| dc.description.abstract | Health Care Waste Management (HCWM) is a process to help ensure proper hospital hygiene and
safety of health care workers and communities. It includes planning and procurement, construction,
staff training and behaviour, proper use of tools, machines and pharmaceuticals, proper disposal
methods inside and outside the hospital, and evaluation. Its many dimensions require a broader
focus than the traditional health specialist or engineering point of view.
The broad objective of this study was to undertake a situational analysis of the status of health care waste
management in the Health Care Facilities (HCF) in Nyanza Province through assessment of policy, legal
and administrative framework in relation to Health Care Waste Management (HCWM); including generation,
segregation, storage and disposal systems of Health Care Waste (HCW), what is generally referred to as
"cradle to grave" of health care waste rnanaqernent. This study also assessed the existing technologies,
levels and presence of scavenging and recycling; established the level of private partnership in health care
waste management and finally reviewed existing training curricula, identifying unmet needs and proposing
appropriate and affordable strategies for the training at various levels.
Rapid Assessment Appraisal tools both qualitative and quantitative, including structured and semi-structured
questionnaires, check lists and guides for participatory appraisal, among others were employed in the data
collection. A sample of health care institutions ranging from those at the provincial, district, health centre and
dispensary levels were picked for the study using both purposive and simple random sampling method to
select the HCFs in the province of Nyanza. The HCFs that were selected from the sampling included;
Nyanza Provincial General Hospital; 3 busy district hospitals were selected from the sample and included
Kisumu District Hospital, Homa Bay District Hospital and the Kisii District Hospital. The 4 health
centres that were selected included; Nyahera Health Centre, Nyamusi Health Centre, Nyangande Health
Centre and Bondo Health Centre. 4 government dispensaries were selected for the study and they
included; Keroka dispensary, Sori Dispensary, Nyakach Dispensary and Lundha Dispensary.
Finally the only private hospital that was selected was the Aga Khan hospital in Kisumu and this
was largely due to financial constraints that could not allow increasing the sample size for private
hospitals. Two public dumping sites were also selected in the sample and they were Kachok
dumpsite in Kisumu and Kisii dumping site respectively.
The study findings indicate that to a given extent there has been some positive effort in the
management of HCW in Nyanza province that is worth mentioning and upon which the need to
develop a Plan of Action for the management of HCW has been recommended by the researcher.
Specifically, the Ministry of Health, in spite of the fact that it does not have adequate resources for
Health Care Waste Management, it does have in almost all the Health Care Facilities (HCFs)
Public Health Technicians (PHTs) and Public Health Officers (PHOs), whom the study found out
are well trained in handling HCWs and are responsible for the management of HCW generated in
these HCFs. These officers have been discharging their duties in respect to HCWM in spite of
several challenges and constraints. Most HCFs have also employed casuals and subordinate staff
who playa major role in the collection and disposal of HCWs although they have received no or
inadequate training in HCWM.
The key findings at different points of HCWM are as summarised here below:
At the health care facilities, there was inadequate or lack of segregation of HCW, there were lack of
HCWM strategies, inadequate HCW receptacles, inappropriate internal HCW storage facilities,
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inappropriate internal transport facilities, delay in HCW collection, lack of budgetary allocations for
HCW, tedious procurement approval process, lack of Personal Protective Equipments (PPE), lack
of pre-treatment of HCW before final disposal. However in all HCFs sampled, the waste that is
properly segregated are sharps, which are placed in sharp boxes.
At the HCW treatment plants, most of the HCFs have broken /dilapidated "incinerators", there is
lack of back up incinerators in cases of failure, broken down auto clave equipments, small capacity
of incinerator and low incinerator stacks.
At the waste disposal sites there was lack of sanitary landfills, presence of HCWs in public
dumping sites, presence of scavengers, poor siting of dumpsites, leachate which is evidence of
pollution of soil and water resources. -
With regard to private sector involvement in HCW management, it was found out that they lack
infrastructure such as standard refuse vehicles and incinerators. The current ones are open
trucks, tractors, canters and pickups.
The research further revealed that Personal Protective Equipment (PPE) is not provided by private
sector players to their staff except for overalls and gloves. In regard to training, all the workers in
the private sector have not been trained in HCW management.
It was found out that no private firm exists specifically for purposes of handling Health Care Waste.
Despite most healthcare institutions having "incinerators", no private firm have incinerator(s) that
could be commercialised in the entire province. Health Care Waste is not separated by the private
firms and this implies that recycling and proper disposal is never practised.
The findings in Training and Awareness on Health Care Waste Management showed little or no
awareness on HCWM among different cadres of personnel engaged in HCW including the health
care workers, general public and scavengers. However, John Snow Inc (JSI) and the Ministry of
Health (MoH) are running a joint project on injection safety in Bondo district, that to a given extent
includes aspects of HCW segregation and colour coding. More so, there are existing institutions
offering training in solid waste management, public health and epidemiology, though none of the
training curricula focuses specifically on HCW.
The findings in Legal and Regulatory Framework indicate that there are weak institutional and
regulatory framework on HCWM specifically the Public Health Act which does not make a specific
mention of HCW other than making reference to nuisance waste. Poor enforcement of the existing
laws that touch on HCWs was found to be a contributing factor to poor HCWM. There was also
delay in the gazzetment of the draft policies addressing HCW including the Bio-medical policy,
Environmental Sanitation policy, Guidelines on Hazardous Health Care Waste and Guidelines on
Injection Safety, among others. Further more now that the guidelines for waste management have
been gazzetted in spite of the long delay, poor enforcement of the guidelines is compounding the
problem of HCWM.
The study findings revealed that the status of health care waste management in Nyanza province
is low and is contributing to environmental, social and health impacts. Therefore the null
hypothesis in this study has been rejected.
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The afore-stated findings formed the basis for the recommendation for the need of developing a
Provincial Plan of Action on HCWs for the province and if possible even a National Plan of Action
on Health Care Waste Management for Kenya as a whole.
The Provincial INational Health Care Waste Management Plan recommended would successfully
form the second part of a wider study (areas for further research) that could be developed based
on the findings of this situational analysis. The proposed plan could be separate Action Plans
addressing different but mutually integrated aspects of HCWM. These could include the following;
• Plan of Action for Training and Awareness Creation on HCW including a communication
strategy.
• Plan of Action on HCW Treatment Technologies including the social concerns and risks
associated with HCW.
• Plan of Action on strengthening Legislative and Institutional Framework on HCWs.
• A Monitoring, Evaluation and Reporting Plan.
• A Plan of Action for Financial Resource requirements necessary for implementing the
Health Care Waste Action Plan.
The Action Plan recommended for development by the researcher for Health Care Waste (HCW)
Management in Kenya should be based on the vision of facilitating the establishment of an
integrated, environmentally sustainable, occupationally healthy and safe, financially viable,
institutionally feasible and operationally practical, comprehensive "cradle-to-grave" management
system for HCW, covering all HCW generators and addressing the short, medium and long-term
needs over the period 2008 - 2012, with the option of extending the period by a further 5 years if
circumstances dictate.
Although it is recommended by the researcher that the Action Plan should focus on Health Care
Risk Waste (HCRW), Health Care General Waste (HCGW) could also be included in the Action
Plan in as far as it would impact on the effectiveness with which HCRW is managed.
All categories of HCRW other than radioactive waste could be included in the HCW strategy.
Radioactive waste is handled in accordance with the provision of the Radiation Protection Act,
Chapter 243 and falls outside the jurisdiction of the HCRW management industry.
For the sake of prioritising activities, the researcher proposes the development of the Action Plan
that should be developed and implemented in four phases.
• Consolidation Phase: Aimed at improving the existing HCW management systems in order to
address the most urgent occupational health and safety needs. Activities to be implemented
under this phase include training of staff on appropriate HCW segregation, containerisation,
handling and storage, supply and maintenance (including disinfection) of appropriate reusable
and disposable HCW containers, provision of appropriate internal HCW storage facilities, and
provision of appropriate internal HCW transport facilities and temporary revamping of existing
onsite HCRW central stores, treatment facilities and disposal facilities.
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• Development Phase: The focus will, during this Phase, be on setting appropriate treatment
efficiency standards as well as emission standards. Against the background of the nationally
agreed upon standards, various options should be evaluated for cost effective HCW
management service delivery. This phase should further include all preparations required for
the roll-out (implementation) of the selected HCW management service delivery models
including setting appropriate thermal and non-thermal HCRW treatment efficiency standards
with corresponding timeframes for compliance; setting appropriate HCRW treatment emission
standards with corresponding timeframes for compliance; investigating different options and
determine the viability of Public-Private-Partnerships for HCW management service delivery;
determining the viability of regionalising HCW management service delivery; develop / upgrade
central HCW storage facilities at all HCW generators; develop a HCW treatment and disposal
infrastructure plan, develop technical specifications, identify sources of funding and call for
tenders for the supply, installation, construction and commissioning of HCW treatment and
disposal facilities; develop commercial terms and technical specifications, identify sources of
funding and potential business partners and invite proposals on Private-Public-Partnerships;
develop commercial terms and technical specifications, identify sources of funding and
potential service providers and invite tenders for the outsourcing of HCW management
services.
• Implementation Phase: Having set the standards and having selected the most appropriate
models for HCW management service delivery, this phase should focus on the establishment
of operational structures as well as physical supply, installation and construction of equipment
and facilities required for environmentally sound, yet healthy and safe HCW treatment and
disposal throughout Kenya which will include awarding contracts for the supply, construction
and commissioning of HCW treatment and disposal infrastructure, introduce management
systems, appoint and train staff and commission HCW management facilities; entering into
Private-Public-Partnerships agreements, introduce management systems, appoint and train
staff, develop HCW treatment and disposal infrastructure and commission facilities; or
awarding Contracts to HCW management service providers for the outsourcing of all or
selected HCW management services and finally operate fully integrated HCW management
systems.
• Monitoring and Control Phase: Although identified as a separate phase, monitoring and
control should be executed throughout the process, i.e. starting from the consolidation phase.
Progress on the implementation of the Action Plan should be evaluated and where required,
adjustments be made to already upgraded HCW management systems to ensure optimum
results. Highlighting the fact that this phase is to continue subsequent to the development and
implementation of improved HCW management systems in Kenya, stresses the importance of
ongoing involvement by the executing as well as the regulating authorities. | en |
