has been fully implemented throughout the Province it will be extended to include private health care facilities and other medical waste generators. The baseline survey is being initiated in the Province in order to develop the Provincial medical waste management database which will guide incorporation of medical waste management strategies for all medical waste generators in the Province.
10 ACTIVITIES 4.1. Finalize and implement Medical Waste Management strategy RESPONSIBILITY DRIVER Environmental Health Directorate and Medical Waste Regulatory Authorities Committee and Role-players and stakeholders TIME- FRAME 29/06/01 INDICATORS OUTPUT/ OUTCOME Strategy document 4.2. Identify and involve role-players and stakeholders Environmental Health Directorate and District EHO's 29/07/ 01 ongoing Structures to coordinate and monitor medical waste management at facility, district and provincial levels 4.3. Undertake IEC Activities Environmental Health Directorate and Health Care Facilities 28/ 09/01 ongoing Number of health education actions 4.4. Create a Medical Waste Management database report Environmental Health Directorate 21/12/01 Profile of medical waste generators in the Province.4.5 Allocate adequate funds, approximately R1622 400 for off site transport, treatment and disposal of medical waste for first and second priority Institutions in Annexure B. Chief Directorate: Financial management + Management of the Institutions concerned. 31/03/02 Budget allocation for participation in medical waste contract..4.6 Allocate adequate funds for off site transport, treatment and disposal of medical waste for third priority Institutions in Annexure B. Chief Directorate: Financial management + Management of the Institutions concerned. 31.03. 03 Budget allocation for participation in medical waste contract.
11 5. IMPLEMENTATION OF THE STRATEGY AND MONITORING The in house control of Medical Waste produced by Health Care facilities should be managed in accordance with the standards and guidelines contained in the undermentioned documents. (a) Minimum requirements for the handling and disposal of Hazardous Waste: Department of Water Affairs and Forestry, 1994. (b) Handling and Disposal of Waste Materials within Health Care Facilities: SABS Code of Practice 0248, 1993 Guidelines for Waste Management at South African Health Facilities: National Health Department RSA and CSIR, 1999. (d) Proposed Regulations for the control of Environmental conditions constituting a danger to Health or A Nuisance: Department of Health Government Gazette No 20796, 14 January 2000. A system of accountability and reporting, in respect of Medical Waste Management, should be established and maintained in order to make improvements in the reduction of risks and the improvements of standards. 5.1 GUIDELINES FOR IMPLEMENTATION (a) The main responsibility for Medical Waste Management lies with each individual health care facility and such programme should have enthusiastic support of the Head of the facility. (b) Appropriate institutional framework for each facility, such as Infection Control Committee if in existence, should be assigned with responsibility for ensuring effective programme of Medical Waste Management: 1. It is recommended that such committee should include the following officers: Infection Control Professional Nurse Maintenance Officer or Artisan Foreman Environmental Health Officer Responsibility Manager of the facility One senior member of the facility management Occupational Health Nurse Pharmacist 11. The primary duties of the committee should include: Define categories of medical waste Assess current medical waste management practices and responsibilities Assess current waste management cost
12 Develop effective medical waste management policy and plan for the facility Implement the medical waste management plan Secure active commitment of Senior Management to implementing, monitoring and evaluating the strategy. (d) (e) Entrust Environmental Health officers with the responsibility of developing inspection programmes to ensure that the proper procedures and methods for medical waste management are followed. Develop and provide a training programme for all staff at the health care facilities to familiarize them with: (i) Procedures for the segregation, collection, storage, labeling and movement of medical waste specified by strategy document and documents mentioned under 5 (a), (b), (c), and (d). (ii) The hazards of the medical waste materials to which workers and the public may be exposed (iii) Personal and environmental hygiene within the health care facility (iv) A threat, caused by scavenging on facility ground, to the facility infection control and patient care, as well as to public and environmental health. (f) Link the medical waste management strategy to the Department's performance management, goal setting and reward structures to ensure ongoing focus sustainability. (g) (h) Information on disposal practices and facilities should be disseminated and used, for guidance of others and where there is a possibility of coordination or sharing of facilities Improvement in medical waste management should start in large hospitals, then extend to smaller health care facilities and finally to the diverse sources of small quantities of waste. (i) The Heads of Health care facilities are responsible for health protection and safety at the workplace and bear legal responsibility for the safe disposal of medical waste generated in their facilities. 5.2 MONITORING AND EVALUATING (a) Establishment of district and Provincial appropriate structures for co-ordinating medical waste management activities of the various health care facilities
13 provides levels of responsibility for monitoring and evaluating. (b) Regular inspections of health care facilities should give priority to monitoring of medical waste management and disposal facilities and reporting thereon. Copies of the reports to be communicated to all relevant role players, stakeholders and interested parties. The Provincial Medical Waste Regulatory Authorities Committee should have an over-arching responsibility for monitoring and evaluating all medical waste management procedures and methods followed in the Province and give appropriate advices and directives thereon
ANNEXURE A INTITUTIONS NOT PARTICIPATING IN THE WASTE DISPOSAL CONTRACT FUEL BURN PRESENT CONDITON ESTIMATED COST HOW&WHERE HOSPITAL R MOKE MODEL SERIAL ING OF UNIT TO REPAIR IS THE ASH INTITUTIONS TEMP DISPOSED? REMARKS CW1 Appelsbosch hospital B Macro Coal fired A08-03 Coal 350 Not good R25 000 00 In the waste Must be repaired Mr G Aysen area Benedictine Hospital D Coal 350 Mr Fimalter Bethesda hospital E Coal 350 Mr Schalkwyk Catherine Booth Hospital H Lucifer Coal 350 Mr Filmalter Ceza Hospital D SA Nu-way 24/8688/4 diesel 600 Mr Filmallter Charles Johnson Hospital G WCR coal 350 Mr Filmalter Church of Scotland G Macro Coal 350 MrFilmalter Church of Scotland G Coal 350 Mr Filmalter Dundee Hospital G Macro Nu-way 330 diesel 600 Mr PF Bryant burn Ekuphumuleni Hospital H Diesel 600 Mr RG Westwood Ekombe Hospital H Coal 350 Mr Schalkwyk Emmaus hospital C Lucifer coal 350 Mr Filmalter Eshowe Hospital H Macro Rielo diesel 600 Mr Schalkwyk 40F20 Gamalakhe Health Ward A Fair N/A ViaTLC Does not comply with Mr TL Walker the latest regulations Greytown Hospital B Macro MDL35169 SN02443612 Diesel 600 Fair Ongoing ±R10 000pa N/A Just serviced Mr G Aysen burn 2 Hlabisa Hospital H Macro Rietto 1245400167 Diesel 600 Mr Schaklwyk 40F20 Hlabisa Hospital H Macro Rietto 1195301329 Diesel 600 Mr Schalkwyk 40F20 Itshelejuba Hospital D Mitchel New Way 02/7139/3 Diesel 600 Mr Schalkwyk Ladysmith Hospital C Macro New-way 462NH3D oil 600 Mr Filmalter Manguzi Hospital E Lucifer coal 350 Mr Fimalter Mbongolwane Hospital H coal 350 Mr Schalkwyk Montobelo Hospital F Macro IP40 MO803 coal 350 Refractory needs to be R20 000 00 Where the Dept Institution has Mr G Aysen done rubble and dirt is contacted the disposed of contractor and plans are in place to implement the system Mosvold Hospital E Nu-way- 24/8923/1 Mr Schalkwyk L3SIS92I f 830 Mosvold Hospital E Nu-way- 28/4208/7 Mr Schalkwyk L3SIS92I f 830 Mseleni Hospital E Mr Schalkwyk 14
15 BURNING TEMP PRESENT CONDITION OF UNIT ESTIMATED COST TO REPAIR HOW & WHERE IS THE ASH DISPOSED? REMARKS HOSPITAL/INSTITUTI ON R MAKE MODEL SERIAL FUEL Ngwelezana Hospital H Macro Coal 350 Contract in use for sharps only CW1 Mr G.J. Van Schalkwyk Nkandla Hospital H Lucifer Coal 350 Mr G J Van Schalkwyk Nkandla Hospital H Macro Riello 40F5 1255201266 Diesel 600 Mr G J Van Schalkwyk Osindisweni Hospital F Macro Manual-220 05/1/1/00 Coal 350 The unit is fired by hand using coal. The process is totally incorrect for the disposal of waste products St Apollinaris Hospital B Macro- Burn St Francis Hospital D Zululand Steam Oil Fired-Nu- Way-120 B The unit is currently being used daily The ash is being dumped on site 28/3775/1 Diesel 600 Fair N/A On site, In the general waste pit The burning process of the incinerators is totally inadequate. Now that the institution falls within the requirements of the Pollution Control of the Durban Metro, the unit will fail to meet the requirement of the Act Does not comply with the latest regulations Mr P F Bryant Mr T L Walker Coal 350 Mr R E Filmalter Stanger Hospital F Macro Miniflam-M3 V84045 Diesel 600 Not Good From Zululand Steam R50 000-00 Taylor Bequest Hospital A Macroburn Oil Fired Nu- Way 100B N/A/ Walls are collapsing near chimney. Stack door rusting away. Diesel 600 Fair N/A Via the Municipality Does not comply with the latest regulations Mr G Aysen Thulasizwe Hospital D Barlows Coal Fired Coal 350 Mr R E Filmalter Umphumulo Hospital F Macro Coal Fired U08803/01 Coal 350 Not good R25 000-00 In waste area Walls are collapsing and Rapidly deteriorating Mr G Aysen Mr T L Walker
HOSPITAL/INSTITUTI ON R MAKE MODEL SERIAL FUEL BURNING TEMP PRESENT CONDITION OF UNIT ESTIMATED COST TO REPAIR HOW & WHERE IS THE ASH DISPOSED? Untunjambili Hospital B Invincible Coal Fired U0803/02 Coal 350 Not Good R25 000-00 Around the institution Roads Untunjambili Hospital B Safumco Coal Fired 20790 Coal 350 Not Good R15 000-0 Around the Institution Roads REMARKS Walls are collapsing and rapidly deteriorating Walls are collapsing and rapidly deteriorating 16 CW1 Mr G Aysen Mr G Aysen Utrecht Hospital (Niemeyer memorial) G Lucifer Diesel 600 Mr R E Filmalter Vryheid Hospital D Macro- Burn Nu-Way-EB25c V88003 Diesel 600 Mr R E Filmalter
17 ANNEXURE B Prioritization of Institutions with poor medical waste management: incinerator Situational Analysis. INSTITUTION NAME ESTIMATED COST OF CONTRACT PARTICIPATION PER ANNUM FIRST PRIORITY 1. Appelsbosch Hospital 2. Montobello Hospital 3. Umpumulo Hospital 3. Untunjambili Hospital 4. Stanger Hospital 5. Ekhombe Hospital 6. Mosvold Hospital 7. Bethesda Hospital 8. Mseleni Hospital 9. Manguzi Hospital 10. Hlabisa Hospital R55 200 R96 000 R36 000 R38 400 R156 000 R120 000 R204 000 R192 000 R156 000 R228 000 R162 000 SECOND PRIORITY 1. Greytown Hospital 2. Osindisweni Hospital THIRD PRIORITY 1. Benedictine Hospital 2. Catherine booth Hospital 3. Ceza Hospital 4. Charles Johnson Hospital 5. Church of Scotland Hospital 6. Dundee hospital 7. Ekuphumuleni Hospital 8. Emmaus Hospital 9. Eshowe Hospital 10. Gamalakhe Health Ward 11. Itshelejuba Hospital R76 800 R102 000 R504 000 R96 000 R228 000 R456 000 R216 000 R240 000 R24 000 R147 600 R252 000 R 9 600 R114 000
18 12. Ladysmith Hospital 13. Mbongolwane Hospital 14. Ngwelezana Hospital 15. Nkandla 16. St.Apollinaris Hospital 17. Francis Hospital 18. Tayler Bequet Hospital 19. Thulasizwe Hospital 20. Utrecht Hospital 21. Vryheid Hospital R504 000 R108 000 R276 000 R144 000 R46 800 R84 000 R81 600 R132 000 R 16 800 R288 000