Environmental Management Framework for Health Care Waste & Infrastructure Development

Transcription

1 Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized Environmental Management Framework 2013 THE GOVERNMENT OF SRI LANKA Environmental Management Framework for Health Care Waste & Infrastructure Development Second Health Sector Development Program Ministry of Health January 8, 2013 Second Health Sector Development Program Page 1

2 Abbreviations CEA : Central Environmental Authority CFE : Caring for the Environment DLI : Disbursement Linked Indicator DEOH: Directorate of Environmental and Occupational Health EIA : Environmental Impact Assessment EPL : Environmental Protection License E&OH : Environment and Occupational Health Unit GCA : Greater Colombo Area GOSL : Government of Sri Lanka HCF : Health Care Facility HCW : Health Care Waste HCWM: Health Care Waste Management HSDP : Health Sector Development Project IDA : International Development Association MoH : Ministry of Health MOH : Medical Officer of Health NAP : National Action Plan NCCWM : National Committee for Clinical Waste Management NCD : Non-Communicable Disease NEA : National Environmental Act NHDP : National Health Development Plan PAD : Project Appraisal Document PHS : Provincial Health Services PMS : Project Management Secretariat PSC : Project Steering Committee PU : Peripheral Unit RE : Regional Epidemiologist SA : Situation Analysis Second Health Sector Development Program Page 2

3 Table of Contents Chapter 1: Overview of the Second Health Sector Development Program 1.1: Program objectives and proposed activities Development Objectives of the 2 nd HSDP Project Description : Objectives of the framework and the intended audience Structure of the report Sources of information Chapter 2: Existing policy/regulatory framework for HCWM in Sri Lanka 2.1: Overview of the organization of the Health sector in the country : Health care waste management in Sri Lanka : General Background Existing health care waste management framework in the country : National Policy : National Guidelines : Code of Hygiene : National Color code : Legislation and regulation : Other sectoral strategies addressing HCW : Recommended institutional and monitoring framework Chapter 3: Review of the present scenario of HCWM in Sri Lanka 3.1: Types of HCW generated : Baseline information on HCW production in different HCFs : Characterization of HCWM in the country : Summary of treatment technologies and infrastructure employed in the country for Achievements and gaps in the implementation of the policy/national action plan and lessons learnt Financial resources available for HCWM in the country Chapter 4: Strategy for scaling up HCWM under HSDP II 4.1: Summary of HCWM strategies addressed in the National Health Development Plan : Priority areas selected for implementation under HSDP II Description of result indicators to be monitored under 2 nd HSDP Second Health Sector Development Program Page 3

4 Chapter 5: Implementation and monitoring arrangements for HCWM under the Second HSDP 5.1 : Project Institutional and Implementation Arrangements Implementation of HCWM under 2 nd HSDP Chapter 6: Technologies available for HCWM and comparison of alternatives 6.1 Treatment Technologies : Incineration : Autoclaving : Microwave irradiation : Chemical Disinfection : Land disposal Chapter 7: Safeguard requirements for infrastructure development under 2 nd HSDP Environmental Clearance under national laws Incorporation of safeguards into plan, design and contract Annexes Healthcare Waste Management Rapid Assessment Tool Assessment of Healthcare Waste Management in Major Health Institutions Second Health Sector Development Program Page 4

5 List of Tables Table 1: Health Institutions and bed strength by District Table 2: Overview of the administration of Health Services and classification of medical institutes Table 3: National Colour Code for segregation of HCW Table 4: Production of non-risk and hazardous HCW per district Table 5: Average production of HCW in different categories of HCFs Table 6: The daily generation of healthcare waste in government-owned hospitals in Sri Lanka, calculated using bed capacities in year Table 7: Estimates of hazardous waste generation in government hospitals of Sri Lanka in Table 8: Quantities of HCW generation in selected HCFs in the Galle District.. 29 Table 9: Quantities of hazardous HCW generated in selected hospitals in the country (results of the rapid assessment done in 2011) Table 10: Current practices in handling HCW in 33 major hospitals evaluated Table 11: Description of current practices in handling HCW in 33 major hospitals evaluated Table 12: Treatment technologies and infrastructure employed in the country for HCWM treatment Table 13: Suitable treatment and disposal technologies according to the different categories of HCW Second Health Sector Development Program Page 5

6 Chapter 1: Overview of the Second Health Sector Development Program 1.1: Program objectives and proposed activities For the country s vision as reflected in the Mahinda Chintana to be realized, investing in the modernization of the health system would be a critical pre-requisite. A more modern health system of international standards, commensurate with the aspirations of a middle-income country population would not only help achieve the objective of improving living standards and social inclusion; rather it would contribute to all the objectives set out in the vision document, including sustained economic growth, and shifting toward a knowledge-based and competitive economy. Without a healthier population and a system that is geared to handle the health challenges thrown up by the rapid demographic and epidemiological transitions facing Sri Lanka, the quantum leaps needed in the availability of highly skilled and more productive labor force would remain an unrealized dream. The Bank s Country Partnership Strategy seeks to deepen the World Bank Group s support to Sri Lanka in addressing its emerging middle-income country agenda. The Second Health Sector Development Program (2nd HSDP) would be an important contributor to all three sub-areas under the area 3 (Improving Living Standards and Social Inclusion) of the Country Partnership Strategy. Thus, its higher level objective would be to enable the health system to play its critical part in helping Sri Lanka actualize its aspirations of economic growth, overall development and improved quality of life of all Sri Lankans. 1.2: Development Objectives of the 2 nd HSDP The project development objective is to improve the public sector health system so as to respond to the challenges facing it, especially regarding nutrition and NCDs. The Project disbursement will be linked to Disbursement Linked Indicators (DLIs) identified from the focus areas of the National Health Development Plan (NHDP); in close collaboration with the MoH and the 9 Provincial Health Ministries. 1.3: Project Description The IDA financing will consist of three components: (i) support to priority areas under the national health development plan; (ii) results-based financing (RBF) pilot interventions on MCH - related to millennium development goals 1c, 4 and 5. This component will be co-financed with a matching grant from the Health Results Innovations Trust Fund (HRITF) and (iii) an innovation and capacity-building fund which will support implementation of the NHDP with funds earmarked for technical assistance, training, workshops, testing innovative ideas, operational research, the proposed demographic and health survey, baseline and end line surveys and other evaluative studies. Component I: Support to Priority areas under the National Health Development Plan (GOSL US$ 5,165 million, of which IDA contribution would be US$ 190 million for 5 years) Component 1 of IDA financing will contribute to the GOSL s NHDP. The IDA funds will be comingled with GOSL funds, while the Bank s technical engagement and monitoring would focus on specific thematic areas (i) addressing nutrition; (ii) improving prevention and control Second Health Sector Development Program Page 6

7 of non-communicable diseases; (iii) addressing maternal and child health and communicable diseases (iv) health system improvement measures - which are described below. Thematic area one: Addressing Malnutrition Under this thematic area, implementation of 1000 days interventions with a focus on the under-served areas will be further strengthened. The nutrition interventions will be specifically targeted at (i) pregnant women (monitoring and promotion of adequate weight gain during pregnancy; appropriate micro-nutrient (iron/folate and calcium) and food supplementation, better monitoring of anemia during pregnancy in the third trimester (at 32 weeks) and deworming; (ii) strengthening monitoring of low BMI mothers; and (iii) children up to 2 years of life focusing on behavior change and communication related to breastfeeding, timely introduction of safe and nutritionally adequate complementary foods, appropriate nutritional care for sick children and hygiene practices; zinc supplementation during treatment/management of diarrhea; integrated management of severe acute malnutrition through facility- and community-based interventions and deworming. The NHDP also ensures improved targeting of these interventions to underserved areas, estate communities and the urban poor. The use of community groups/mobilizers will be piloted and encouraged for the implementation community-based nutrition activities. The GOSL/IDA resources will be utilized to improve the capacity of the human resource pool engaged in nutrition interventions across all age groups of the community will be improved. This would entail various forms of training, mentoring and supervision to deliver effective and appropriate nutrition interventions at facility and community levels. Enhancing the capacity of, as well as empowering community organizations to plan, implement and monitor relevant nutrition interventions will also be supported where necessary. The GOSL/IDA resources will be utilized to establish an island-wide monitoring and evaluation system and a nutrition surveillance (NS) system. The system will monitor the (i) implementation of the key nutrition (1000 day) interventions; (ii) strengthen the utilization of NS reports for decision making at national and divisional levels; (iii) link the surveillance data to the national nutrition information system and to existing tools and systems of the government of Sri Lanka. IDA credit funds release will be linked to the achievement of the following disbursement linked indicator for the thematic area addressing nutrition. % of MCH clinics with an agreed package of equipment and supplies for monitoring pregnant women (DLI) In addition to the DLI for nutrition the following indicator/s relevant to nutrition will also be monitored during the project period. % of MOH areas with at least 5 health and nutrition community support groups Nutrition related PDO indicator - needs to be added based on discussions during Appraisal Second Health Sector Development Program Page 7

8 Thematic area two: Improving prevention and control of Non-Communicable Diseases The GOSL/IDA resources will be utilized to further improve the implementation of framework convention for tobacco control (FCTC, the tobacco control act and support the introduction of legislation for the control of indoor air pollution, pesticides and excessive alcohol, salt, sugar and trans fat usage. Furthermore, using GOSL/IDA resources, mechanisms for increasing safety awareness and supporting the establishment of safe communities will be encouraged. These activities will be supported with the development of appropriate and targeted communication strategies for prevention and control of chronic and acute NCDs. Acute NCDs will be managed more effectively with the availability of fully functioning 24-hour emergency treatment units (ETUs) at all levels of hospitals. The GOSL/IDA resources will be utilized to have in place fully functional 24 hour ETUs at each of the identified hospitals at each of the levels of care, according to accident and emergency policy, standards and guidelines that would be finalized in the first year of the project s implementation. It is expected that the ETUs will manage acute and chronic NCDs and any other emergency medical / surgical situations which would improve the quality of services provided to the patients and will also improve the efficiency of hospital performance. In addition, under this component the GOSL will explore options for providing pre-hospital services to the population which is essential to improve outcomes of acute health situations. The GOSL/IDA resources will also be utilized to establish at least one healthy life style center in each of the 325 MOH areas in Sri Lanka. These centers will be established at the primary care hospital level and are expected to prevent/ delay the onset and promote healthy living to reduce the burden of chronic NCDs (especially heart diseases, Diabetes Mellitus and early detection of selected cancers (breast, cervix and oral cavity). Early screening of higher risk individuals, referral of positive patients for care and health promotion for adopting healthy lifestyles and regular follow up will be promoted in these centers. These activities are based on the national guidelines for the screening, diagnosis and management of chronic NCDs in Sri Lanka. In addition, GOSL/IDA resources will be utilized to expand the screening services and strengthen the services available in hospitals to improve the quality of care provided for NCD case management. The use of mobile health screening system for screening at workplaces (informal and formal) and by further strengthening screening of out-patients attending all primary and secondary care level hospitals. In addition, quality improvement (includes infrastructure improvements) of the services provided at hospital clinics (long term) for the management of the increasing number of diagnosed NCD patients will be strengthened. Within hospitals, following a needs assessment, expansion of services including strengthening the laboratory and other investigative services, ICU services, clinic facilities, and other ancillary services will be supported with the development of master plans for larger facilities along with the development of networks of health facilities. As appropriate NCD drugs are required for improving prevention and control of NCDs at all levels of care, GOSL/IDA resources will be utilized to improve drug quality assurance, drug logistics and distribution system related to NCD drugs. Second Health Sector Development Program Page 8

9 The GOSL / IDA resources will be utilized to establish at least one comprehensive rehabilitation unit in the most advanced health facility in every province to strengthen the tertiary care services in Sri Lanka. These units would be linked with a two-way referral arrangement for follow up care along with appropriate facility strengthening of the lower level facility for providing long term care. Furthermore, appropriate human resource development for these centers will be supported. The IDA credit funds release will be linked to the achievement of the following disbursement linked indicators for the thematic area addressing NCDs. % of MOH areas with at least one healthy lifestyle center % of centrally managed health facilities with ETUs for that level of facility based on standard guidelines % of provincially managed health facilities with ETUs for that level of facility based on standard guidelines In addition to the DLI for addressing non communicable diseases, the following indicator/s relevant to NCDs will also be monitored during the project period. % of persons (over 35 years) screened for selected NCDs at healthy lifestyle centers % of provinces with at least one health facility providing rehabilitation services % of regional drug stores and health facilities having one month s buffer stock for 16 selected NCD drugs Thematic area three: Addressing maternal and child health and communicable diseases The NHDP plans to further improve the services provided for MCH and communicable disease achievements of Sri Lanka. GOSL/IDA resources can be utilized to further improve the hospital based services for mother and child care and also strengthen the priority communicable diseases affecting the population. Some of these interventions include improving the prevention and control of TB, Dengue, Rabies, Leptospirosis, HIV/AIDS. The above mentioned activities will be planned and implemented utilizing the GOSL/ IDA resources under the NHDP. IDA funds will not be linked to a DLI under this thematic area but the following indicators will be monitored under the thematic area addressing MCH and Communicable diseases. % of facilities providing Comprehensive Emergency Obstetric Care (CoEmOC) (will need to be defined during Appraisal) Case detection rate for Tuberculosis Thematic area four: Health systems improvement NHDP plans to modernize the HMIS, in line with the country s overall vision of promoting e- governance, information and communication technologies and turning Sri Lanka into a knowledge economy. GOSL / IDA resources will be utilized to scale up relevant and useful on going pilot e-initiatives based on the draft e-health policy and strategic plan for e-health in Sri Lanka. In addition, resources will be utilized in converting the Indoor Morbidity and Mortality Return (IMMR) which reports all in-patient information using a modified ICD 10 coding system Second Health Sector Development Program Page 9

10 to an e-immr using the complete ICD 10 coding in secondary and tertiary hospitals managed by central and provincial health teams. The World Bank financed HSDP, during the period 2005 to 2010, had supported several interventions aimed at improving health services quality in Sri Lanka. Additional GOSL/IDA resources will be utilized to establish a national standard on laboratory accreditation for Sri Lanka and other relevant accreditation standards, guidelines and policies where necessary. The GOSL/IDA resources will help establish Quality Management Units (QMUs) in each of the hospitals both centrally and provincially managed. The role of the QMU is to help institutionalize use of clinical care guidelines and standards required to improve quality of services. Some of these activities include establishing mechanisms for sample death audits, morbidity and mortality analysis, premature death analysis, within 48 hour death analysis, improving the service and clinical quality in laboratories, labor rooms, family planning services, health care waste practices, and in piloting a responsive grievance mechanism for users of the health system. HCWM practices with regard to the following will be addressed using GOSL/IDA resources: (i) development of annual HCWM plans of larger hospitals and consolidated district HCWM plans; (ii) prioritizing a few of the larger hospitals in the country for further improving their health care waste management practices; (iii) capacity building of the Environment and Occupational Health unit (EOH) at the CMOH to take forward the overall planning and management of HCWM in the country; and (iv) formalization of the draft national HCWM policy, by obtaining the required approvals of it. In addition to QMUs, the GOSL /IDA resources will be utilized to further strengthen the drug quality assurance laboratory to expand its testing facilities for assessing quality of drugs prior to distribution. Resources will also be utilized to strengthen the drug logistics and storage system to plan for adequate buffer stocks of selected drugs and supplies at all levels of services. The NHDP will support strengthening basic, in service and continuing medical education programs to all levels of staff. The GOSL/IDA resources will be utilized to strengthen expenditure management and internal controls in the sector by institutionalizing Financial Management (FM) and procurement. Comprehensive capacity building program for health sector staff at the central, provincial and sub-provincial levels will be developed and implemented. Furthermore, the GOSL/IDA resources under the project will support strengthening the regional and central training centers providing basic and in service training of all required human resource categories. The IDA credit funds release will be linked to the achievement of the following disbursement linked indicators for the thematic area - system improvement. % of fully functioning quality management Units (QMUs) in central MOH managed secondary and tertiary level hospitals Base hospital and upwards) % of fully functioning quality management Units (QMUs) in provincially managed secondary and tertiary level hospitals Base hospital and upwards) % of central MOH managed health facilities sending indoor morbidity data through e- IMMR Second Health Sector Development Program Page 10

11 % of provincially managed health facilities sending indoor morbidity data through e- IMMR % of the 6 monthly cash forecast (for non-salary recurring and capital expenditures) released In addition to the DLI indicator for health system improvement the following indicator/s relevant to health systems improvement will also be monitored during the project period. No of laboratories in health facilities that have been accredited using a national standard % of training institutes managed by the Ministry of Health meeting national standards No trained on relevant areas (training areas to be discussed) % of NCB contracts awarded within the first nine months of the previous calendar year Component II: Innovation and Capacity-Building Fund This component is meant to support the implementation of innovations within the NHDP and provide opportunities for capacity building. Funds would be earmarked for technical assistance (includes the salaries and maintenance of a core team for project implementation and monitoring), training, workshops, testing innovative ideas, operational research, the demographic and health survey, baseline and end line surveys and other evaluative studies. The fund would be accessible to all implementing teams which include the CMOH, PMOH, MLGPC, MOFP and FC. The proposals / activities financed under this component will be reviewed and approved by a committee established to monitor this fund. The committee would be appointed by the Secretary Health in consultation with the World Bank. Criteria for selection and approval will be defined and cleared by the World Bank before approving proposals /activities under this component. An operations manual would be prepared prior to implementation of this component. Approximately US $ 10 million will be allocated from the IDA credit for the fund. (Reference: Draft Project Appraisal Document, January 11, 2013) Second Health Sector Development Program Page 11

12 1.4 Objectives of the framework and the intended audience Projects and Programs financed with IDA resources need to comply with World Bank Operational Policies. Therefore, components eligible for funding under the 2 nd HSDP will be required to satisfy the World Bank s safeguard policies, in addition to conforming with Environmental legislation of the Government of Sri Lanka (GOSL). The 2 nd HSDP is categorized as Environment Category B and will trigger the safeguard policy on Environmental Assessment (OP/BP 4.01). When OP 4.01 is triggered the borrower is required to carry out an assessment of potential issues triggered by the project/program and to prepare necessary mitigation plans. The 2 nd HSDP being a sector support will supplement the national health budget and monitor performance in selected strategic areas. As such, the exact activities funded by IDA resources may not be earmarked and hence what is possible is to look at the key environmental issues in the health sector and come up with a framework of actions to be supported during program implementation. In the health sector, environmental issues creating adverse impacts vary widely in nature. Of them Health Care Waste Management (HCWM) is considered to be one of the significant issues, although some other important issues like food safety, occupational health and safety, management of industrial carcinogens, indoor air pollution, etc. deserve due attention. Over the program period, support will be provided to expand/improve the services of health care facilities throughout the country. This is likely to generate more HCW, which in the absence of safe management and disposal practices can greatly increase the risks to people and the environment through exposure of infectious and hazardous substances contained in it. Secondly, the environmental and health impacts related to unsafe disposal of waste water and sewage from Health Care Facilities (HCFs) are considered to be significant warranting safe disposal options. Apart from impacts of HCW, waste water and sewage, other environmental impacts directly caused by program implementation are likely to be triggered by the construction of HCFs. However, these are likely to be relatively small scale, spread in different locations of the country and most likely confined to existing premises of the medical institutions and with localized impacts. The objective of this report is to present a framework for improving HCWM including waste water and sewerage management in HCFs in the country. The policy and legislative framework for HCWM in the country and related technical guidelines, evaluate HCWM practices, treatment and disposal technologies in use, provide an update of the achievements and gaps in the implementation of HCW systems (especially in view of the policy and national action plan prepared in 2001), present level of compliance with legal requirements and the presentation of an action plan for improving HCWM based on identified gaps. In addition, the report also provides safeguard requirements for managing impacts from civil works construction under the 2 nd HSDP. Second Health Sector Development Program Page 12

13 1.5: Structure of the report The structure of the report is as follows. Chapter Focus Chapter 1 Introduction to 2 nd HSDP Objectives of the report Chapter 2 Overview of the organization of the health sector in the country Policy and regulatory framework, related guidelines and institutional set up for standardizing HCWM Chapter 3 HCW generation in the country Overview of present HCW handling and management practices Treatment technologies and infrastructure employed by various HCFs Implementation progress of the policy and national action plan prepared in 2001 Achievements, gaps and lessons learnt Financial resources available for HCWM Chapter 4 National Health Development Plan and HCWM activities Strategies and action plan for improving HCWM in the next 5 years Indicators to monitor performance and progress in the identified priority areas Time bound implementation plan and resource requirements Chapter 5 Institutional arrangements for implementing and monitoring HCWM activities Chapter 6 Technologies available for HCWM and comparison of alternatives Chapter 7 Safeguard requirements for civil works Occupational health and safety guidelines Environmental provisions for inclusion in the contractor agreements Second Health Sector Development Program Page 13

14 1.6 Sources of information Situation Analysis and National Action Plan, 2001, Ministry of Health and Indigenous Medicine Draft Health Care Waste Management National Guidelines, October 2001, Ministry of Health and Indigenous Medicine Draft National Policy for HCWM, October 2001, Ministry of Health and Indigenous Medicine Situation Analysis and Action Plan for Chest Clinics, STD Clinics and Blood Banks, 2002, Ministry of Health and Indigenous Medicine Program of Action for Health Care Waste Management, November 2005, Health Sector Development Project Draft Report on Situation Analysis of the Waste Generation and Existing HCWM Systems in Hospitals, October 2006, Health Sector Development Project Infection Control Handbook, 2008, Ministry of Health Caring for the Environment , 2008, Ministry of Environment and Natural Resources Health Budget 2012, Ministry of Health National Health Development Plan , Ministry of Health Draft Project Appraisal Document for the 2 nd Health Sector Development Program, June 2012, World Bank Annual Health Bulletin, 2007, Ministry of Health Guidance Manual for the Preparation of National Health Care Waste Management Plans in Sub-Saharan Countries, World Health Organization and the Secretariat of the Basel Convention Health Care Waste Management in Sri Lanka, 2007, CORDAID Guidelines for the Management of Scheduled Waste in Sri Lanka, 2009, Central Environmental Authority Rapid Assessment of HCWM practices in 40 Hospitals in the Country carried out by the Ministry of Health in support of the preparation of this report Second Health Sector Development Program Page 14

15 Chapter 2: Existing policy/regulatory framework for HCWM in Sri Lanka 2.1 Overview of the organization of the Health sector in the country In Sri Lanka, both public and private sectors provide health care services. The public health care sector is larger and has a wide coverage that provides accessible care throughout the country. It is estimated that the public sector provides health care for nearly 60% of the population and 95% of the total in-patient care. It consists of a hospital based curative care system and a preventive community health care system which are administered by the Ministry of Health and the Provincial Health Services 1. Curative services For curative services, the government has a well established referral system that functions through an extensive network of HCFs situated across the country. As such, it has been estimated that a majority of the population has easy access to free western type government health care services within an average 4.8 km of a patient s home 2. The network of HCFs comprises of, hierarchically, Peripheral Units (PU) at the village level, District Hospitals at the district level, Base Hospitals which act as referral units with Medical, Surgical, Paediatrics and Obstetrics and Gynaecology (OBG) specialties, District General Hospitals in each district with specialties like ENT/Ophthalmology, Dermatology, Radiology apart from Medical, Surgical/Paediatrics and OBG, Provincial General Hospitals in each province and one National Hospital in Colombo which has all the specialties, and super specialties, and which is the apex referral centre in the health system. In addition, there are Teaching Hospitals attached to Medical Colleges with all the specialties. Table 1 provides details of the different HCFs available and the total bed strength by district in Preventive services For preventive services, each Divisional Secretariat has a Medical Officer of Health (MOH) in charge responsible for an average population of 60,000 people. The Medical Officers of Health are assisted by Public Health Nursing Sisters (PHNSs), Supervisory Public Health Mid wives (SPHMs), Supervisory Public Health Inspectors (SPHII), Public Health Inspectors (PHII) and Public Health Mid Wives (PHMs) who are responsible for the Mother and Child Health programme and the Environmental and Occupational Health programme including food safety. In addition, preventive health care services are overseen at the district level by a Deputy Provincial Director of Health Services (DPDHS) and at the provincial level by a Provincial Director of Health Services (PDHS). At the national level, all health care services come under the purview of the Director General of Health Services (DGHS). 1 Annual Health Bulletin, (2003), Ministry of Health 2 Annual Health Bulletin, (2003), Ministry of Health Second Health Sector Development Program Page 15

16 Private health care service sector The private sector provides mainly curative care, which is estimated to be nearly 50% of the outpatient care of the population and is largely concentrated in the urban and semi-urban areas 3. It consists of a number of large hospitals, private general practitioners, laboratories, blood banks, and dental clinics. 4 3 Annual Health Bulletin, (2003), Ministry of Health 4 Annual Health Budget, 2012, Ministry of Health Second Health Sector Development Program Page 16 Table 1 Health Institutions and bed strength by District

17 Administratively, the national health system which comprises of a network of curative and preventive health care facilities as described above is divided into three levels Central, provincial and district. While the MoH administers the major hospital categories such as the National Hospital, Teaching Hospitals and the Central Blood Bank at the central level, the provincial services are administered through the Provincial Directors of Health Services (PDHS) offices which in turn deliver services through Provincial General Hospitals, General Hospitals, Base Hospitals, District General Hospitals and Peripheral Units. They generate all sorts of HCW in significant quantities. Rural Hospitals, Central Dispensaries and Maternity Homes come under the direct supervision of the MOH units. They do not have surgery units and mostly generate only general medical wastes and sharps. Health Administration HCF category Type of Medical Activity Central level Ministry of Health National Hospital All kinds of medical Director General of Teaching Hospitals care activity, including Health Services Central blood Bank specialized treatment and surgery Provincial Level Provincial Ministry of Health Provincial Secretary Provincial Director of HS Provincial Hospitals Provincial Banks General Hospitals Base Hospitals General Blood All kinds of medical activity including surgery Type of HCW generated All categories of medical wastes are generated including specific medical waste in some facilities such as cytotoxic waste Same as above District Level Deputy Provincial Director of HS Divisional Director or MOH District General Hospitals Regional Blood Banks Peripheral Units Rural Hospitals Maternity Homes and Central Dispensaries Central Dispensaries (Primary Care Units) Curative health care and only small surgery that do not require general anesthesia Mainly outpatients Primary health care including vaccinations. Same as Base hospitals but small quantities Disposable syringes in small quantities and small quantities of general medical waste Table 2 - Overview of the administration of Health Services and classification of medical institutes 5 5 Adopted from the Situation Analysis and National Action Plan, 2001, Ministry of Health Second Health Sector Development Program Page 17

18 2.2: Health care waste management in Sri Lanka 2.2.1: General Background With HCW gaining greater importance as a significant public health and environmental risk, the GOSL has over the last decade or so, taken several positive steps to set up better standards of HCWM in the country and to consider HCWM as an integral part of the delivery of health care services. The background to this was paved when between 1994 and 1997 the Colombo Environmental Improvement Project published findings of a study on solid waste management in the city of Colombo, which indicated that prevailing HCW disposal practices posed a huge threat to the public and hence needed drastic improvements. Subsequently, when the Colombo Municipality Council (CMC) defined a 25 year plan to treat municipal waste in a composting plan with private sector participation, it stipulated that no medical waste should be present in the waste collected. As a result, an urgent need arose to find a satisfactory alternative solution for the disposal of HCW generated from the hospitals in the Greater Colombo Area (GCA). In 2000, the GOSL requested external support to assist the MoH to develop an integrated Health Care Waste Management system for the country. As a result, within the framework of the HIV/AIDS Prevention Program initiated by the GOSL and funded by the World Bank, a three phased program was launched under the direct supervision of the National Steering Committee for Clinical Waste Management (NCCWM). Initially, an assessment was carried out in analyzing HCWM practices in HCFs around the country with a specific focus on hospitals located in the GCA. In the subsequent phase, National Guidelines and the National Policy for HCWM were drafted and a National Action Plan was prepared aimed at gradually expanding improved HCWM practices throughout the country in a systematic way over a period of 5 years including a specific system for the hospitals in the GCA. It was intended that with the implementation framework in place, the final phase would to be dedicated to implementation of the recommendations provided in the first two phases. In addition, under the HIV/AIDS Prevention Project, it was also determined that specific and immediate action needed to be taken to reduce biological hazards associated with HCW generated from chest clinics, STD clinics and the blood banks within the country 6. As such, a situation analysis and an action plan were prepared targeting this specific sector of the health services. Equipment was supplied and training programmes were conducted. Over the past several years the MoH has successfully implemented a number of programs in support of the key recommendations made above to improve HCWM in the country. A system to treat all infectious waste generated from public hospitals within the GCA, which was estimated to be about 25% of the total generated in 2001, was commissioned and is currently in operation.. 6 Situation Analysis and National Action Plan, 2001, Ministry of Health Situation Analysis and Action Plan for Chest Clinics, STD Clinics and Blood Banks, 2002, Ministry of Health Second Health Sector Development Program Page 18

19 Several more treatment equipment has been commissioned in various major HCFs across the country with external as well as government funding support. Despite such achievements (which are highlighted in greater detail later in this chapter as well as the next), safety from HCW is still a challenge for Sri Lanka given its total national generation and the resources available for treatment/disposal. Addressing these challenges in order to have a standardized HCWM system covering the whole island with sustainable solutions that suit local requirements and conditions would certainly require current efforts to be stepped up both qualitatively and quantitatively. The package of enforcement and backstopping documents which were developed by the MOH between years , referred to above, basically form the implementation framework for HCWM in the country. Although a decade has passed, these documents still provide a sound basis on which better HCW planning can be enforced and hence should be strongly considered in deciding the way forward for future HCWM activities/programs. The sections below provide greater detail of the policy and legislative framework. 2.3 Existing health care waste management framework in the country 2.3.1: National Policy Policies, guidelines, procedures and codes of practice are essential to support any health care waste management system. In 2001, the Government of Sri Lanka drafted a comprehensive national policy on HCWM. It was divided into three main sections: General considerations on HCWM and the institutional mechanism for policy implementation that should be set up at national level. Provisions for the safe management of HCW in medical Institutions, including regulations and HCWM plans. Provisions for the implementation of and the monitoring of HCWM plans at national and provincial levels including legislation, provision of human and financial resources, training and awareness and participation of private sector 7. Some salient features of the draft policy are discussed below. The draft National Policy for Healthcare Waste Management states that all healthcare waste generated by the medical institutions of the public and private sector must be safely handled and disposed of. It states that every hospital is legally responsible for the proper management of waste that it generates until its final disposal and considers HCW as an integral part of hospital hygiene and infection control. It refers to the legal responsibilities of HCFs under the National Environment Act (NEA) and other regulatory needs, internal 7 Draft National Policy on Health Care Waste Management, 2001, Ministry of Health Second Health Sector Development Program Page 19

20 hospital rules etc for creating the legal and regulatory framework for HCWM at the national, provincial and institutional levels. Another important feature of the draft policy is that it requires major hospitals to prepare specific HCWM plans outlining needs, objectives, strategies and procedures for approved management and disposal of HCW and timeframe for implementation and submit to Central or Provincial Health Services for validation and support. At the provincial level, the draft policy requires PHS to set up annual Provincial and District HCWM plans presenting the strategy for HCM that should be developed at the regional level. This plan shall compile all the HCWM plans of the HCFs they are responsible and approved by the Central Health Services before implementation. The policy recommends specific budget lines to be developed relating to hospital hygiene and HCW management in the National Accountancy of the Health System in order to ensure sufficient human and financial resources are allocated to implement the HCWM plans in medical institutions. It also states that policy implementation needs to be monitored on the basis of the specific objectives defined in the National Action Plan (the plan developed to implement the policy country wide - see section below) and that institutionally, the National Steering Committee on Clinical Waste Management will be responsible for the overall monitoring and evaluation and the PHS for the implementation of monitoring procedures in HCFs within their area of jurisdiction. Approved HCWM practices, equipment for treatment and disposal, training and awareness, involvement of civil society, private sector participation are some of the other key aspects reviewed in the draft policy. Though the draft policy was submitted to the Cabinet of Ministers and referred to different agencies for their feedback, official approval was not granted, because before the process could be completed a cabinet reshuffle took place and the process was interrupted and remains as it is up to date : National Guidelines In 2001, the GOSL drafted national guidelines for HCWM with an aim to providing a better understanding of the fundamentals of HCWM planning and directing HCFs in setting necessary procedures and standards to comply with policy and legislative requirements. These were drafted in a form that attempts to provide fundamental elements that should be integrated into future legislation specific to HCW. Although guidelines were reviewed by the National Committee for Clinical Waste Management as well as the MoH, it did not receive formal endorsement by the government. Second Health Sector Development Program Page 20

21 The draft national guidelines contained both practical and conceptual information on HCWM covering four main sections: Definition and categorization of HCW including potential harmful effects that can result from its harmful management Procedures for segregation, packaging, labeling, collection, storage, transportation and disposal of HCW that should be applied and followed in all HCFs in the country and for selection of appropriate treatment and disposal technologies and facilities Instructions for the implementation of HCWM plans including detail description of duties and responsibilities of health care provider at various levels Instruction for personnel of Central and Provincial Health Services that should deal with HCWM to ensure smooth implementation of the guidelines and to set up regular monitoring mechanisms In 2007, concise guidelines for HCWM were prepared under the Hospital Efficiency and Quality component of the Sri Lanka Health Sector Development Project based on the detailed draft guidelines prepared in The concise guidelines which mainly contain sections in waste categorization and HCWM procedures have been formally adopted and incorporated into the Handbook of Infection Control : Code of Hygiene Management of HCW is an integral part of hospital hygiene and infection control that must be reinforced with internal rules. As such the GOSL developed a Code of Hygiene for STD/TB clinics in The national code of hygiene contains HCWM procedures and is seen as part of an overall set of actions to control the hygiene conditions within the hospital. It sets out duties and responsibilities of medical and non-medical staff regarding hygiene procedures to be applied, recommended practices to maintain high level of hygiene and on-going management and managerial activities to be carried out in the hospital. The code of practice has to be implemented along with the HCWM guidelines : National Color code Separating different waste streams based on the type of treatment and disposal practices is a key step in the HCW management cycle. To implement a uniform system of segregation throughout the country, the MoH developed a National colour code for health care waste, dated March 2006 and circulated to all the government health care institutions, which is presently being implemented. With a view to streamlining the collection of waste, technical specifications for bags Second Health Sector Development Program Page 21

22 and bins to be used for different waste types were also made available for all hospitals. The national colour code identifies 7 specific categories. Colour Category Contents Yellow Infectious Cultures or stocks from microbiology, tissues from surgeries/autopsies, material or equipment in contact with blood or body fluids soiled linen, dialysis equipments such as tubing and filters. Yellow with red stripes Sharp waste Sharps, needles and IV sets contaminated with body fluids Black General waste General or municipal waste that is uncontaminated Green Biodegradable Garden, kitchen and food waste waste Red Glass waste Uncontaminated bottles, pieces of glass Blue Paper waste Paper, cardboard and office stationary Orange Plastic waste Uncontaminated plastic medicine bottles, saline bottles without IV sets, plastic bags Table 3 National Colour Code for segregation of HCW 2.3.5: Legislation and regulation National legislation is the backbone for planning HCWM in any country and provides the legal basis for establishing controls and permits. It is vital in making medical and non medical staff in hospitals for being responsible at their own level and in securing the HCW disposal process. In Sri Lanka the NEA No 47 of 1980 and its amendments (No and No 53 of 2000) are the basic legal documents that regulate hazardous waste and consequently HCWM in the country. Although it s a comprehensive document and specific regulations on hazardous waste has been in force since 2002, medical institutions were not included in the list of institutions/activities for which an Environmental Protection License (EPL) must be requested from the Central Environmental Authority (CEA) until The comprehensive analysis of the situation regarding HCWM in the country conducted in 2001 highlighted that the lack of a legislative framework for HCWM as one of the main shortcomings and recommended that the government consolidated existing legislation by editing a specific regulatory document most appropriate for the management and disposal of HCW. In 2008, the GOSL consolidated the NEA by incorporating medical institutions in the list of institutions/activities that require an EPL. Second Health Sector Development Program Page 22

23 Part II of the National Environmental (Protection & Quality) regulation No. 01 of 2008 includes Health care service centers generating infectious wastes, including medical laboratories and research centers as a prescribed activity that requires a license. Schedule VIII lists Healthcare waste as a scheduled waste from specific sources that no person shall generate, collect, transport, store, recover, recycle or dispose except under the licence issued by the Authority and in accordance with standards and other criteria as may be specified by the Authority. Source - Guidelines for the management of scheduled waste in Sri Lanka (2009) Accordingly, every HCF is legally responsible for the proper management of HCW from the point of generation until its final disposal to ensure minimum environmental and public health impacts. However, the regulations on HCWM classify all categories of HCW and emphasize the importance of safe disposal of all categories of hazardous waste : Other sectoral strategies addressing HCW Caring for the Environment (CFE) , which is the second successive sectoral environmental action plan prepared by the Ministry of Environment and Natural Resources to implement the National Environmental Policy of 2003, recognizes HCWM as a significant public health issue in the country that needs intervention, The CFE, which has been focused on 6 key sectors and addresses clinical waste under the waste management sector, has been prepared Second Health Sector Development Program Page 23

24 with close consultation with the relevant sector agencies including the MoH. With regard to clinical waste, the CFE broadly identifies the related public health and environmental issues and refers to the draft national policy and other initiatives that were planned and on-going at the time with the support of the MoH. Given below in the table are the key strategic actions recommended in the CFE in order to achieve better institutional and administrative mechanism for HCWM. Source Caring for the Environment : Recommended institutional and monitoring framework The institutional mechanism for implementing the national policy was broadly envisaged under three levels of management: At the central level, co-ordination and development of strategies and mechanisms to implement policy commitments, in accordance with national requirements, has been vested with the NCCWM. In addition, development of training and capacity building packages, training implementation supervision, setting up of HCW monitoring protocols, overall monitoring and evaluation has been assigned to the NCCWM. The Central Health Services are responsible for technically backstopping HCFs under its management purview. At the provincial level, implementation of the policy has been vested with the Provincial Councils. In particular the PHS is responsible for setting up provincial HCWM plans, synthesized from individual hospital HCWM plans coming under its area of jurisdiction, development of financial resources and for the implementation of HCW monitoring/auditing procedures. At the local level, setting up of HCWM plans that outline needs, objectives, strategies, procedures and timeframes for medical institutions has been vested with the hospital management National Committee for Clinical Waste Management (NCCWM). NCCWM is chaired by the Secretary of MoH with representatives of Sri Lanka Medical Association, CEA, Ministry of Environment, Ministry of Provincial Councils and Local Governments, MoH relevant staff, Second Health Sector Development Program Page 24