Introduction

Wastes generated from health care facilities are varied in nature, ranging from ordinary organic waste to highly hazardous liquid and solid waste. The waste thus generated is a potential health and environmental hazard, and if not properly managed can pose a serious health risk to health care providers, patients, and the general public. Therefore, institutionalizing effective waste management systems in all health care facilities is understood by RHSDP as a key prerequisite to improving efficiency and effectiveness of health care. Government of India promulgated the Bio-medical Waste (Management and Handling) Rules, which detail good practices to be followed and the roles and responsibilities for all those concerned in the generation and effective disposal of health care waste. The development and implementation of effective waste management system is based upon cooperation and ongoing interaction between all the stakeholders, which includes hospital management, municipal bodies, pollution control board, manufacturers of equipment and supplies, environmentalists, NGOs, media, medical and nursing schools and the general public.

The Government of Rajasthan has developed and implemented strategy to address to this important subject and responsibility of the same lies with DM&HS. The solid hazardous waste include human anatomical waste, animal waste, microbiological and biotechnology waste, sharps, discarded medicines and cyto-toxic drugs, chemicals and soiled waste (items contaminated with blood, fluids including cotton, dressings, soiled plaster casts, linen, beddings, and other material contaminated with blood) and solid waste (waste generated from disposable items other than the waste sharps such as tubing, catheters, intravenous sets, etc.).

The details of the Bio Medical Waste (Management & Handling) Rules are available on the website of Ministry of Environment & Forest, Government of India www.envfor.nic.in at following web link http://www.envfor.nic.in/legis/hsm/biomed.html

Authorization (Legal Aspect)

In compliance with Bio-medical waste (Management & Handling) Rules1998, the health care facilities are required to obtaining authorization / renewal of authorization certificate from state pollution control board. Obtaining authorization from RPCB is necessary for all health care facilities with registered patient (OPD & IPD) in excess of 1000 per calendar month. However, implementation of HCWM system is recommended at all health care establishments. The formats of authorization application and affidavit are as following:
• Formats of Authorization Application for 50 and more than 50 bedded hospitals
• Formats of Authorization Application for 30 to 49 bedded hospitals
• Formats of Authorization Application for PHCs and Dispensaries

Hospital Waste Management Plan

Hospital Waste disposal is a multifaceted activity in which different stages as given below are highly interdependent both technically as well as organizationally. The guiding principals are broadly understood as follows

• Generation / Minimization: - According to the Rules waste generated in the hospitals is classified into ten f categories viz. Human Anatomical waste, Animal waste, Microbiology & Biotechnology waste, Waste sharps, Discarded medicines and Cyto toxic drugs, Soiled waste, Solid waste, liquid waste, Incineration ash, Chemical waste. Significant reduction of waste generated in healthcare facilities is encouraged by adopting the principles of 3 R’s, i.e., Reduction, Recycle and Reuse.

• Waste Segregation: - Segregation is the most important step, which is followed for individual type of wastes as per bio-medical waste category. It is done at the point of generation e.g. all patient activity areas, diagnostic service areas, operation theatres, labor rooms, treatment rooms, etc. The responsibility of segregation lies with the generators of bio-medical waste, i.e., doctors, nurses, technicians, etc.

• Collection: - Bins / receptacles: Only non-chlorinated plastic collection bags are being used. This ensures that the items are not being recycled or reused by rag pickers. Waste is being collected daily and transported to the designated storage site / deep burial pits. Bags are removed after they are 2/3 rd filled with bio medical waste.

• Transportation: - Within the hospital, waste routes are designated and time of transfer of wastes to avoid the passage of waste through crowded and patient care areas. Dedicated wheeled containers, trolleys/carts are in use to transport the plastic bags to the site of storage / deep burial. The containers are so designated that waste can be easily discharged into them and the foot operated lid closes the infected waste inside in a secure manner.

• Storage: - According to Bio-Medical Waste Rules, storage means holding of biomedical waste for such period of time, at the end of which waste is treated and disposed off. A storage location for hospital waste collection is designated inside the establishment. The waste, in bags or containers is being stored in an area earmarked for the purpose.

• End Treatment and Disposal: - The Department of Local Bodies, functioning Under the Local Self Government (LSG), GoR has been entrusted the responsibility to set-up Common Treatment Facilities (CTFs’) in select cities / towns. The CTFs are responsible for waste collection and transportation from the hospitals site, followed by treatment and destruction as necessary and finally disposal at the site of CTF. The owner of CTF seeks authorization from the prescribed authority under the BMW Rules, namely Rajasthan Pollution Control Board (RPCB) before installing the equipment and treatment techniques. There is a provision of payment for CTF hiring charges to CTF operators through RHSDP at the rate of Rs. 1000/- per bed per year for project-supported facilities only. The payment for CTF hiring charges is being made through RMRS; which is reimbursed on actual basis. This facility of reimbursement of CTF connectivity fees is till the project period (September 2011), beyond which it becomes liability of the DM&HS.

Civil work (Burial Pits / Storage)

Until the CTF is installed at some locations, infectious waste along with the anatomical waste and other hazardous waste is being disposed off into deep burial pits. Earlier, the bio medical waste was being indiscriminately disposed in open or burnt & buried in open, in a non scientific manner. The deep burial pits for scientific disposal of the bio medical waste; and storage spaces for collection of the bio medical waste were constructed by the RHSDP at all secondary level health facilities which are in use. The deep burial pits are being constructed at all PHCs by the NRHM.

HCWM Related Supplies

The supplies required for HCWM implementation are being supplied by the RHSDP at 343 secondary level health facilities and by the NRHM at other CHCs (upgraded PHCs) and all PHCs. The following items are required for proper implementation of health care waste management at the health care facilities:
1. Protective Clothing (Boots, Gloves, Apron, Cap, Mask, etc.)
2. Color Coded Bins (Red, Yellow, Blue, Black and Green)
3. Color Coded Bags (Red, Yellow, Blue, Black and Green)
4. White Bin for Disinfection of plastic and sharp waste
5. Puncture Proof Translucent Container (PPTC)
6. Sodium Hypo Chlorite Solution (4 %)
7. Needle Cutter (Electronic / Manual)
8. Plastic Cutting Scissor
9. Weighing Machine
10. Wheel Barrow

Health Care Waste Management Training

Training and sensitization of various functionaries in the health care systems as well as outside the health care systems was vital for the successful implementation of hospital waste management plan across the State. The first round of on site HCWM trainings was conducted at all 343 secondary level health facilities. Hands on trainings were imparted to about 13000 health personnel at all 343 project supported health facilities. The training was focused on simple principles of waste management; employee’s responsibility; employer’s role in waste management program and standard operative procedures for waste management. The trainings for Doctors, nursing, para-medical, laboratory technicians, IV class and sweeper were conducted by the trainers at hospital itself.

The second round of on site HCWM trainings has been planned by the RHSDP project, addressing a much larger domain of operations by including all the NRHM supported PHCs. Trainings are currently on in the field and will be imparted at all 406 secondary level health facilities & all 1500 PHCs. The trainings are being provided by professional agencies in the field and an effective monitoring mechanism has been put in place at the stats, district and block level for monitoring the training activities closely.

Monitoring of the HCWM Activities

Coordination, Monitoring and Evaluation (CM&E) Committee for health care waste management has been constituted under chairmanship of the Director-Hospital Administration in the department of Medical, Health and Family Welfare. This committee is monitoring all activities related to health care waste management. Regular coordination between the RHSDP, DM&HS and NRHM officials is ongoing for sustainability and convergence of all HCWM interventions & practices with Department of Medical & Health, Government of Rajasthan.

Information, Education & Communication (IEC)

HCWM posters, flexi sheets, audio and video CDs were prepared by the RHSDP and distributed at all 343 secondary level health facilities. The IMEP (Infection Management and Environment Protection) guidelines were prepared by the Government of India and the World Bank. The IMEP guidelines are to be used for uniformity in the trainings of HCWM. Accordingly Hindi version of IMEP guidelines was developed for CHCs and PHCs. These guidelines (Hindi version) have been disseminated at all primary and secondary level health facilities.

Four posters depicting task specific protocols of HCWM practices were designed at PIU and approved by the World Bank. These posters have also been disseminated at all primary and secondary health facilities.

The IEC material for HCWM is as follows:
• IMEP guidelines (Hindi Version) for CHCs
• IMEP guidelines (Hindi Version) for PHCs
• Presentation on using of burial pits at the hospitals
• जैव चिकित्‍सा अपशिष्‍ट को एकत्रित करने के लिए सी.टी.एफ की गाडी (फोटोग्राफ)
• जैव चिकित्‍सा अपशिष्‍ट के निस्‍तारण के लिए सी.टी.एफ. प्‍लाट (फोटोग्राफ)
• जैव चिकित्‍सा अपशिष्‍ट के निस्‍तारण के लिए डीप बरियलपिटस (फोटोग्राफ)
• प्रयोगशाला के रसायनों एवं उपकरणों का व्‍यवस्थित निस्‍तारण (पोस्‍टर)
• अस्‍पताल को स्‍वच्‍छ एवं साफ-सुथरा रखें ( पोस्‍टर)
• बिखरे हुए द्रव का तुरन्‍त प्रबंधन करें ( पोस्‍टर)
• कचरे को उचित रंग के बिन में डालें (पोस्‍टर)
• अस्‍पताल में कचरे को ले जाने के लिए गाडी (फोटोग्राफ)