Strategies, Constraints and Recommendations for Sustainable Hospital Waste Management in Bangladesh – Shishir Reza & Sharmin Akter

Article

To ensure environmental security and toxicant free nature, sustainable medical waste management is indispensable. This paper explains the importance of sustainable treatment of medical waste for nature-ecology nexus and provides some recommendations for superior management of medical wastes. The study was conducted in some selected Health Care Establishments (HCEs) of Ishwarganj upazila under Mymensingh District. For the evaluation of medical waste management capacities, 1 government hospital and 7 private diagnostic centers of Ishwarganj upazila were selected. Data were collected from total 78 respondents, among them, 34 patients, 8 administrative officers, 2 doctors, 15 technicians, 12 cleaners and 7 nurses to inspect the present medical waste management, level of awareness and training of the individuals involved in the hospital premises. In Addition, data were collected from each Health Care Establishments (HCEs) to quantify waste generation rate that found to be 1.08 kg-1bed-1day-1 and 0.31 kg -1patient -1day-1. The percentage of reusable waste, sharp waste, infectious waste, general waste and chemical and radioactive waste generation were 11.3%, 10.75%, 9.13%, 67.5% and 1.5%, in that order. In this study, respondents provided their outlook in relation to nearby discarding places of waste in open dumping at Kachamatia river site (very inimical for river ecology), pits, municipal dustbin and others respectively 50.68%, 30.14%, 10.16% and 8.22% of total respondent. About 30.5% respondents stated that existing hospital waste management is adequate and 69.5% stated as inadequate. In the statistics of getting training, 35% staffs got training and 65% staffs did not get training on sustainable medical waste management strategies. In relation with the training methods 64.5% respondents showed their interest in video and lecture method, 19% for video, 11.5% for lecture and 6% for other methods.

Setting the Scene
The scenario of medical waste management in different types and category of hospitals are not satisfactory. It pollutes the environment with toxic substances contributing public health problem. Bangladesh has many public hospitals, medical college hospitals, district hospitals and upazila health complexes. A good number of private hospitals and clinics are also providing health care services. In most of the public and private hospitals there are no systemic approaches to medical waste disposal.
The Ministry of Health and Family Welfare (MOH and FW) already started to address the medical waste management as one of the priority program by including it as one of the critical factor among the identified six critical factors under health, nutrition and population sector program. The rapid increase of hospitals, clinics, diagnostic laboratories etc. in Mymensingh district in Bangladesh exerts a tremendous impact on human health ecology.
As for example, about 5 % of the total population in Bangladesh is thought to suffer from chronic hepatitis B infection. Most of the clinical wastes (e.g. syringes, needles, saline drips, discarded food, gauze, vials, and ampoules) are collected by poor women and children who re-sell those despite of deadly health risks. However, the fundamental objectives of this study are:
1. To investigate the existing management status of hospital wastes in the study area,
2. To observe the level of knowledge and awareness of individuals involved in the hospital premises,
3. To suggest remedial measures for better management of medical wastes in the study area.
The study was conducted in some of the Health Care Establishments (HCEs) belonging to the Ishwargonj upazila under Mymensingh district. They are Ishwarganj Upazilla Health Complex (IUHC), Emdo Diagnostic Centre (EDC), New Incaf Diagnostic Centre (NIDC), Buda Diagnostic Centre (BDC), Modern Diagnostic Centre (MDC), New Lab Diagnostic Centre (NLDC), Apon Diagnostic Centre (ADC), and Sheba Diagnostic Centre (SDC). One government hospital and seven private diagnostic centers were selected as the sample points.
Primarily, the categorization of waste in a hospital includes – clinical waste, laboratory waste, non-clinical waste and kitchen waste. A large storage size is required for a communal container, while an individual storage is sized to accommodate the waste generated by a family for normally in two or three days. The ultimate disposal of waste includes those wastes that are collected and transported directly from the residual substances from various waste processing plants that are of no further use. The options available for disposal are – open dumping, sanitary land filling and incineration. The respondents provided information from their practical experience. In order to minimize the response error questions were asked in simple Bengali language. After completion of each interview, it was checked to be sure that information had been properly recorded.

Results and Discussion
Blood bags, saline bags, syringe, bottle of medicine, plastic materials etc were categorized as reusable medical waste. Among the HCEs, Ishwarganj Upazilla Health Complex (IUHC) generated the lowest (7%) of reusable waste, Emdo Diagnostic Centre (EDC) generated second highest (13%) percent of reusable waste, New Lab Diagnostic Centre (NLDC) and Buda Diagnostic Centre (BDC) generated 10% reusable waste, Modern Diagnostic Centre (MDC) generated 11% reusable waste, New Incaf Diagnostic centre (NLDC) generated and Apon Diagnostic Centre (ADC) generated 12% reusable waste, and Sheba Diagnostic Centre (SDC) generated highest (14%) of reusable waste.
Among the HCEs, private diagnostic centers named Apon Diagnostic Centre (ADC) generated the highest (13%) and Ishwarganj Upazilla Health Complex (IUHC) along with Buda Diagnostic Centre (BDC) generated the lowest (6%) infectious hospital waste. Emdo Diagnostic Centre (EDC), New Incaf Diagnostic Centre (NIDC), Modern Diagnostic Centre (MDC), New Lab Diagnostic centre (NLDC) and Sheba Diagnostic centre (SDC) generated 9%, 12%, 8%, 11% and 8% of infectious hospital waste respectively. Among the HCEs, Ishwarganj Upazilla Health Complex generated the highest (81%) and Apon Diagnostic Centre generated the lowest (61%) amount of general hospital waste. Emdo Diagnostic Centre, New Incaf Diagnostic Centre, Buda Diagnostic Centre, Modern Diagnostic Centre, New Lab Diagnostic centre and Sheba Diagnostic Centre generated 66%, 64%, 71%, 66%, 65% and 66% of general hospital waste respectively.
Among the HCEs, Ishwarganj Upazilla Health Complex, New Incaf Diagnostic Centre, Buda Diagnostic Centre, New Lab Diagnostic centre generated 2% and Emdo Diagnostic Centre, Modern Diagnostic Centre, Apon Diagnostic Centre, Sheba Diagnostic centre generated 1% of chemical and radioactive hospital waste. In Ishwarganj upazila, average hazardous and non-hazardous medical wastes were 67.5% and 32.5% respectively. The highest (81%) hazardous waste were generated from, Ishwarganj Upazilla Health Complex. Among private diagnostic center Buda Diagnostic Centre generated the lowest (29%) non-hazardous medical waste.

Medical Waste Management in the Studied Areas
At private diagnostic centers the frequency of onsite waste handling as once per day twice per day and irregular, respondents were sixteen, five and three, respectively and they were 66.67%, 20.83% and 12.50%, respectively of the total respondents.
In the studied HCEs 78 respondents reported in measuring the onsite handling (from storage place to municipal disposal site or other) of generated hospital waste. At government hospitals the frequency of onsite waste handling was categorized as once per day, twice per day and irregular and the respondents were 46.65%, 79.45% and 56% of the total respondents respectively. At private diagnostic centers the frequency of onsite waste handling as once per day twice per day and irregular, respondents were 20.55%, 53% and 75.20%, of the total respondents respectively.

Disposal Place of Medical Waste
In the studied HCEs total 73 respondents provide their opinion about existing disposal place of waste in collection system. Among them 37 respondents preferred dispose their waste in open dumping at Kachamatia river site; they were 50.68% of total respondents.22 respondents preferred dispose their waste in pits and they were 30.14% of total respondents.8 respondents preferred dispose their waste in municipal dustbin and they were 10.16% of total respondents, rest 6 respondents preferred dispose their waste in others, they were 8.22% of total respondents. In the studied HCEs total 73 respondents provide their opinion about time of waste collection from secondary source to final disposal place. Among them 42 respondents preferred morning about time of waste collection from secondary source to final disposal place; they were 57% of total respondents.18 respondents preferred noon and they were 25% of total respondents. Rest 13 respondents preferred random time and they were 18% of total respondents.

Awareness on Medical Waste Security
The field survey shows different levels of awareness from different respondents. In the measurement of getting training of the studied HCEs, 35% staffs got training about the hospital waste management and 65% staffs did not get training of the total respondents. In connection with the training methods, in govt. upazila hospital and private diagnostic centre showed their highest interest in video and lecture, respectively 63% and 66%, followed by video 18% and 20%, lecture 11% and 12%, and others 8% and 4%. According to their rate of interest about training methodology combined video and lecture will ensure more awareness in reducing harmful environmental impact of medical waste.
In Ishwarganj Gov. Upazila Health complex, about 28% of the total 73 respondents stated their satisfaction in existing hospital waste management. The remaining 72% respondents stated their dissatisfaction of existing hospital waste management. In private diagnostic centre satisfaction and dissatisfaction rate was 33% and 67% respectively.

Concluding Remarks and Recommendation
The research focuses generation of medical wastes and the existing management system of medical wastes in hospitals and diagnostic centers in Ishwarganj upazila. The level of awareness on medical waste is medium but systematically management is not satisfactory as there are lacking of systems, rules and regulations, and financial support. Recommendations are given below: Raise awareness and education on medical waste issues, segregation of medical waste should be done at the point of generation. Different colored bags should be use to collect of hazardous and non-hazardous waste, modem techniques and technological devices such as moving dustbins, crane, separate collection system bins etc. may be use in hospital waste security. To avoid the risk of health effect from the wastes on-site incineration of the entire hospital waste with appropriate air pollution controls, is the best available means of processing prior to disposal, Re-use, recycle and reduce of waste generation should be followed through composting and following other process, To minimize the generation of medical waste, good housekeeping, replacement of chemicals, etc. may be adopted, Training program on safe handling of medical waste can be organized for medical staff. Government should promulgate and implement laws and regulations regarding medical waste management, A strong monitoring system should expand to monitor the whole management system. 

Shishir Reza is an Associate Member, Bangladesh Economic Association, & Sharmin Akter is an Urban Planner, Bangladesh Institute of Planners.