MEDICAL WASTE REPORT Table of Contents

MEDICAL WASTE REPORT Table of Contents Introduction... 4 Why conduct an audit of medical waste?... 4 What is medical waste?... 5 a)infectious waste... 5 b)hazardous waste... 5 c)radioactive waste... 5 Audit Objective and Questions... 5 Audit Objective... 5 Audit Questions... 6 Audit Scope and Methodology... 6 Audit criteria... 6 Source of Audit Criteria... 6 Assessment Criteria... 7 Handling... 7 Storage... 8 Transportation... 8 Disposal... 9 It further provides that the infection control officer shall organize and supervise training programmes for all staff in collaboration with the waste management officer and other member of the waste management team. Audit Findings... 10 Handling... 10 Storage... 11 Transportation... 12 Disposal... 13 Waste Management Plan... 16 Conclusion... 19 Recommendations... 19 Appendices... 21 1

Executive summary The audit on medical waste management in the health institutions has revealed serious weaknesses in the manner in which health care waste from Health Care Facilities (HCF) is treated. It is discernible from the findings that a lot needs to be done to raise the standards of waste management from points of generation to disposal. It has been observed that although the Ministry of Health and the Environmental Council of Zambia who are the policy-maker and regulatory authority on the protection of the environment respectively, have provided in some cases guidance in form of policies, standards and regulations on how medical waste should be managed, it is evident that these policies, standards, regulations and guidelines have not been complied with. The lack of effective handling of waste has posed a danger to the environment. The potential consequences of poor management of health care waste have been that patients, health workers and the general public have been at risk of infection through exposure to the waste. The hospitals, clinics and other health care facilities visited did not take due responsibility for the waste they generate to the environment and the public to ensure safe, efficient, sustainable and culturally acceptable methods for collection, storage, transportation, pre-treatment and final disposal within their premises. In particular, it has been observed from the results of the investigation carried out with regard to management of medical waste, through the risk chain, i.e. from generation, handling, storage, transportation to final disposal that: Most of the health care facilities visited did not maintain records of waste generated contrary to ministry policy, legislation or regulations. This may lead to improper planning and allocation of resources. Furthermore, waste handlers were not provided with appropriate protective clothing and not subjected to periodical medical check ups. The majority of health facilities had not implemented or had no colour coding and labelling system in place leading to difficulties in segregation of waste. In addition, interventions by cooperating partners, both local and international, have advised and provided contrary colour coding and labelling systems. This has added more confusion to the health institutions as to the type of coding and labelling system they should use. Also, most of the health facilities did not have or were not using bin liners, posing health risk to the public and the environment. Some health facilities did not have 2

recommended puncture- resistant sharps boxes which can lead to injuries through pricks, to staff and patients. In most of the health care facilities, waste was being transported by hand from the points of generation to disposal sites due to unavailability of suitable equipment such as trolleys, wheelbarrows, etc. This posed potential health risk to the handlers, patients, the public and environment. Out of 85 health institutions audited 49 representing 58% of the health institutions did not have incinerators in place and those which had incinerators. The majority of the incinerators were not of the required standard prescribed by the Environmental Council of Zambia. This resulted in improper and ineffective treatment of medical waste. It was further observed that some health facilities, without incinerators, were using refuse pits and some had also improvised ordinary drums to burn both medical and domestic waste. This resulted in failure to completely burn the waste and posed a health risk to the public and the environment. Most of the health facilities disposal sites did not have biohazard signs and were not fenced. This could lead to unauthorised entry and scavenging. A survey conducted in the 85 HCFs revealed that there was no Waste Management Plan prepared in most of the HCFs. Furthermore, Waste Management Teams and procedures for collection and handling waste were not in place. The investigations have also revealed that most of the health centres have not conducted deliberate training interventions in medical waste management. This has resulted in poor attitude towards waste management by staff. In addition, it has been observed that there is insufficient staff particularly in rural health centres leading to poor management of medical waste. 3

Introduction The government of the Republic of Zambia has attached importance to safeguarding environmental protection and sustainable development. It has enacted laws, formulated and implemented policies and measures aimed at protecting the environment. In this respect government has established institutions and agencies and tasked them with the responsibility of protecting the environment. These institutions include the Environmental Council of Zambia (ECZ), Ministry of Health (MOH), local authorities and a ministry responsible for the environment. Why conduct an audit of medical waste? Medical waste or health care waste is a source of contamination and pollution on both humans and the natural environment. Improper disposal may be hazardous if it leads to the contamination of air, water supplies or local sources used by nearby communities or wildlife. Medical waste is potentially capable of causing disease and illness in man, either through direct contact or indirectly by contamination of soil, groundwater, surface water and air. The handling, storage and final disposal of waste are of importance to the hospital staff, the public and the environment. Medical waste can cause harm as it may contain contaminated blood, human tissue, fluids and sharps, which could be highly infectious. On the other hand, the public do not want to find medical/infectious waste on general disposal sites or used needles, piercing refuse in plastic bags, which could cause injuries to municipal waste removers. Reports in the public and private media and general public outcry regarding inappropriate exposure and mishandling of waste in hospitals and other health institutions, which has resulted in the risk of infection to the public and contamination of the environment, necessitated the investigation on medical waste. In addition, there is evidence of lapses in disposing of expired drugs highlighted in the financial audit report for 2005 on the Ministry of Health. The Office of the Auditor General has therefore decided to conduct an environmental audit on medical waste management in order to assess the implementation of the laws and regulations governing the administration of health facilities with regard to waste, compliance with good medical 4

waste management practices, as required by appropriate standards and guidelines adopted from regulatory authorities, throughout the risk chain, i.e. handling, storage, transportation, treatment and final disposal. What is medical waste? Medical waste is a by-product of health care that includes sharps, nonsharps, blood, body parts, chemicals, pharmaceuticals, medical devices and radioactive materials. It is a reservoir of potentially harmful microorganisms which can infect hospital patients, health-care workers and the general public. Medical waste can be categorised as: a) Infectious waste This is waste that has the possibility of causing infections to humans. It includes human or animal tissue (blood or other body parts), blood soaked bandages, discarded surgical gloves, cultures, swabs to inoculate cultures. b) Hazardous waste This is waste that has a possibility to affect humans in noninfectious ways. This type of waste includes sharps, which are generally defined as objects that can puncture or lacerate the skin, and includes needles and syringes, discarded surgical instruments such as scalpels and lancets, culture dishes and other glassware. Hazardous waste also includes chemicals, both medical and industrial. Some hazardous waste can also be considered infectious waste, depending on its usage and exposure to human or animal tissue prior to discard. c) Radioactive waste This waste results from nuclear medicine treatments, cancer therapies and medical equipment that use radioactive isotopes. Pathological waste that is contaminated with radioactive material is treated as radioactive waste rather than infectious waste. Audit Objective and Questions Audit Objective The objective of the audit is to assess to what extent, the management of medical waste is in compliance with laws, rules and regulations in place and to identify causes and consequences of the insufficient waste management in order to enable provision of relevant recommendations on how the deficiencies could be improved. 5

Audit Questions Based on the audit objective, the audit was designed to answer the following questions: Is the management of medical waste taken care of appropriately, in accordance with the laws, rules, regulations and guidelines? What are the causes of inappropriate management of medical waste at the levels of the Ministry, hospitals and clinics? Audit Scope and Methodology The audit covered the Ministry of Health headquarters, 26 hospitals and 59 clinics through out the country for the period January to June 2008. It focused on the entire waste stream from generation to final disposal. For details of the hospital and clinics visited see Appendix 1. In gathering audit evidence, the followings techniques were used; Audit criteria Documents such as laws and regulations, operating standards, guidelines, reports and strategic plans were reviewed in order to establish the audit criteria. Interviewed ministry officials, heads of hospitals, clinics, wards and incinerator plant operators in order to gain understanding and knowledge of medical waste areas and how the systems in place were functioning. Conducted surveys in order to obtain quantitative information from the hospitals and clinics with the view of establishing the systems in place; Through observation, verified whether the operations on the ground complied with operating standards and procedures; Took photographs of waste and facilities used in its management in order to have visible evidence of the operations. Our evaluation of the performance and compliance levels of the health institutions with regard to medical waste management is primarily based on the provisions of the laws and regulations. It also considers the specific requirements of the various guidelines, processes and procedures provided by regulatory authorities. For the purposes of this audit this is what we consider as our audit criteria and are divided into sources of audit criteria and assessment criteria. Source of Audit Criteria The Environment Protection and Pollution Control Act 6

The principal law on the environment is the Environmental Protection and Pollution Control Act (EPPCA) Number 12 of 1990 cap 204 of the Laws of Zambia as amended by the 1999 Act and is founded on the polluter pays principle. The Act empowers the Environmental Council of Zambia (ECZ): To give specific or general directions to local authorities regarding collection and disposal of waste; and To formulate and provide standards and regulations for the sound management of waste Assessment Criteria The technical guidelines on sound management of health care waste prepared by Environmental Council of Zambia are in accordance with the EPPCA, the Hazardous Waste Management Regulations Statutory Instrument no.125 of 2001 and other relevant laws. We have sampled some of the guidelines that will be used as a basis for assessing efficiency and effectiveness of medical waste management as follows; Handling The health care worker or any other person generating waste should carry out segregation. This should be done as close to the point of generation as possible; Suitable HCW receptacles of appropriate size and number, to accommodate the different waste types being generated, should be used. The personnel involved in HCW management should ensure that the waste bags are removed and sealed when they are not more than three-quarters full. Segregation system should be uniformly applied throughout the whole country and should be maintained throughout the entire waste stream up to disposal. Adequate spill kit and protective clothing such as gloves, overall, nose mask etc. must be provided at the storage sites. The kit must include absorbent materials, disinfectant, buckets, shovels etc. for staff to clean up any spills and must be easily accessible; Receptacles for sharps should be non-corrosive, puncture resistant (metal or high density plastic), rigid, with fitted covers, and impermeable to retain any residual liquids from syringes. 7

Reusable waste containers should be washed with a suitable disinfectant as recommended in the Infection Prevention Guidelines. All waste receptacles should be labelled with basic information on their content and the waste producer. This information may be written directly on the receptacle or on pre-printed labels, securely attached. Labels on containers should be permanent and legible for the entire storage period. In the case of reusable receptacles, the location of that receptacle should be written clearly on the side, and should always be kept in the same room. Colour coding for the bin liners should always correspond or match with the waste containers both at the internal and external storage sites. All bags, containers, bag holders and trolleys should be black, brown or yellow to reinforce the separation of types of waste. Storage The storage area should have water supply for cleaning purposes; easy accessibility for staff in charge of handling waste and at the same time secure so that unauthorised people cannot gain access to the waste receptacles; good lighting and ventilation; not situated in the proximity of food stores or food preparation areas; and the floor should have good drainage. Sharps should be stored in puncture-resistant containers; Puncture resistant containers should be placed as close as possible to the area where sharp items are used; To ensure that waste is kept separated, the central storage receptacles for each colour coded bags should be placed in similarly colour coded receptacles. Waste from the separate external storage points for general waste and potentially infectious waste should go to different final disposal facilities. Transportation Collection and transportation of HCW from Health Care Facilities (HCFs) should merge into the general waste management plan of the local authority. No bags should be removed without labelling indicating the point of generation (hospital and ward) and content; 8

Separate trolleys should be used for different types of waste. This is to avoid increased possibilities of wastes becoming mixed and being transported along inappropriate disposal routes. The use of closed wheeled trolleys with lids is recommended and should not be used for any other purpose. The use of wheeled trolleys, containers that are user friendly (easy to load, no sharp edges and easy to clean) is recommended for transportation within the health care facility. Waste bags should not be hand carried around the HCF, since it increases the risk of injury to the legs, arms and torso from incorrectly disposed of sharps or other items. Disposal The following Health Care Waste (HCW) should not be incinerated: Pressurized gas containers. Large amounts of reactive chemical waste. Silver salts and photographic or radioactive waste. Halogenated plastics such as polyvinyl chloride (PVC) (blood bags, IV tubing or disposal syringes). Exhaust gases contain hydrogen chloride and may contain dioxins. Waste with high mercury or cadmium content, such as broken thermometers, use batteries and lead-lined wooden panels. Sealed ampoules or ampoules containing heavy metals. Access to the disposal site should be restricted by building a fence around the site to keep animals and human beings away. The selected site should be at least 50 metres away from any water source to prevent contamination of the water table. The site should have proper drainage, be located downhill from any wells, free of standing water and not in an area liable to floods. Bio-hazard symbols and other warning signs should be conspicuously posted on door to prevent people from unnecessarily gaining access to the area. Health Care Waste Management Planning 9

The proper management of health-care waste depends largely on good administration and organization but also participation by trained and informed staff. The head of the hospital should form a Waste Management Team (WMT) to develop a Waste Management Plan. The Waste Management Plan which stipulated among other things the following: Duties and responsibilities for each category of staff within the HCF, Present situation (waste practices, personnel, equipment, etc.), Quantities of waste generated, Waste segregation and potential hazards, Handing, transport and storage practices, Monitoring procedures to trace Health Care Waste (HCW) inside HCF to ensure the health care waste management rules are respected, Training needs of staff, etc. It further provides that the infection control officer shall organize and supervise training programmes for all staff in collaboration with the waste management officer and other member of the waste management team. Audit Findings The audit of medical waste management carried out in nine provinces involving the Ministry of Health headquarters, 26 hospitals and 59 clinics through out the country revealed the following: Handling According to the technical guidelines adequate spill kits and protecting clothing such as gloves, overall, nose mask etc must be provided. However it was observed that the waste handlers for the health care waste in all health care facilities visited did not have appropriate protective clothing. The Waste Management Plan stipulates that HCF should maintain records of quantities of waste generated. However, all the health care facilities audited were not maintaining waste records to keep track of the volume of medical and domestic waste generated and disposed off a practise that make it difficult to estimate the quantities and types of waste generated in a particular HCF to aid in waste management planning. The regulations required that personnel involved in HCW management should ensure that the waste bags are removed and sealed when they are not more than three-quarters full. However, 10

waste bins and sharp container were sometimes overfilled as shown below contrary to the regulations. A sharps box filled to the brim at Buntungwa Clinic in Mansa Waste receptacles filled to the brim at Kalingalinga Clinic in Lusaka Storage According to the ECZ regulations and guidelines, the health care worker or any other person generating waste should carry out segregation. This should be done as close to the point of generation as possible. In addition, segregation systems should be uniformly applied throughout the whole country and should be maintained throughout the entire waste stream up to the disposal. In addition, colour coding for the bin liners should always correspond or match with the waste containers both at the internal and external storage sites. However, a physical inspection of all the Health Care facilities visited revealed that: Waste was not being segregated and only sharps were separated from the rest of the waste. If waste is not segregated there is a danger that large quantities of contaminated waste are produced resulting in high cost of managing the contaminated waste. Waste receptacles were not corresponding to the different waste types being generated and the segregation system was not uniformly applied. It was observed that in most health centres visited colour coding and labelling was hardly used or non existent, and inappropriate bin sizes and types were being used. Although most of the staff were aware of the colour coding system for bins and bin liners they were not implementing them both at the internal and external storage site. The details of the health care facilities that complied with some selected guidelines are tabulated below: 11

Percentage of HCF per Province which followed the required guidelines Following colour coding (%) Bin liners availability and use (%) Availability of sharp boxes (%) Labels (%) Aware (%) Appropriate bin size (%) Southern (N=10)* 0 10 70 0 0 0 Western (N=4)* 25 0 100 25 0 100 Eastern (N=7)* 0 0 0 29 57 0 Lusaka (N=8)* 25 12,5 100 25 0 0 Central (N=8)* 0 12,5 100 0 0 0 Luapula (N=16)* 0 0 0 0 0 0 Copperbelt (N=20)* 0 95 100 0 95 85 N/Western (N=5)* 20 20 100 20 20 100 Northern (N=9)* 11 11 11 11 11 11 Total (N=87)* 6 28 61 30 29 31 *Number of Health Care Facility (HCF) visited It was further observed that contrary to the regulation which required that sharps should be stored in puncture-resistant containers which should be placed as close as possible to the area where sharp items are used. However, in most HCFs visited sharp boxes were generally not available, resulting in the HCFs using improvised card board boxes to dispose off sharps as shown in the picture below. Open carton boxes used as sharps boxes at Wusakile Clinic in Kitwe... The implication was that there is a danger of cross contamination which may occur, as waste is not easily identifiable and exposure of health workers and patients to dangerous and infectious diseases through piercing or cutting from sharps. Transportation The technical guidelines on the management of health care waste stipulate that: 12

Separate trolleys should be used for different types of waste. This is to avoid increased possibilities of wastes becoming mixed and being transported along inappropriate disposal routes. Waste bags should not be hand carried around the HCF, since it increases the risk of injury to the legs, arms and torso from incorrectly disposed of sharps or other items. The use of closed wheeled trolleys with lids is recommended and should not be used for any other purpose. The use of wheeled trolleys, containers that are user friendly (easy to load, no sharp edges and easy to clean) is recommended for transportation within the healthcare establishment. However, a visit to most HCF revealed that 5% of the audited HCF used trolleys to transport waste and 1% took the initiative to subcontract a transporter to do that for them, where as 94% of the HCF were carrying waste to the disposal site by hand instead of using suitable equipment such as trolleys leading to spillages and fly-offs which pose a potential health risk. Disposal ECZ regulations provided that: Incinerator emissions should comply with the Air Pollution Control Regulations of the Environmental Protection and Pollution Control Act of 1990. Chimney gases contain fly ash, composed of heavy metals, dioxins, furans, thermally resistant organic compounds, etc., and gases such as oxides of nitrogen, sulphur and carbon, and hydrogen halides. Access to the disposal site should be restricted by building a fence around the site to keep animals and human beings away. The disposal site should be lined with a material of low permeability (e.g. clay) if available. The selected site should be at least 50 metres away from any water source to prevent contamination of the water table. The site should have proper drainage, be located downhill from any wells, free of standing water and not in an area liable to floods. Contrary to the ECZ regulation mentioned above, a visit to all the HCF revealed that: Except for Nchanga North, Arthur Davison, Kitwe and Ndola central Hospitals, local authorities were not involved in management of 13

domestic waste for all the HCF visited. As a result the health centres resorted to digging of pits to cater for the domestic waste. It was further observed that due to the lapses in segregation of waste at generation point, sharps and other infectious medical waste such as blood-soiled cotton wool, tubes and syringes being found in the pits which were not secured as shown in the picture below. Unfenced refuse pits containing infectious waste Milima Rural Health Centres Lack of Incinerators 0ut of 85 HCF visited only 36 HCF (42%) were found to have incinerators. Out of the 36 HFC with incinerators, 10 HCF had incinerators which were not of ECZ standard and not of adequate size. Some incinerators found were obsolete, old, and in need of replacement as shown in the picture below. A dilapidated incinerator used at Sino-Zam Hospital in Kitwe An ordinary drum improvised as an incinerator at Chongwe Clinic in Chongwe It was further observed that Choma General Hospital incinerator and refuse pit were found poorly positioned, as they were situated in a water logged place, hence making incineration and treatment of waste difficult and ineffective especially in rain season. This also pose a risk of contamination to ground water. 14

11% of HCFs visited were disposing human waste inappropriately in a pit latrine and septic tank respectively, without chemical treatment to facilitate speed biodegradation of placentas. This resulted in bad smell and flies which may pose a health risk to the community. Five (5) HCFs; Ngombe, Mahatma Ghandhi, Maramba, Monze urban and Manunga clinics had no incinerators and were supposed to transfer their waste to another HCF which had the facility. Transportation was a constraint hence they were not doing that and resorted to burning the waste in pits which resulted in waste not being consumed to ashes as temperatures where below the required levels. This practice also results in air pollution as there are no properly belt chimneys to direct the fumes. In some instances they kept it unsafely as shown in the picture below until such a time that transport was available, a practice that is prone to high health risk for communicable diseases. Filled up sharps boxes kept in an open area at Monze Urban Clinic 44% of the HCFs were using pits which were unsecured and contained both medical and domestic wastes. A practice that causes high risk of infectious diseases due to scavenging. It was also noted that the skips (large storage bins) at UTH, Ndola General, Arthur Davison, Kitwe General and Nchanga North Hospitals meant for domestic waste also contained sharps and other medical waste, and had neither restricted access nor bio hazardous signs. In addition the skips were full and waste was spilling as shown in the pictures below. 15

A domestic waste skip containing infectious waste and filled to the brim in an unprotected area at UTH in Lusaka A skip filled to the brim containing infectious waste at Arthur Davison Hospital in Ndola Waste Management Plan According to the Health Care Waste Technical Guidelines HCFs where required to form a Waste Management Team (WMT) which was responsible for the development of Waste Management Plan. However, a survey conducted on the 85 HCFs revealed the following: a) Non-availability of Waste Management Plan, Waste Management Team and procedures for collection and handling waste i) Failure to establish waste management teams It was observed that 73% of Health Care Centres, 40% of District Hospital and 50% of General Hospitals did not have waste management teams contrary to the guidelines. ii) Lack of waste management plan Our analysis of questionnaires revealed that 95% of Health Care Centres, 70% of District Hospital and 83% of General Hospitals did not have waste management plan. iii) Lack of clearly defined procedures for collection and handling waste in HCFS It was further observed that 30% of Health Care Centres, 20% of District Hospital and 17% of General Hospitals did not have clearly defined procedures for collection and handling waste. The observation made in a)i) to a)iii) above is illustrated in the table below; 16

From the observations above, it is evident that the HCFs lacked a well defined strategy to facility careful implementation of procedures for management of health care waste in terms of minimization, segregation, packaging, storage, transportation, treatment and disposal. This could have resulted to failure to allocate resources to priority activities. b) Lack of Manual or Guidelines on Management of Health Care Waste A survey conducted revealed that 81% of Health Care Centres, 20% of District Hospital and 50% of General Hospitals did not have a manual or guideline on the management of health care waste. It was further observed that although the Ministry of Health had prepared infection prevention guidelines, 70% of Health Care Centres, 30% of District Hospital and 33% of General Hospitals were not aware that the Ministry had prepared these guidelines as shown in the table below and were therefore, not using them. 17

c) Failure to provide Training to Staff The guideline provides guidance on the form of training to HCF staff in waste management. In this regards, the infection control officer shall organize and supervise training programmes for all staff in collaboration with the waste management officer and other member of the waste management team. However, a survey conducted revealed that 30% of Health Care Centres, 20% of District Hospital and 17% of General Hospitals did not conduct training in waste management to newly hired waste management staff as analysed in the table below: 18

Conclusion The results of the study show that a lot needs to be done to raise the standards of waste management from points of generation to final disposal. The hospitals, clinics and other health facilities do not take due responsibility for the waste they generate to the environment and the public to ensure safe, efficient, sustainable and culturally acceptable methods for collection, storage, transportation, pre-treatment and final disposal within their premises. It has been observed that although the Ministry of Health and the Environmental Council of Zambia have provided guidance in the form of policy, standards and regulations on how medical waste should be managed, these have not been followed and complied with. Recommendations In order to correct the situation of waste management in the country s health institutions and consequently, ensure that the safety of patients, workers, the public and the environment is guaranteed, we propose that the following issues be considered for implementation. a) Developing a comprehensive waste management policy which will be aimed at improving health care waste management can be achieved through: building up a comprehensive system addressing responsibilities, planning, resource allocation, training needs, handling and disposal; raising awareness and training about risk related to health care waste; selecting safe and environmentally friendly waste management options to protect people from hazards when collecting, handling, storing, transporting, treating and disposing of waste; carrying out of regular reviews of the system by putting in place a monitoring and evaluation committee; A deliberate programme for medical check ups for personnel involved in waste management. b) Establish a well coordinated colour coding and labelling system and liaison with donors on the system in place to ensure consistency in supply of assistance to health institutions. 19

c) There is need to construct temporal storage facilities at points of generation before transfer to external storage sites, well segregated, appropriately labelled, and located away from immediate patient environment. d) There is need for secondary storage facilities to store waste after removal from primary storage, to await collection for final disposal and treatment. e) The waste storage facilities must be properly secured by fencing or otherwise. f) Waste must be moved appropriately in equipment that is properly covered to avoid spillages and fly offs and possible injuries and infection to waste handlers. g) Provide incinerator facilities to HCFs in order to enhance efficiency and effectiveness in the manner the waste is disposed, and reduce air pollution. The incinerators should follow the required standard. h) Make available appropriate and standard placenta disposal pits and make available treatment chemicals so that the waste can be disposed of in a safe and hygienic manner. i) All health facilities must record the quantities and types of waste disposed of at the disposal sites as provided by the guidelines. This will also assist in planning for health care waste management. j) HCF need to work hand in hand with the councils to ensure collection of domestic waste generated by health care facilities and safe disposal. k) All HCF must formulate the Waste Management Plan and provide training in line with the technical guidelines on the sound management of Health Care Waste and Infection Prevention Guidelines which must be monitored and reviewed. Inquiry Your comments and explanation on the above observation are requested within 14 days of receipt of the report, as it may merit mention in Auditor Generals annual report. 20

B Iňutu Lubasi Kapijimpanga (Mrs) Acting Director Specialised Audits and Consultancy For /Auditor General OFFICE OF THE AUDITOR GENERAL Appendices MEDICAL WASTE MANAGEMENT Appendix 1 HEALTH CARE FACILITIES (HCF) PROVINCE NO. HEALTH CARE FACILITIES TYPE OF HCF Luapula 1 Buntungwa RHC Health Care Centres 2 Mwansa Kombe RHC Health Care Centres 3 Kawambwa Hospital District Hospital 4 Kawambwa Clinic Health Care Centres 5 Mbereshi Mission Hospital District Hospital 6 Kala Refuge Clinic Health Care Centres 7 Mundubi RHC Health Care Centres 8 Mufwaya RHC Health Care Centres 9 Munkanta RHC Health Care Centres 10 Mansa Central Clinic Health Care Centres 11 Mansa General Hospital General Hospital 12 Samfya RHC Health Care Centres 13 Lubwe Mission Hospital District Hospital 14 Mabumba RHC Health Care Centres 15 Chembe RHC Health Care Centres 16 Senama Health Care Centres Copperbelt 17 Nchanga Clinic 1 Health Care Centres 18 Nchanga North Hospital District Hospital 19 Ipafu RHC Health Care Centres 20 Kalilo RHC Health Care Centres 21

21 Chiwempala Hospital District Hospital 22 Kitwe Central Hospital General Hospital 23 Sino Zambia Hospital District Hospital 24 Zam Tan Clinic Health Care Centres 25 Chimwemwe Clinc Health Care Centres 26 Ndeke Maternity Clinic Health Care Centres 27 Mulenga Clinic Health Care Centres 28 Wusakile Health Centre Health Care Centres 29 Kamitondo Health Centre Health Care Centres 30 Kwacha Health Centre Health Care Centres 31 Ndola Central Hospital General Hospital 32 Arthur Davison Hospital District Hospital 33 Kansenshi Prison Clinic Health Care Centres 34 Kaniki RHC Health Care Centres 35 Kava RHC Health Care Centres 36 Lubuto RHC Health Care Centres North Western 37 Solwezi General Hospital General Hospital 38 Mukinge Mission Hospital District Hospital 39 Solwezi Urban Clinic Health Care Centres 40 Kasempa Urban Clinic Health Care Centres 41 Mutanda Mission RHC Health Care Centres Northern 42 Kasama General Hospital General Hospital 43 Mpika District Hospital District Hospital 44 Location Urban Clinic Health Care Centres 45 Tazara Clinic Health Care Centres 46 Musa RHC Health Care Centres 47 Milima RHC Health Care Centres 48 Nakonde RHC Health Care Centres 49 Chibansa RHC Health Care Centres 50 Mwenzo RHC Health Care Centres Southern 51 Livingstone General Hospital General Hospital 22

52 Choma General Hospital General Hospital 53 Monze Mission Hospital District Hospital 54 Batoka RHC Health Care Centres 55 Mahatma Ghadi Clinic Health Care Centres 56 Dambwe Clinic Health Care Centres 57 Shamapande Clinic Health Care Centres 58 Monze Urban Clinic Health Care Centres Western 59 Lewanika General Hospital General Hospital 60 Limulunga Health Centre Health Care Centres 61 Liyoyelo RHC Health Care Centres 62 Kaoma District Hospital District Hospital Eastern 63 Chipata General Hospital General Hospital 64 Mwami Mission Hospital District Hospital 65 Petauke General Hospital General Hospital 66 Peatuke Urban Clinic Health Care Centres 67 Katete Urban Clinic Health Care Centres 68 Sinda Zonal RHC Health Care Centres 69 Kasenengwa RHC Health Care Centres Central 70 Kabwe General Hospital General Hospital 71 Mahatma Ghadi Health Centre Health Care Centres 72 Katondo Health Centre Health Care Centres 73 Kapiri Mposhi District Hospital District Hospital 74 Tazara Health Centre Health Care Centres 75 Munkonchi RHC Health Care Centres 76 Mukushi District Hospital District Hospital 77 Mansansa Health Centre Health Care Centres Lusaka 78 UTH General Hospital 79 Chilenge clinic Health Care Centres 80 Kalingalinga Clinic Health Care Centres 81 Ngombe RHC Health Care Centres 23

82 Matero Clinic Health Care Centres 83 Kafue District Hospital District Hospital 84 Chongwe District Clinic Health Care Centres 85 Kanakantapa Clinic Health Care Centres 24