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KINGDOM OF LESOTHO
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NATIONAL HEALTH CARE WASTE MANAGEMENT PLAN
THE MINISTRY OF HEALTH AND SOCIAL WELFARE
P. O. BOX 514
MASERU, 100
Report Summary Sheet
|Client: |Client Contact Person(s): |
|Ministry of Health and Social Welfare |Mr L. Nthunya |
|P. O. Box 514 |Procurement Manager. |
|Maseru, 100 |Mr. Mokitimi Thekiso |
|Lesotho |Pollution Control Officer |
|Title of Report: |
|NATIONAL HEALTH CARE WASTE MANAGEMENT PLAN |
|Summary: |
|This report contains the findings of a study conducted by Synergy Holdings (Pty) Ltd as a consulting company on behalf of The Ministry of |
|Health and Social Welfare. The plan has been developed on the basis of local conditions and very closely following the WHO and World Bank |
|guidelines. |
|Keywords: |
|Health Care Waste Management, Segregation, Storage, Treatment , Disposal, Training and Awareness |
| |
|Work Carried out By: Synergy Holdings (Pty) Ltd |
|Rev No |Issue Date |Reason for Issue |Compiled By |Reviewed By |
|3 |March 2005 |Client Request, per |Dr K. Khalema |The World Bank |
| | |contract |62858484 |& |
| | | |Ms. M. Letsie |National Workshop |
| | | |63007767 | |
FOREWORD
Since independence, the Government of Lesotho has recognized the importance of good health of the entire nation and has given it a high priority. The government adopted a Primary Health Care approach and expanded rapidly the number of health care facilities under an extensive referral system, based on a cost-sharing principle. To date, there are 22 hospitals and 152 health centres in the country catering for a population of over 2 million. Health care services in these institutions result in the production of wastes that if not properly managed, have the potential of adversely affecting the health of healthcare workers and the general public due to their hazardous nature.
Issues of waste management are increasingly taking a front stage position in the overall pollution control and environmental protection in Lesotho. Lesotho is a party to the Basel convention on Trans-boundary movement of hazardous substances and she is also a party to the Stockholm convention on persistent organic pollutants. Medical waste is characterized as hazardous and as such, it becomes highly important for it to be handled with care.
The fate of any waste should be a sanitary landfill, which is properly managed and designed to retain all the waste without any paths to the environment. Hazardous waste is normally incinerated first and the ash disposed of in the landfill. Incineration is the destruction of wastes in a technological furnace. Medical waste in Lesotho is disposed of in various ways except true incineration and land-filling, and as such, poses risk to human health in all media. A unified collection, treatment, and disposal programme for medical waste is more involving than the municipal waste programmes, however, it can be more manageable because the production points are well defined and potentially cooperative.
The production of this document should be seen as the country’s recognition of its limitations and commitment to instituting proper health care waste management practices that will ensure the protection of health of all her citizens and is based on true principles of sustainable development.
Dr. Motloheloa Phooko
Minister – Health and Social Welfare
Table of Contents
Table of Contents 2
List of Acronyms and Abbreviations 4
List of Tables 5
List of Figures 5
Executive Summary 6
1.0 Introduction 10
1.1 Country profile 10
1.2 Health Delivery System 11
1.3 The Health Sector Reform Process 14
1.4 Waste Management in Lesotho 16
1.4.1 Solid Waste Management 16
1.4.2 Wastewater 17
2.0 Project Description 18
2.1 Development Objective 18
2.2 Scope of Service/Terms of references 18
2.3 Methodology 20
2.3.1 Assessment of Policy, Legal and Administrative Framework 20
2.3.2 Assessment of Health Care Waste Generation 20
2.3.3 Determination of Technology and Siting Facility 21
2.3.4 Determination of Disposal Sites 21
2.3.5 Assessment of Private Sector Participation 22
2.3.6 Training and Awareness Building Programme 22
3.0 Policy, Legal and Administrative Framework 23
3.1 Policies 23
3.1.1 Health and Social Welfare Policy 23
3.1.2 National Environment Policy 24
3.2 National Legislation 24
3.2.1 Constitution of Lesotho 24
3.2.2 Public health Order 1970 25
3.2.3 Environment Act 2001 25
3.2.4 Urban Government Act 1983 26
3.2.5 Sanitary Services and Refuse Removal Regulations 1972 26
3.2.6 Labour Code (Chemical Safety) Regulations 2003 27
3.3 International Conventions 27
3.4 National Permits 28
3.5 Institutional Frameworks and Administrative Issues 29
3.5.1 Government Health Facilities 29
3.5.2 Christian Health Association of Lesotho (CHAL) 30
3.5.3 Private Surgeries 30
4.0 Baseline Data/Current Situation 33
4.1 Waste quantities 33
4.2 Segregation and Storage 35
4.3 Treatments and Disposal 36
4.3.1 Hospitals 36
4.3.2 Clinics and Surgeries in Peri-urban Areas 36
4.3.4 Clinics in Rural Areas 37
4.4 Disposal sites 37
4.5 Level of awareness 38
4.6 Current Operational Constraints 38
4.7 Communities Response 39
5.0 Assessment of Health Care Waste (Management in Lesotho) 40
5.1 Health Care Waste Hierarchy 40
5.2 The Queen Elizabeth II Hospital 40
5.3 Risk Assessments and Analysis 46
6.0 Determination of Technology 48
6.1 Handling, Storage and Collection 48
6.2 Treatment 49
6.3 Incineration 50
6.5 Other technical issues: 53
7.0 Determination of Disposal Sites 55
7.1 National Official Dump Sites 57
7.2 Healthcare Waste Water 60
8.0 Private Sector Participation 63
8.1 Public-Private Partnership Options for Lesotho 64
8.2 Cost-Benefit Analysis 67
9.0 Training Needs and Awareness Assessment and Programs 68
9.1 Health Centers 68
9.1.1 Health Center Management 68
9.1.2 Medical Staff 68
9.1.3 Waste handlers 69
9.2 Communities 74
9.3 Institutions and Agencies 75
10.0 Summary of HCWM Plan for Lesotho 76
10.1 Preconditions and Reservations 76
10.2 Segregation and Handling 76
10.3 Collection and Disposal 77
10.3.1 All areas 77
10.3.2 Urban Areas 78
10.3.4 Peri-Urban Areas 78
10.3.5 Rural Areas 79
11.0 Monitoring Plan 88
12.0 Evaluation of Financing Possibilities 91
13.0 Conclusions and Recommendations 92
REFERENCES AND BIBLIOGRAPHY 94
ANNEX A 95
ANNEX B 97
ANNEX C: 100
ANNEX D 106
ANNEX E 108
ANNEX F 117
List of Stakeholders consulted 118
List of Acronyms and Abbreviations
APC Air Pollution Control
CBD Central Business District
CHEMAC Chemicals Management Committee
CHW Community Health Worker
COWMAN Committee on Waste Management
DHP District Health Package
EHI Essential Health Package
EIA Environment Impact Assessment
EIS Environmental Impact Statement
ENT Ear, Nose and Through
LEA Lesotho Environment Authority
HCW Health Care Waste
HCWM Health Care Waste Management
HIV/AIDS Human Immune Virus/ Acquired Immune Deficiency Syndrome
HSA Health Service Area
LSPP Lands Survey and Physical Planning
MCC Maseru City Council
MoFDP Ministry of Finance and Development Planning
MoHSW Ministry of Health and Social Welfare
MoLG Ministry of Local Government
NEC National Environment Council
NES National Environment Secretariat
NHTC National Health Training College
OPD Out-Patients Department
OSH Department of Occupational Safety and Health
PRSP Poverty Reduction Strategy Paper
TB Tuberculosis
WASA Water and Sewage Authority
List of Tables
Table 1 Summary of services offered by type of health facility and type of waste expected
Table 2 Waste categories.
Table 3 Licenses and permits required for construction and operation of Healthcare and waste Management Facilities.
Table 4 The results of weighing different categories of HCW at Queen Elizabeth II Hospital.
Table 5 Healthcare waste generated by major facilities in Lesotho.
Table 6 Roles and Responsibilities of various actors in Waste Management.
Table 7 Training for Health facilities.
Table 8 Methods to be used to raise awareness to different target groups.
Table 9 Institutions to be trained for participation in Medical waste Management.
Table 10 Examples of typical items in separate waste containers.
Table 11 Summary of Waste Management Plan.
Table 12 Monitoring Plan for implementation of HCWM Plan.
List of Figures
Figure 1 Mixed waste in a bin at Thamae Municipality clinic.
Figure 2 A small capacity incinerators at Mabote Filter Clinic.
Figure 3 Disposal of Sharps at one of the hospitals located in the Highlands.
Figure 4 General waste dumped at Queen Elizabeth II Hospital premises.
Figure 5 the incinerator at Queen Elizabeth II Hospital; the largest hospital in Maseru.
Figure 6 Waste dumping site at Thaba-Tseka.
Figure 7 Emissions from the uncontrolled burning of all types of waste at Tsosane dump site in Maseru.
Box 1 Training of waste handlers; points to be emphasized.
Box 2 Step-by-step approach for medical departments.
Executive Summary
Lesotho is a small country with a population of just above 2.1 million. About 75% of the country is mountainous or foothills, with 80% of the population living in rural areas. Because of this terrain, population distribution is sparse and a great proportion of the country is not easily accessible.
The country is demarcated into ten administrative districts, each with a center town that can be regarded as the urban center. There are further 11 peri-urban centers. There are four recognizable ecological zones, namely; Lowlands, Foothills, Mountains and Senqu valley. The zones differ in terms of topography, altitude, climate, the number of people and population concentration. Three quarters of the population is distributed in the mountains and the other three zones share the remaining one-quarter. The Lowlands have gained a good share of the population through rural-urban migration while the other zones have lost that share. The population density on arable land is estimated at 531 people per square kilometer, a better indication of the real density in urban areas.
The annual population growth rate has declined slightly from 2.29% in 1966 to 2.10% in 2000. The current growth rate indicates that the country population will double in 33 years. 43% of the population is under 15 years of age and the life expectancy is 45.1 years for males and 54.1 years for females. The proportion of females to males is about equal and women in reproductive age constitute 24% of the national population. The total dependency rate is about 47%.
Falling under the category of “Least Developed Countries”(LDC), Lesotho is currently faced with deeper development challenges than was the case at the time of independence. The basic challenge is the fundamental need to provide a sustainable basis for a better quality of life for Basotho. Despite the intensified focus on poverty reduction, the proportion of Basotho households living below the poverty line is estimated at 50 percent of the total population. The majority of this population does not have adequate access to basic human needs and about 40 percent of the labour force is still seeking gainful employment. Preliminary estimates have indicated that, in order to make a significant impact on unemployment figures, approximately 40 000 new jobs have to be created annually for a sustained period.
The government’s response to the negative economic developments lies in the formulation of a series of initiatives to correct the growing macroeconomic imbalances and lay the foundation for renewed economic growth. These include;
Accelerated divestiture of state-owned enterprises
• Improvement in the domestic financial intervention
• Increased diversification of the revenue base and
• Containing of government expenditure through public sector reforms
Lesotho’s Health delivery System can be described as a tripartite arrangement. There are government owned Hospitals and Clinics on one corner of the triangle, with Church owned Hospitals and clinics on another corner and the triangle completed by privately owned clinics and practitioners.
The government of Lesotho is further partnered with Non-governmental Organizations and United Nations (UN) agencies in the delivery of health services, especially in funding and delivering other social welfare activities.
The catchment areas for existing hospitals divide the Administrative structure of the Health system as the Health Service Areas (HSA), making a total of 19 HSA within the 10 national districts. The total number of Health Facilities in the country is estimated at 208 and the number is decreasing due to lack of capital to operate. This figure includes Hospitals and Clinics, called Health Centers (H/C), Village Health Posts, Maternity Homes and Out-reach stations and private clinics. It does not however cover private practitioners.
The Health Service Area is characterized by one Referral hospital and several Health centers.
Typical Population served per Health Service Area ranges from 41292 in Semonkong HAS, the smallest, to 310442 in Queen Elizabeth II HSA, which is the largest.
According to the Health statistics, the two Prevalent Diseases causing institutional deaths are HIV-AIDS and TB. There are reports that Hepatitis has been increasing since the advent of HIV-AIDS
Since independence, various policies were introduced by successive governments to improve the state of health of the people of Lesotho. The policies have had varying degrees of success. Improvements that were seen over time started to show erosion in the last 15 years, mainly due to economic decline, political instability, unhealthy lifestyles and AIDS.
The Review of this process highlights several achievements and drawbacks. An improvement in HCWM has not been part of this process until now.
The Health sector is financed through Government tax revenue, grants from donors and loans. User fees are the only other source of financing. The user fees contribute minimally to financing Health care. This is because the cost recovery is still very low at about 7.4% and the money so collected is reverted to the Ministry of Finance.
The observations in most health centers show that:
• HCWM is not assigned any specific authority
• Segregation of HCW is not observed by the medical staff
• Staff engaged in HCW handling is not provided with appropriate protective equipment
• All staff is not trained in HCWM
• HCW is not accorded effective treatment
• There is rampant theft of plastic bucket type medical bins
• Hospital grounds are not maintained in a manner deserving of a health care institution
• There is general poor maintenance of equipment from the incinerator to the sewerage network
Lesotho’s economy is still low to sustain a full-fledged waste management expenses. Due to unemployment and general poverty, people cannot afford to fund waste management. The successful implementation of HCWM shall require a more efficient economy.
Institutional collaboration is very poor among government ministries and departments, as such crosscutting programs like waste management, which are heavy on individual authority in charge are not fully functional. Collaboration should be improved and roles clearly defined down to financial responsibilities.
Communication channels and responsibilities are often neglected as a result of unclear roles (undefined) and the general attitude of hoarding program by the management in public service, in general. All programs within the sector should be publicized in the sector newsletter so that information reaches everybody and the public knows their roles.
Healthcare Waste Management is relatively poor in Lesotho and does not seem to receive any attention as a serious infection prevention program.
There is no legislation that governs HCW directly, except for the new Environment Act, which encompasses it in hazardous waste. Regulations and guidelines are non-existent.
Generally, the National Waste Management is inadequate to address the requirements of environmentally sound disposal of HCW.
Little support, especially in terms of resources to the healthcare workers has led to low morality and demotivation among workers at all levels.
Misadministration, such as late payments to non-payment of bills has crippled many operations of the healthcare system and still remains a serious threat to smooth operation.
Investment in HCW management should be regarded a national issue, not health sector issue. Hence collaboration between the major role players namely; MoHSW, MoLG, MTEC, and MoFDP must be strengthened with a view of harmonizing responsibilities and priorities.
It is further recommended that;
- MoHSW, MoLG, and MTEC share the funding of the capital costs of this plan, preferably at the ratio of 2:2:1 respectively. Other related operational costs can be funded within the recurrent budgets of individual ministries. The budget for these three ministries need to be thoroughly reviewed whereas budget lines pertaining to HCWM will be established.
- For purposes of accountability, the department of Environmental health should be assigned the responsibility of ensuring that all healthcare facilities implement the proposed HCWM plan. And for support to this department, the two committees – National HCWM Committee and HSA HCWM Committees - have to be established.
- The approved plan, through the national HCWM committee and HSA HCWM Committee should be made available and disseminated to all units of HHC facilities, including practices.
- Regulations on Hazardous waste and technical guidelines should be developed to address day-to-day operational issues.
- A system for evaluation, licensing and monitoring of private sector participation in hazardous waste management should be developed to enable considerable participation of private sector.
1.0 Introduction
1.1 Country profile
Lesotho is a small country with a population of just above 2.1 million. About 75% of the country is mountainous or foothills, with 80% of the population living in rural areas. Because of this terrain, population distribution is sparse and a great proportion of the country is not easily accessible.
The country is demarcated into ten administrative districts, each with a center town that can be regarded as the urban center. There are further 11 peri-urban centers. There are four recognizable ecological zones, namely, Lowlands, foothills, Mountains and Senqu valley. The zones differ in terms of topography, altitude, climate, the number of people and population concentration. Three quarters of the population is distributed in the mountains and the other three zones share the remaining one-quarter. The Lowlands have gained a good share of the population through rural-urban migration while the other zones have lost that share. The population density on arable land is estimated at 531 people per square kilometer, a better indication of the real density in urban areas.
The annual population growth rate has declined slightly from 2.29% in 1966 to 2.10% in 2000. The current growth rate indicates that the country population will double in 33 years. 43% of the population is under 15 years of age and the life expectancy is 45.1 years for males and 54.1 years for females. The proportion of females to males is about equal and women in reproductive age constitute 24% of the national population. The total dependency rate is about 47%.
Falling under the category of “Least Developed Countries”(LDC), Lesotho is currently faced with deeper development challenges than was the case at the time of independence. The basic challenge is the fundamental need to provide a sustainable basis for a better quality of life for Basotho. Despite the intensified focus on poverty reduction, the proportion of Basotho households living below the poverty line is estimated at 50 percent of the total population. The majority of this population does not have adequate access to basic human needs and about 40 percent of the labour force is still seeking gainful employment. Preliminary estimates have indicated that, in order to make a significant impact on unemployment figures, approximately 40 000 new jobs have to be created annually for a sustained period.
Development strategies implemented by the government, involving the five-year or three year rolling plans have previously articulated policy direction for socio-economic development. Such multi-pronged policies have not been able to achieve primary objective of improving the livelihoods of the people. Economic growth has been erratic and performance has been marked by highly unsustainable short-term successes.
Lesotho’s national income is derived from both domestic activity and migrant labour remittances. The country’s economy has traditionally been based on subsistence agriculture and animal husbandry, as well as small-scale industries that include clothing, footwear, textiles, food processing and construction. The small but expanding manufacturing base depends largely on farm products to support the milling and canning industries.
Economic sectors such as manufacturing and telecommunications are beginning to show good signs of growth, but much needs to be built on this progress. Lesotho’s major natural resource is human and water. The Lesotho Highlands Water Project (LHWP) is seeing the sale of water to neighbouring South Africa and an establishment of a hydropower facility. This is generating royalties that are an important source of income for the country. Along with other developing countries, Lesotho faces a number of risks and threats to its political and socio-economic development. Through a new national vision, such weaknesses and issues are being isolated and efforts being made to turn them into national capacity.
The government’s response to the negative economic developments lies in the formulation of a series of initiatives to correct the growing macroeconomic imbalances and lay the foundation for renewed economic growth. These include;
Accelerated divestiture of state-owned enterprises
• Improvement in the domestic financial intervention
• Increased diversification of the revenue base and
• Containing of government expenditure through public sector reforms
The national budget for the financial year 2003/04 stood at M 3.0 billion, where the Health sector drew M 261.0 millions, 8.7%. The Gross Domestic Product (GDP) stands at 1 billion maloti. A look at the sector budget shows no budget line for HCWM. This falls within normal operational costs, where as it is regarded as a simple cleaning procedure.
1.2 Health Delivery System
Lesotho’s Health delivery System can be described as a tripartite arrangement. There are government owned Hospitals and Clinics on one corner of the triangle, with Church owned Hospitals and clinics, coordinated by the Christian Health Association of Lesotho (CHAL) on another corner and the triangle completed by privately owned clinics and practitioners.
The government of Lesotho is further partnered with Non-governmental Organizations and United Nations (UN) agencies in the delivery of health services, especially in funding and delivering other social welfare activities.
The catchments areas for existing hospitals divide the Administrative structure of the Health system as the Health Service Areas (HSA), making a total of 19 HSA within the 10 national districts. The total number of Health Facilities in the country is estimated at 208 and the number is decreasing due to lack of capital to operate. This figure includes Hospitals and Clinics, called Health Centers (H/C), (includes Village Health Posts, Maternity Homes and Out-reach stations) and private clinics. It does not however cover individual private practitioners.
The Health Service Area is characterized by one Referral hospital and several Health centers, and The Ministry of health is the overall overseer of health issues in the country. The structure of the sector is indicated in organogram in Annex B.
The services offered at these different Health facilities are indicated in Table1. Following the WHO classification of Health Care Waste(table2) possible generation of each category of waste is indicated in the same table.
Table 1: Summary of Services offered by type of health facility and type of waste expected:
|Health Care Facility |Out Patient |
|Private practitioners |√ |
|1.Infectious waste — Waste suspected to contain pathogens |Laboratory cultures, waste from isolation wards, tissues, swabs, materials or equipment that have been in |
| |contact with infected patients, excreta |
|2.Pathological waste - Human tissues or fluids |Body parts, blood and other body fluids. |
|3.Sharp waste - |Needles, infusion sets, scalpels, knives, saws, blades, broken glass, and nails |
|4.Pharmaceutical waste - Waste containing pharmaceuticals |Pharmaceuticals that are expired or no longer used or needed, items contaminated by or containing |
| |pharmaceuticals (bottles, boxes) |
|5.Genotoxic waste - Waste containing substances with Genotoxic properties |Waste containing cytostatic properties (used in cancer therapy), |
| |genotoxic chemicals |
|6.Chemical waste - Waste containing chemical substances |Laboratory reagents, film developer, |
| |Disinfectants that have expired or are no longer needed, solvents |
|7.Heavy metals - Waste with high content of heavy metals |Batteries, broken thermometers, blood pressure gauges, etc. |
|8.Pressurized containers |Gas cylinders, gas cartridges, aerosol cans |
|9.Radioactive waste - Waste containing radioactive substances |Unused liquids from radiotherapy or laboratory research, contaminated glassware, packages or absorbent |
| |paper, urine and excreta from patients treated with unsealed radio nuclides, sealed sources |
Typical Populations served per Health Service Area ranges from 41292 in Semonkong HAS, the smallest, to 310442 in Queen Elizabeth II HAS, which is the largest.
According to the Health statistics, the Top ten Prevalent Diseases causing institutional deaths are:
• HIV-AIDS
• TB
• Pneumonia
• Diarrhea and gastroenteritis
• Diabetes mellitus
• Meningitis
• Heart failure (including CCF)
• Stroke
• Dehydration
• Upper Respiratory Tract infections (URTI)/Asthma
There are reports that Hepatitis has been increasing since the advent of HIV-AIDS.
Health Sector is probably the only sector that has established a training institution within its establishment to cater for most medical training needs of the sector, with exception of doctors. Initiatives in improving the health delivery system are discussed below.
1.3 The Health Sector Reform Process
Since independence, various policies were introduced by successive governments to improve the state of health of the people of Lesotho. The policies have had varying degrees of success. Improvements that were seen over time started to show erosion in the last 15 years, mainly due to economic decline, political instability, unhealthy lifestyles and AIDS.
In 1979, the health Sector adopted a Primary Health Care (PHC) as the strategy for health service provision. The cardinal feature of PHC was to bring services nearer to the people with their participation. A multi-sectoral approach to health service provision was also instituted in recognition of the fact that improvements in health status are not the sole responsibility of the health sector.
The concept of HSA was introduced to ease over-centralized administration and health care provision. The country was divided into 18 HSAs based on catchments areas of existing hospitals. Community participation would be ensured through District Management Teams, HSA Management teams and Health Center Committees. A hospital in the HAS would form the highest level of referral, being responsible for the supervision of all health centers within its catchments boundaries.
An additional cadre in the health care service was created. The nurse Clinician was meant to address scarcity of doctors and offer improved capacity to the nursing cadre. The nurse clinician was expected to carry out medical functions of diagnosis, prescription as well as usual nursing and midwifery functions.
The District Management Improvement (DMI) project was introduced to improve the management capacity of MOHSW, particularly the HSA management. This came with the Community Health Worker programme that saw 6000 CHWs trained, the Rural Health Service project, which rehabilitated the physical infrastructure of the Health centers, augmented by Rural Health Maintenance Project. Population Health and Nutrition (PHN) project was also run, under which filter clinics were constructed. It is noteworthy that these projects targeted only government facilities.
The Expanded Programme on Immunization (EPI) and that of Control of Diarrhoeal Disease (CDD) were instituted and became highly instrumental in reducing child mortality rate.
Programmes on TB control, reproductive Health, Sexual Health and Family Planning, Mental health, Environmental, Sanitation and Sexually Transmitted Diseases took great strides and made modest gains. However sustainability of these gains is seen as one of the major challenges still facing the sector.
The past two decades have not only realized some gains in aspects of health service in Lesotho, but have also shown erosion of some of those gains. Among the reasons identified for this negative trend are:
• Lack of a comprehensive and clear policy framework
• Lack of appropriate management and planning expertise
• Insufficient resources together with inefficient allocation and management of these resources (financial and human)
• The existence of dual system (CHAL & GOL) resulted in a fragmented and uncoordinated delivery of health services
• The advent of HIV-AIDS pandemic, together with resurgence of TB
• The persistently high population growth rate.
In an attempt to address some of these issues, The National Health and Social Welfare Policy was work-shopped in 1993, The national Health sector Plan in 1995 and the Round Table Conference held in 1995, followed by institution of the Health Sector Reform process.
The reform programme will be implemented over a period of ten years, starting in 2000. Phase I, the first three years are focused primarily on capacity building in order for the Ministry to institute the necessary changes. The overall programme is thus aimed at improving both the Technical and Administrative aspects of health services. Within the technical aspects, notably are district Health Package(DHP), Infrastructure, Pharmaceuticals and Social welfare, while in administration, Human resource, Finances, decentralization and donor coordination and Partnership are the key issues. The Review of this process highlights several achievements and drawbacks. An improvement in HCWM has not been part of this process until now.
The Health sector is financed through Government tax revenue, grants from donors and loans. User fees are the only other source of financing, which, however contributes minimally to financing Health care. This is because the cost recovery is still very low at about 7.4% and the money so collected is reverted to the Ministry of Finance. The reasons for this recovery rate are the same for all other negative trends as indicated above. The Health Sector Reform programme review paper however indicates that in successive years there are under expenditures, particularly in capital budget. The 2002/03 saw an overall under expenditure of M15.6million. Actual expenditure for 2002/03 financial year totaled M26.3miillions against M61.9miillion budget, only 42%. The major draw back can only be directed at poor leadership and management of the sector.
1.4 Waste Management in Lesotho
1.4.1 Solid Waste Management
Currently the ministry that is mandated for management of waste in Lesotho is the Ministry of Local Government, through the services of the Council in Maseru (Maseru City Council) and the Town Clerks in other towns. Their main duty in this regard is to remove collected waste from residential areas, commercial areas, industrial areas and health centers. Since these institutions exist in towns only, these services are not available to villages outside the demarcations of urban areas. It should also be noted that these institutions do not provide treatment facilities for waste, they only provide services of removal and disposal for which each household, business industry and health center served has to pay for.
The legal mandate that govern and support this service comprises of Local Government Act 1997, Urban Government Act 1983, Sanitary Services and Refuse Removal Regulations 1972, Environment Act 2001 (yet to be fully functional) and Public Health Order 1970.
There is no town in Lesotho with a sanitary landfill. There are only official disposal sites, which have been selected by the council and the town clerks and most of which are inappropriately located. All the urban waste, including medical waste, is dumped and burned in these sites without any form of cover afterwards. Apart from that, most of the disposal sites are unprotected - only two are fenced (Butha-Buthe and Maseru)– and this poses high risks of scavenging by the nearby communities.
In the capital city, Maseru, the city council bearing the responsibility of solid waste collection and disposal, do so in selected residential areas based on the old reserve demarcation, in commercial areas which include offices and retailers. They also collect in Institutions namely schools, prisons and Queen Elizabeth II hospital and banks, and then in the industrial areas. The frequency of collection varies from daily at industries and commercial areas to weekly at all other areas.
Maseru City Council offers special load service to areas not covered by regular service and to industrial sector that seem to have a higher generation rate. This service is the one used during cleaning campaigns. The arrangement with the hospital, which is regarded a special case is that they have recommended two skips on site and the hospital draws orders for payment of the skips. A skip is about M600.00 (six hundred maluti) a month.
The city council is plagued with a number of operational problems. These range from frequent breakdowns of the only four trucks that they have and two tractors. One other truck belonging to the works department has to be regularly engaged and often-small vans are used to supplement collection services. Another crucial problem is low labour force. The city is forced to operate with only 5 to 6 runners (refuse collectors) per truck. This number is said to be very low, and the optimum one is expected to be at least 10. Once in that group of 6, two are not at work for various reasons, work stops. A further problem is that of lack of storage facilities like bins and skips. Often litter is found lying around the small existing container and in other places simply dumped in some location. This leads to delays in collection and thus inefficiency.
1.4.2 Wastewater
The institution that is mandated to manage wastewater is Water and Sewage Authority (WASA).
WASA has oxidation ponds in most towns and peri-urban areas, which in most situations are connected to hospitals by a sewer line. Some have been constructed by the hospital and WASA inherited them. WASA used to run a sewage collection service with tankers, collecting on request in all other areas where septic tanks are built. The oxidation pond were meant and designed to handle domestic-like waste with minimal organic matter loading, and low chemical load. Therefore any effluent with chemical and organic loading higher than the set standards (see Annex C) needs to be pretreated before it can be directed into WASA sewer pipelines. So far there are no pre-treatment facilities; these have to be erected by individual generators of wastewater.
2.0 Project Description
2.1 Development Objective
The main objective of the study is to identify the level of Health Care Waste Management that will be relevant to help implement and enforce proper health environmentally sound, technically feasible, economically viable and socially acceptable systems for management of Health Care Waste in Lesotho.
2.2 Scope of Service/Terms of references
To achieve this objective, the terms of reference that were laid out for the consultant were divided into the following tasks:
TASK I
Assess the Policy, Legal and Administrative Framework as well as the Regulatory Framework on Health Care Waste Management (HCWM) and treatment/destruction facility in the country including air emission standards which are currently required by law and which are likely be required in the next ten years.
Identify permits requirements, including environmental, building, and other permits and procedures that Health Care Waste (HWC) treatment/destruction facilities would need to address.
Outline any public participation or public hearing requirements and procedures. For each requirement, list the lead agency to be contacted.
Assess the typical time demands for proposed facilities to obtain permits and address environmental impact requirements and public participation requirements.
Assess the health care waste generation at the hospital(s) or health centers to be determined by the Ministry of Health and Social Welfare (MoHSW). The details should include the minimum weight of total health care waste generated at each health care facility per week. Composition of the waste should be determined through segregation at the waste end point. Extrapolate the results to cover the entire country.
Assess the level of scavenging, if any, or recycling taking place inside health care facilities, along transportation routes, and at final disposal sites. Determine social issues in relation to scavenging taking place.
Review and analyze existing health care waste storage, collection, and disposal systems with due regard to level of separation. Determine the frequency of collection and environmental and health impacts for existing treatment.
TASK II
Determination of Technology and Sitting Facility
For the types and quantities of HCW generated in the study area, assess alternative technologies and facility sizes for treatment and destruction. The assessment shall compare the alternatives on the basis of capital cost, operating cost, ease of operation, local availability of spare parts, local availability of operational skills, demonstrated reliability, durability, and environmental impact. On the basis of this assessment, recommend a process flow for economic and environmentally sound treatment and final disposal of HCW leading to selection of appropriate technology. The government and/or facility should make the final decision on choice.
Determination of Disposal Sites
If site for disposal exists, collect all existing plans for suitable sites to be considered for the locations of the treatment facilities and review general transport and traffic systems relative to appropriate sites. Consider:
a) Accessibility to the site
b) Distance from the health care facilities to the site
c) Distance to sensitive areas
d) Future development plans of the area
e) Possibility to acquire the area
f) Cultural and historical sites,
g) Public opinion and
h) Noise and dust impact to nearby areas
Public consultation/hearing will be held as part of the final assessment for sitting of the treatment facility.
Analysis of site
Analyze the above information to determine whether there is sufficient appropriate material on site for daily and final cover, whether the site soil, hydrological and geo-hydrological conditions would ensure adequate protection of any ground and surface water used for drinking and/or irrigation. If the sites prove to be unsuitable, inform the client stating the reasons.
Financing
The Central Government or Local government, potential with municipal or other solid waste treatment and disposal activities where these exist, will finance this process. An alternative approach is for the private sector to provide the health care waste treatment and disposal activities or waste transport within districts.
Assess private sector participation as service provider.
Assess public-private partnership and cost recovery at national and district level, based on the polluter pays principle, where each health care facility pays according to the volume generated.
TASK III
Review existing training and public awareness programs on health care waste management at hospitals and other health care establishments and prepare training needs assessment.
Working in conjunction with the relevant government institutions and the municipality prepare a costed training programme and a well targeted Awareness Building Campaign Programme including the general public, and more specifically health care workers, dump site managers, municipal workers, incinerator operators (if that is the choice of technology), nurses, scavengers/pickers, families and street children. The design of the material required for the awareness building programmes should be discussed with the relevant authorities and the general public to ensure that their concerns that are deemed appropriate are incorporated in the design of the programme, sitting layouts, mitigation measures and community communication programmes. The Training and Awareness building programme and the management Programme shall be appropriately costed and the plan shall be presented in a national Workshop.
TASK IV
Revise the draft report in accordance with the comments of the World Bank, the Government and other interested parties and submit the Final Report incorporating all changes and modifications required to the Project Task Team.
2.3 Methodology
2.3.1 Assessment of Policy, Legal and Administrative Framework
All stakeholders relevant to waste management in general were consulted to inquire about their role in this aspect as well as the policies and legal mandates that support their involvement. All the documents prescribed were collected and reviewed.
2.3.2 Assessment of Health Care Waste Generation
This exercise was done in two parts, which are as follows:
- Assessment of current practices of waste management at different health centers. This exercise investigated how medical waste is managed from generation point up until its disposal point. The issues that were investigated are; types of waste generated; the extend of segregation; storage; treatment methods used; disposal methods used; the personnel handling it at all these points; their level of knowledge and skills on how to handle medical waste as well as the equipment and protective clothing used to handle this waste.
A questionnaire was designed and was used in all the health centers that were visited. And the centers visited were hospitals, clinics, and private surgeries. Their selection was based on representation of four different ecological zones of Lesotho, namely the Highlands, Lowlands, Foothills and Senqu River Valley as well as representation of rural areas and urban areas. The information was not sourced by use of the questionnaire only, but also through observation on how waste is handled from point of generation to point of disposal.
- Determination of Quantities of Medical Waste Generated. This exercise was carried out at Queen Elizabeth II Hospital in Maseru, where the waste from different sections of the hospital was segregated and weighed as a way of determining its quantity. The data found from this exercise was extrapolated to the rest of the health centers in the country according to types of waste generated and capacity of service provision at those centers. This was further compared with the estimated generation rate used in Dioxins and Furans inventory report of the Persistent Organic Pollutants (POPs) project.
2.3.3 Determination of Technology and Siting Facility
The determination of Technology was essentially a desktop study. A consideration was first made with regard to the processes required at every stage of waste management, and the technology options thereof. From containers at generation point, through internal transportation, protective equipment, treatment, storage and disposal, comparison was made on the basis of:
• Effectiveness and environmental performance
• Capital and operation costs
• Ease of operation
• Availability of spare parts/maintenance capacity
• General acceptability of the technology
2.3.4 Determination of Disposal Sites
The discussion centers on existing dumping sites for localities around the health centers and towns. This is derived from observations during visits before and during this work. The analysis here of is then based on:
Exposure risk to public (scavenging and emissions)
Potential environmental pollution (air, water, and land)
Hydro geological analysis was not performed on account of time frame. The real constraint became lack of consensus between Health, Environment and Local Government as to which sites have been earmarked as most suitable. There is however agreement among these role players that the existing dump sites are not suitable. The fore going analysis in his work used the NES guidelines or criteria for choice of a suitable dumpsite attached as annex B. This highlights the following points:
• Accessibility to the site
• Distance from the health care facilities to the site
• Distance to sensitive areas
• Future development plans of the area
• Possibility to acquire the area
• Cultural and historical sites,
It should be noted that the final choice of site will only be undertaken where there has been consensus among local authorities regarding the best option. It is the consultants’ understanding that the exercise is being spearheaded by COWMAN.
2.3.5 Assessment of Private Sector Participation
On top of the views and opinions of authorities regarding private sector participation, an analysis was made based on experiences of other countries. A basis for engaging private sector is laid down by national development goals and improvement of efficiency of services.
Within this analysis, the three principles are engaged, namely Polluter Pays Principle, Best Practices and Cost Recovery.
2.3.6 Training and Awareness Building Programme
As mentioned in section 2.3.3 above, a questionnaire was designed to source information from health centers, and this questionnaire had a part that investigated training needs for the personnel of the health centers. The training needs were assessed from management level of the health centers to the lower level personnel (e.g. cleaners, labourers). The questionnaire also investigated the best methods to be used for training and dissemination of information to health centers.
Another questionnaire was designed for use when consulting with communities. This questionnaire was addressed the following issues: Whether communities get in contact with medical waste; level of scavenging; how are they affected by the waste; their level of awareness on risks associated with this kind of waste as well as best methods to use for dissemination of information to them.
3.0 Policy, Legal and Administrative Framework
There are legal instruments in Lesotho that cover waste management and pollution control but they are not specific on management of medical waste. However the national policies and legal instruments that have to be taken into consideration in management of medical waste management are discussed below.
3.1 Policies
3.1.1 Health and Social Welfare Policy
This policy encompasses the subject of waste management in general and does not pin-point on medical waste. According to this policy, the priority setting for the Ministry of health and Social Welfare is based on the fact that the country’s disease burden overwhelms the available resources; therefore the available limited resources will be used as prudently as possible to have the largest possible impact on disease burden. To achieve this, two ways will be followed: firstly, the target will be on health problems and diseases with the heaviest burden; and secondly only health care and social interventions with proven cost effectiveness will be used.
As a result, the District Health Package (DHP) has been developed based on the Essential Health Package (EHP) concept. DHP consists of selected health interventions that address priority health and health related problems that result in substantial health gains at low cost that can be funded by the Government and will cover the whole country. One of the constituents of DHP is Essential Public Health Interventions, which include among others the following:
- Health Education and Promotion: The Government will run a campaign to change peoples’ risky and unhealthy lifestyles.
- Environmental Health: Government will promote environmental health by ensuring safe water and sanitation, vector control, occupational health and safety, waste disposal, food hygiene and port health.
Apart from that, the Health service stipulated by the policy is Environmental Health Services with the aim to address all potential and actual threats to human health and welfare. The Policy Objective is “to influence environmental conditions that will enhance health and social welfare” and the Policy Measures are:
a) Equitable access to resources and the satisfaction of people’s basic needs are fundamental to the concept of sustainable development
b) Environmental health interventions will involve education, promotion, advisory functions, inspection, monitoring and setting of standards
c) A multidisciplinary approach will be promoted to secure collaboration between different sectors
d) Review of different areas of legislation that impact on environmental health.
The policy may adequately cover the aspect of waste management within the broad environmental policy. What remain to be seen are the instruments of concretization of the policy, the weakest point in Lesotho’s public administration.
3.1.2 National Environment Policy
The National Environment Policy of Lesotho was developed by the National Environment Secretariat to address a broad range of environmental problems. Among other objectives that this policy has, there are those relevant to medical waste and these are for:
Toxic and Hazardous Substances: The objective is to regulate introduction, manufacture, import, sale, transportation, use, distribution and disposal of toxic, hazardous and radioactive substances in Lesotho. Management of these substances is to be guided by international conventions like Basel convention, Montreal Protocol, Bamako convention and others. The strategies to achieve this include: maintaining a data register of these substances; setting up the standards against their transboundary movement; and using environmentally safe and technologically sound techniques for their disposal.
Sanitation and Waste Management: The objective is to ensure that there are guidelines for the proper handling and disposal of waste in order to reduce pollution and the spread of disease. The strategies to achieve this objective include: the design of environmentally friendly waste disposal and treatment systems; establishment of standards; and establishment of monitoring programmes.
Air Pollution: The objective is to ensure that established ambient air quality standards are observed and improved. The strategies to be used include establishment of air quality standards and monitoring stations, and provision of guidelines to abate air pollution.
In a way, this policy directly addresses issues of Health Care Waste. It is a matter of legislation and regulations that would translate the policy into reality.
3.2 National Legislation
3.2.1 Constitution of Lesotho
The entire environmental legal mandates are derived from the Constitution of Lesotho, Section 36 which states that:
“Lesotho shall adopt policies to protect and enhance the natural and cultural environment of Lesotho for the benefit of both present and future generations and shall endeavor to assure all citizens a sound and safe environment adequate for their health and well being.”
The constitution therefore sets an adequate stage for legislation and regulation of human activities that are detrimental to the environment, including poor waste management. Several pieces of legislation have been developed with various degree of addressing the HCWM. These pieces of legislation are:
3.2.2 Public health Order 1970
This is a legal instrument that makes provisions for Public Health and the Ministry of Health and Social Welfare implements it. These provisions are obligatory to all health institutions in the country, including hospitals, clinics, and pharmacies.
In this mandate are found the clauses that address the issue of waste management at community, business and industrial levels only. It does not give provisions on waste generated from health institutions and applicable standards to its management. This mandate is to be enforced by health officers and other officers that may be appointed by the Ministry of Health and Social Welfare.
The law is highly outdated and should be reviewed with the objective of harmonizing it with other relevant laws, but even more to include specific issues on general administrative regulations of Health facilities, Environmental management regulations within health facilities and provision for technical guidelines for all major professional procedures within the health care system.
3.2.3 Environment Act 2001
This Act was developed to “provide for the management of the environment and all natural resources and for connected matters” (Environment Act 2001). Where environmental issues are concerned, it supersedes all other national legal instruments. The Act does not have sections that precisely address issues on Medical Waste Management but there are sections that may be applicable.
Environmental Impact Assessment (EIA)
Under Section 27 of this Act, it is stipulated that Environmental Impact Assessment shall be undertaken for all projects and activities listed in the schedule attached to the Act, and some of the activities listed are applicable in construction of health facilities, treatment of medical waste and its disposal. The act also authorizes the Lesotho Environment Authority (LEA) to monitor and audit operation of such facilities.
Environmental Quality Standards
The Act allows for LEA to establish the Environmental Quality Standards, namely, Water Quality Standards; Air Quality Standards; Standards for Waste; Soil Quality Standards; Standards for Noise; Standards for Ionization and other Radiation; Standards for the control of Noxious Smells; Guidelines for Environmental Disasters and other relevant standards. These standards, though not yet established will require all medical facilities to observe them.
Pollution Control
This part of the Act prohibits discharge of hazardous substances, chemicals and materials into the environment. It also stipulates the procedures on acquisition of Effluent Discharge License, Pollution License and Ionizing Radiation License, all of which most hospitals in the country are obliged to have.
Environmental Management
This section addresses the issues of management of hazardous waste, importation and exportation of hazardous waste and acquisition of disposal sites are addressed. And according to Section 77, for an institution to own and operate a waste disposal site or plant other than one used for domestic waste, it has to be in possession of a license to operate such facility.
Apart from that, it is stated in this act that LEA shall issue guidelines and prescribe measures for the management of toxic and hazardous substances. Therefore national health centers shall handle these substances in accordance with those issued guidelines and prescribed measures.
This Act is currently undergoing review towards updating and harmonizing institutional frameworks.
3.2.4 Urban Government Act 1983
The Urban Government Act of 1983 was meant to provide for the establishment and regulation of urban local authorities and to provide for matters incidental thereto. The powers of the councils as provided by the Act include ‘generally promote the public health, welfare and convenience, and the development, sanitation and amenities…’
In this Act the urban councils are mandated to provide, when a need arises, the sanitary services and refuse removal within the defined boundaries of the municipality. This Act has up to date been partially implemented. In Lesotho there is only one Municipality, which is Maseru City, managed by Maseru City Council. The Council does offer refuse collection services, within its capability. No waste is referred to or even treated as hazardous; hence the city’s waste is collected as mixed and disposed as mixed. The current situation in this municipality is that small government and private medical centers transport their needles to the referral hospital for incineration, and MCC collects the ash from this referral hospital and other centers that operate incinerators and transport it to the official disposal site.
The act is adequate for its purpose, however it has to be extended to all other districts and be adequately funded. The major failure of the Council and Town Clerks in other towns is general lack of funds. The local authorities do not have adequate mandate to collect taxes and fees such as rates. As a result even waste collection fees are difficult to collect, leading to poor services afforded.
6 Sanitary Services and Refuse Removal Regulations 1972
In these regulations, the clauses that are relevant to medical waste are found in Section 14. The general stipulation of these is that no waste should be deposited or kept or stored within a public view in such a manner that it becomes nuisance, injurious and dangerous to health. These were promulgated under the local Administration Act of 1969, administered by the then the ministry of Interior. These regulations also derive their power from the Public Health Order of 1970.
The regulations are also, outdated, providing for pail latrines and they are still laying penalties of M50 for offenders and refuse removal fee of 75 cents per quarter.
3.2.6 Labour Code (Chemical Safety) Regulations 2003
These regulations were developed specifically for Industrial Sector of Lesotho and with intention of protecting the employees of this sector from hazardous waste that they come in contact with at workplace. The regulations are silent about the exposure of the public and the environment in general towards the chemicals referred to. However, they have clauses that are relevant for use in medical waste management and that can be used as guidelines. These clauses address the following issues:
- Labeling and packaging
- Identification and classification of chemicals
- Display of safety signs, posters and notices
- Material Safety Data Sheets
- Exposure to Radioactive Chemical Substances
- Workplace and Health surveillance
- Training and Information of workers
- Personal Protection
- Personal Hygiene
- First Aid and Fire Safety
- Reporting of Accidents, Dangerous Occurrences and Diseases
- Records of Use of Chemicals at Workplace and Exposure of Workers to them
- Housekeeping
3.3 International Conventions
Lesotho is a party to a number of multilateral environmental agreements. The agreements in which Lesotho participates which are relevant to chemicals used in health facilities and the resulting waste are:
Stockholm Convention on Persistent Organic Pollutants
The Parties to this Convention:
Recognizing that persistent organic pollutants possess toxic properties, resist degradation, bioaccumulate and are transported, through air, water and migratory species, across international boundaries and deposited far from their place of release, where they accumulate in terrestrial and aquatic ecosystems,
Determined to protect human health and the environment from the harmful impacts of persistent organic pollutants,
Have agreed to institute measures to reduce or eliminate releases from both intentional and unintentional production and use, as well as reducing releases from stockpiles and wastes of the twelve persistent organic chemicals, listed in the annexes A, B and C of the convention. Among the major sources of one group of these pollutants, Dioxins and Furans (includes PCBs) are thermal processes, of which medical waste incineration is one of the contributors.
Basel Convention on the Control of Transboundary Movement of Hazardous Wastes and their Disposal
The Basel Convention makes specific reference to control of special HCW: sharps, pathological infectious waste, hazardous chemical waste, and pharmaceutical waste. Annex I of the Basel Convention includes the following waste categories that specifically refer to healthcare waste:
• Clinical wastes from medical care in hospitals, medical centers, and clinics.
• Wastes from the production and preparation of pharmaceutical products.
• Waste pharmaceuticals, drugs, and medicines, and
• Waste from the production, formulation and use of biocides and phytopharmaceuticals.
Rotterdam Convention on Prior Informed Procedure for Certain Hazardous Chemicals and Pesticides in International Trade
The purpose of this convention is to reduce hazards posed by chemicals and pesticides by facilitating information exchange about their characteristics by providing for a national decision-making process on their import and export and by disseminating these decisions to parties.
The convention covers pesticides and chemicals that have been banned or severely restricted for health or environmental reasons by parties and which have been notified by parties for inclusion in the Prior Informed Procedures. These include some chemicals that are used in medical practice.
The country has, however not been able to implement its political will on these conventions due to constraints of lack of financial resources, limited institutional capacity and inadequate environmental awareness.
3.4 National Permits
For construction and operation of health and waste management facilities, there are a number of departments that should be involved to give approval and in most cases in a form of a license. The licenses required are given in Table 1 below. Those that derive from Environment Act 2001, are currently being operated on good faith as the law is not yet fully operational.
Table 3: Licenses required for construction and operation of Healthcare and Waste Management Facilities.
|License/Approval |Department /Ministry to be |Division Issuing |Period of Acquirement |
| |Consulted | | |
|EIA License |National Environment |EIA & Pollution Control|When EIS has been reviewed by all relevant stakeholders and LEA|
| |Secretariat |Division |is satisfied that it is adequate and the project should be |
| | | |approved. |
|Effluent Discharge License |National Environment |EIA & Pollution control|Issuing of this license not yet operational and period of |
| |Secretariat |Division |acquirement not specified |
|Pollution License |National Environment |EIA & Pollution control|Issuing of this license not yet operational and period of |
| |Secretariat |Division |acquirement not specified |
|Ionising Radiation License |National Environment |EIA & Pollution control|Issuing of this license not yet operational and period of |
| |Secretariat |Division |acquirement not specified |
|Building Operations Approval |Ministry of Local Government |Building authority |30 days after an authority has received an application |
|Lease |Lands Survey and Physical |Physical Planning |Maximum of 6 months |
| |Planning | | |
|Disposal Site License |National Environment |EIA & Pollution control|Issuing of this license not yet operational and period of |
| |Secretariat |Division |acquirement not specified |
3.5 Institutional Frameworks and Administrative Issues
3.5.1 Government Health Facilities
The Government Health Facilities are administered by the Ministry of Health and Social Welfare (MoHSW) through different departments and units, most of which filter down to the level of hospitals and filter clinics. These departments are described below.
Planning Unit
This is the arm of the Ministry of Finance and Development Planning and it assists the departments under the MoHSW to formulate policies, plans, strategies and proposals. It also monitors implementation of these activities. The Planning Unit is responsible for sourcing funds, allocation of available funds to the Ministry’s departments and in mobilisation of resources.
The Planning Unit is centralized with its officers located in Maseru but they assist all the districts to develop the operational plans and annual budgets. While the unit may procure funds for Health care activities, the final use of such funds does not lie in the unit. The central finance dictates the ceiling for annual budgets. The best planning can do is to prioritize and fit all activities within that budget.
Health Education
This department is responsible for the development of health education and promotion policy for the country and it implements and monitors it. It designs and develops information, education, communication (IEC) messages, materials, media and other professional services for use by health workers and the communities. The department also distributes the IEC materials and ensures their efficient and effective use. So far there has not been any programme on HCWM.
Environmental Health
The Environmental Health department formulates implements and monitors the policy on environmental Health. This is the department that enforces the public health and environmental laws. It also creates awareness to health centres and the communities about environmental factors that contribute to poor health.
This department has been decentralized to all districts and it operates from the hospitals. Each district has at least one health inspector who works with the hospital, other health facilities that are serviced by the hospital, the town clerk and the urban boards, on environmental issues.
However, the Department of Environmental Health does not consider environmental management of the Hospitals and its implementation as their responsibility. They only get involved at advisory level where they give recommendations regarding the environmental state of the hospitals, and these are usually ignored since the health facilities do not have personnel that are accountable for enforcement and implementation of appropriate environmental management.
Estate Management Department
This department has two subdivisions that are important in medical waste management and these are:
- Maintenance whose functions, among others, is to liaise and advise other departments about standards specifications for medical equipment maintenance and
- Transport that holds the responsibility of managing the Ministry’s vehicles.
Each HSA has its own fleet of vehicles that is managed by the hospital and serves all the health facilities within that HSA. These vehicles include ambulances, trucks for transportation of equipment, 4 X 4 vehicles for transportation of health workers to remote areas, but none of these vehicles are specialized for transportation of medical waste.
Though MoHSW has the unit of maintenance, it has no specialized personnel for maintenance of medical waste technology, which is why most government hospitals are not incinerating their waste though they have appropriate incinerators.
3.5.2 Christian Health Association of Lesotho (CHAL)
There are about eight (8) hospitals and 70 clinics in the country that are owned and managed by the churches; and these churches are Roman Catholic, Evangelical Church and Seventh Day Adventist and Anglican. The national health and environmental laws and regulations govern these health facilities, and CHAL acts as a coordinator between them and the Government of Lesotho (MoHSW).
Originally, the churches managed to raise adequate funding for their operation and staffing. In the advent of donor fatigue or diminishing interest, particularly to these traditional churches, it has been difficult for them to sustain their operations. In an attempt to recover costs, their fees are higher than those of the government. An attempt was made to help them out and plans are underway to harmonize this partnership, in the interest of the nation. CHAL still lacks adequate capital cost for improvement, but their management is far better than the government health facilities.
3.5.3 Private Surgeries
Individual medical doctors registered with Lesotho Medical Council own the private surgeries. The national laws and regulations also govern these surgeries. Monitoring of the activities of these institutions is currently non-existence, and it seems the Medical Council and Association are dormant, due to internal conflicts and lack of clear mandate and relationship with the parent Ministry.
6. External Institutions
1. Operational Links
A number of Governmental Ministries share substantial responsibilities in management of waste. In a case of medical waste, MoHSW is responsible for putting in place the systems that will allow for appropriate management of this waste in all health facilities, from point of generation to disposal sites. Apart from MoHSW, there is the Ministry of Tourism, Environment and Culture (MTEC) which has a responsibility of protecting the environment by developing environment policies; drawing action plans; issuing environmental management guidelines and advising other ministries and sectors in environmental issues. The arm of MTEC in implementation of these activities is the National Environment Secretariat (NES).
The Ministry of Local Government has a major role in management of medical waste since it is its responsibility to provide refuse removal and disposal services. The implementing institutions for this Ministry are the urban council in Maseru (Maseru City Council) and the offices of town clerks in other districts. The Ministry of Natural Resources as an overseer towards protection of water resources comes in where wastewater is concerned. There are two departments under this ministry that work together for this cause and these are:
- The Department of Water Affairs which is responsible for drawing water policies and monitoring water quality, both surface and ground; and
- Water and Sewage Authority (WASA), which provides waste water treatment facilities.
Another major role player in medical waste management is the Ministry of Labour and Employment. Through its department of Occupational Safety and Health it has a responsibility of protecting the workers from health threatening working conditions and risks.
2. Advisory Committees
Committee on Waste Management (COWMAN)
This is an advisory committee established under NES with the primary objective to create conditions for environmentally sound waste management systems in Lesotho. Its membership consists of representatives from different governmental and parastatals institutions and NGO’s. To mention a few of these institutions, there is Ministry of Trade and Industry, Ministry of Natural Resources, WASA, Maseru City Council, Ministry of Labour and Employment (the Department of Occupational Safety and Health), National University of Lesotho (Faculty of Science), Lesotho Highlands Development Authority etc. The only weakness in composition of this committee is that the general public and the private sector are not represented.
The duties of this committee are mainly but not limited to:
- advise NES on issues relating to waste management
- assist in the management and disposal of waste in an environmentally sound and sustainable manner and to
- Provide an opportunity for exchange of information and experiences.
Since this committee is very big (consists of about 25 members), it operates by selecting task team for each assignment they have at hand. And in management of healthcare waste the health facilities and MoHSW in general can reap several benefits from this committee including:
- expertise advise on technical and social issues linked to medical waste management
- free survey and determination of appropriate sites for disposal provided there are some sites that are proposed and
- information based on experiences by different departments.
Chemicals Management Committee (CHEMAC)
This committee is also an advisory committee established under NES with the primary objective to create conditions for environmentally sound management chemicals in Lesotho. Its membership consists of representatives from different governmental and parastatals institutions and NGO’s.
4.0 Baseline Data/Current Situation
The current situation has been reflected in two fold, regarding medical waste management in Lesotho. Firstly Quantities of overall Hospital waste was estimated using empirical calculations on the basis of SA Incinerator company research findings. Secondly the most pertinent issues in medical waste management are discussed. Lastly, the constraints that were reported and observed are accounted. This is so that the baseline situation can be cohesive.
4.1 Waste quantities
Queen II HCW determination study
For effective development of a waste management plan, the quantities of different categories of HCW generated have to be established. It was agreed that a thirty days (one month) period would provide an adequate assessment of generation trends at QEII hospital. To achieve this, segregation of HCW at generation points had to be practiced. Given the prevailing conditions at QEII, certain measures had to be employed to solicit cooperation from the medical staff. First was to get support from management, which was duly provided from the Medical Superintendent to the Hospital Administrators. The latter went out of their way to introduce the study team to different sections of the hospital and afford them audience with staff on the study expectations.
Second was to procure equipment necessary for effective segregation at generation points given the current practices and determine the amounts of each category of HCW generated. The following equipment was procured:
• 10 litre medical waste bin x 41
• 25 litre medical waste bin x 16
• 90 litre refuse bin x 28
• black polythene refuse bag x 500
• red polythene refuse bag x 500
• digital scale x 1
• gazebo tent x 1
Apart from the scale and tent, the other equipment was meant to complement the already available equipment at the hospital.
Table 4 below is a summary of waste generation as measured at Queen Elizabeth II over a period of one month.
Table 4: The results of weighing of different categories of HCW at Queen Elizabeth II Hospital.
|Date |Quantities of Wastes Generated |
| |(kg) |
| |Sharps |Infectious |Anatomical |General |Pharmaceutical |
|Dec 7 |0 |35.0 |70.8 |129.5 |0 |
| 8 |8.7 |146.5 |79.0 |246.6 |0 |
| 9 |16.3 |122.7 |75.2 |146.5 |0 |
| 10 |4.5 |47.9 |64.2 |290.8 |0 |
| 11 |1.4 |63.5 |16.4 |30.7 |0 |
| 12 |0 |42.7 |46.9 |9.4 |0 |
| 13 |9.9 |116.6 |92.2 |300.7 |0 |
| 14 |22.7 |105.2 |37.2 |259.2 |0 |
| 15 |1.5 |71.9 |69.9 |199.1 |0 |
| 16 |5.8 |101.6 |50.8 |224.1 |0 |
| 17 |28.6 |66.8 |87.3 |190.7 |0 |
| 18 |4.1 |51.2 |43.1 |25.8 |0 |
| 19 |0 |46.6 |24.3 |5.1 |0 |
| 20 |6.5 |137.2 |91.8 |260.5 |0 |
| 21 |2.2 |92.8 |66.4 |169.0 |0 |
| 22 |0 |82.8 |50.3 |125.5 |0 |
| 23 |0 |121.8 |43.1 |167.0 |0 |
| 24 |12.5 |101.8 |55.1 |152.5 |0 |
| 25 |0 |50.7 |49.0 |27.0 |0 |
| 26 |0 |50.7 |26.0 |0.6 |0 |
| 27 |1.4 |157.7 |56.1 |198.0 |0 |
| 28 |3.2 |98.0 |85.5 |157.1 |0 |
| 29 |20.4 |91.0 |68.9 |106.6 |0 |
| 30 |0 |90.0 |41.4 |145.6 |0 |
| 31 |24.4 |107.5 |39.8 |96.2 |0 |
|Jan 1 |4.1 |32.7 |33.6 |2.6 |0 |
| 2 |0 |28.6 |49.2 |10.1 |0 |
| 3 |7.4 |171.2 |56.1 |181.2 |0 |
| 4 |5.5 |78.2 |14.7 |194.2 |0 |
| 5 |53.2 |81.5 |36.3 |226.4 |0 |
|Total |*244.3 |2 592.4 |1 620.6 |4 278.3 | **0 |
*the normal sharps container used at QEII is the 25 litre plastic bucket type which weighs 4.9 kg of sharps when full. Therefore the total number of buckets required for the 244.3 kg of sharps recorded during the study period is 50.
**the zero amount recorded for pharmaceutical wastes is due to the policy mentioned earlier of stockpiling expired or wasted medicines and drugs instead of destroying or disposing of them until they can be verified and their destruction witnessed by the relevant stakeholders.
4.2 Segregation and Storage
In all health centers visited, the waste that is religiously separated from the rest comprise of needles, which are placed in needle containers, two liter medicine containers or in desperate situations in card board boxes. All other waste – gloves, anatomical, swaps, etc, - are mixed in one container, which in most cases is an ordinary dust-bin. To make removal of this waste from the generation point to treatment/disposal point easier, black plastic bags are used. There is no labeling at all, neither on the dust-bin nor plastic bag. There is also no recording of waste on removal from one point to another. In most cases if not all, it is the cleaners who remove waste from the generation point to the treatment point.
[pic]
Figure 1: Mixed waste in a dustbin at Thamae Municipality clinic
In all health centers there are no appropriate storage facilities for the waste generated before it can be treated. It is therefore kept in the same room of generation, still in its black plastic bag and dust-bin, until it is removed by the cleaners. In small clinics where the needles have to be transported to large hospitals for incineration, one of the rooms at the center is used for storage of containers full of needles. In some centers these containers are removed from storage to incineration on weekly basis while in others they are removed only when transport is available, and at times it takes about two months before it gets available.
From the visits undertaken by consultants, it became evident that, the segregation practice that is consistent was that of sharps (almost always in their respective containers), the rest of the waste is mixed together, sometimes at source or during collection to the treatment site. One category that is almost always separated is anatomical waste. Mainly from the Gynaecology department, human tissues are separated and disposed separately. There are however, high incidences of mixing those with other infectious waste, such as items contaminated with blood and excreta materials.
Three streams of waste could thus be identified (sharps, infectious waste and general waste).
4.3 Treatments and Disposal
For treatment and disposal of HCW there are three different situations depending on the size and location of the health center. These situations are as follows:
4.3.1 Hospitals
All hospitals visited had appropriate incinerators that can operate at temperatures above the recommended minimum temperature of 1,200oC. However, all but one incinerator was operating, and still, the latter was operating only at 800oC. Most hospitals have constructed the incinerator with bricks where they place the waste and use diesel to burn it. In a few cases, the same process of manually spraying the waste with diesel and then burning it is used with the appropriate incinerators that are supposed to operate automatically.
[pic]
Figure 2: A small capacity incinerator at Mabote filter clinic.
The reason given for this entire situation was that these incinerators need maintenance and there is no personnel at the centres that have such skills. As all hospitals with this problem are government hospital, it was also mentioned that the Ministry of Health and Social Welfare has been informed on numerous occasions
ions about this problem but there has not been any response. After incineration of waste, the resulting ash mixed with remnants of sharps is placed in dustbins where the municipal or hospital laborers will collect it and dispose it at official disposal sites.
In the district of Thaba-Tseka, the central Hospital belongs to CHAL and has no incinerator whatsoever, the sharps are being buried in an old septic tank which is now full to the brim (see figure 3) The anatomical waste is either buried in very shallow pits and covered or disposed in pit latrines.
4.3.2 Clinics and Surgeries in Peri-urban Areas
These include clinics and surgeries in towns of Lesotho and in the villages that access those towns easily. These centers transport their needles to the nearest government hospitals. The rest of the hazardous waste is burnt or buried while general waste is placed in the dustbins for the municipality to collect for disposal.
[pic]
Figure 3: Disposal of sharp at one of the hospitals located in the Highlands of Lesotho.
4.3.4 Clinics in Rural Areas
Most of these clinics are located in remote areas of Lesotho far from the towns. They are supposed to transport their needles to the Hospitals that serve them, but due to lack of transport this is not possible. As a result they bury these needles, and most clinics bury them outside their compound while a few bury them within the compound or pit latrines, along with anatomical waste like placentas. The rest of the waste is burned using any form of fuel, and is disposed on disposal heap or in a pit where it is later buried.
2 Disposal sites
In the whole country there is no sanitary landfill. The Ministry of Local Government is the one responsible for allocation and management of disposal sites. And the areas currently used in urban areas for disposal of solid waste are undeveloped and inappropriate sites that have been selected for such purpose by the municipality or town clerks. The very same sites are used for disposal of medical waste in urban areas. Most of these sites are also unprotected and this can attract the people to come for scavenging.
There are no legal or official disposal sites in rural areas. Each health center has its own way of disposing of the waste. As mentioned above some clinics send their needles to the hospitals for incineration, and the hospital will take care of the disposal too. The anatomical waste is buried, and in some other cases the needles are buried along with anatomical waste, while the rest of the waste is burned at the disposal heap. There are a few clinics that have built kilns where they burn all their waste and bury it afterwards.
4.5 Level of awareness
Management personnel are very much aware of the need to manage HCW properly. They are even aware of the practices, which they acknowledge that they are definitely not appropriate or adequate.
Doctors are also aware and they try by all means to segregate at least into three categories. They have noted that final management of waste is left to cleaners.
Nursing staff: being the most central group in medical processes, they are not only aware of the requirements of standard practices, but they also know what should happen. They are limited by capacity, in terms of their numbers, required equipment and infrastructure in general.
Cleaners and porters: these are the groups that simply handle the waste from where it has been collected in various containers. Out of cultural intuition, they are aware that anatomical waste should be handled and disposed in some special way, however, since burning has been provided as an option, they normally would mix everything, when transporting to the treatment site. To them, all is going to be burnt after all. The risks are vaguely understood even though they are acknowledged.
Gardeners: This group of staff has been rather misused. They are occasionally required or posted to operate incinerators and to bury some anatomical waste in non-specific areas within the health center campus. Because they have no light whatsoever on medical waste management, they simply follow orders, putting themselves to all possible risks.
4.6 Current Operational Constraints
The first and probably most important constraint that was observed was demotivation among all staff members at all levels. This is observable through the general attitude of not caring, relinquishing responsibilities and general feeling of helplessness and negligence. As a result of lack of incentives (especially financial) staff members tend to do the least expected of them. There are conflicts across all cadres as to whose responsibility it is to segregate and ensure proper waste management. There is no monitoring and as a result individuals do things haphazardly.
Capacity constraints: Capacity problems indicated by almost all respondents include inadequate staffing at all levels, hence the core functions are redefined, in all cases leaving the aspect of waste management out. This has further led to overworked staff that would take any opportunity to rest, thus neglecting duties.
Poor knowledge of proper waste management processes and protective requirements is yet another constraint, especially among the cleaners and gardeners/porters who are used to collect and operate “incinerators” and burn it in pits and kilns.
There is a general lack of clear job descriptions and reporting as well as monitoring responsibilities, leading to no accountability. A very great proportion of the staff have no idea as to what are the priorities of the sector, everything is business as it comes.
The major complaints received from all staff at all levels were that:
• The management does not seem to care or show much commitment to staff welfare even normal operations (budget allocation and frequent breakdowns of equipment were cited as examples), the management pointed upwards.
• Communication channels are broken, and information does not reach/trickle down to lower levels and sometimes even to targeted groups
• Managers lack proper management skills in general, they are normally medical technocrats, who have not received any administrative training.
4.7 Communities Response
In all districts visited other than Maseru, the information found from the communities and the health centres are that the people do not scavenge on medical waste. On observation too, there were no people found scavenging on waste within the compounds of the health centers. However, the nearby communities are still exposed to high risks since the places where the medical waste is stored, incinerated or disposed of are not securely protected and there are no signs that show the people that such places are dangerous.
When asked about their level of awareness, the response from the communities was that the people have a general knowledge that medical waste can be hazardous but they do not really know how. Other than that they do not know how to manage and handle it in case they come in contact with it.
5.0 Assessment of Health Care Waste (Management in Lesotho)
5.1 Health Care Waste Hierarchy
There are generally four key steps to HCW management. :
1) Segregation into various components, including reusable and safe storage in appropriate containers; Waste is produced or generated within hospital units/wards indifferent categories. It is therefore commendable to separate it in order to dispose of each category appropriately. Costs are involved in the management process, hence the separation also allows for cost reduction through reuse or recycling within general wastes.
2) Transportation to waste treatment and disposal sites; this requires minimization of exposure to workers, hence should be done in a manner that does not require further removal from its containers.
3) Treatment: Disposal methods vary according to type of waste, local environment, available technology, acceptance and costs. Burial of substances is an accepted method in Lesotho, probably because the dead are also buried. The practice has been extended to all other tissue materials. The risk to ground water is high, however this does not seem to be an issue regarding burial sites in all villages. The final choice of treatment must consider above all operation expense and secondary waste.
4) Final disposition: This in turn also depends on the treatment. Land filling is the most effective means, if well managed and well sited. This choice is sustainable and environmentally sound, though relatively expensive to build.
Within the Health Care facility, the first three steps do apply, while the last step requires external intervention. The drive behind proper HCW management is a public and workers health issue, as such; solutions cannot come only from the health sector, but from all relevant role players.
5.2 The Queen Elizabeth II Hospital
The discussion of the state of the largest Health facility in Lesotho offers a clearer picture in terms of the situation in most of the hospitals, and what the public is facing and could be facing in other facilities if proper interventions are not urgently instituted.
General Premises
The premises are not accorded the level of cleanliness deserving of such an institution. Old equipment including beds, examination tables, shelves, trolleys, sponges (mattresses), pillows, and others is dumped at various locations within the premises. Added to these are collapsed roofing materials comprising purlines and corrugated iron sheets, builders rubble from earlier renovations, and the general waste such as bottles, plastic, cans, paper, surgical gloves and an assortment of debris which have not found their way to waste receptacles and are scattered all over the premises and in some cases, even causing blockages to the drainage system.
There is an inadequate distribution of general waste receptacles to cater for people awaiting health services at different areas of the hospital, with some areas lacking any receptacles at all. For instance, the Dental and ENT area has none, the eye clinic has one, the TB clinic area one, and the casualty and registration area one.
The area next to the eastern gate that is currently used as the main entrance has a convergence of vendors with the resultant generation of all sorts of wastes which due to the absence of waste receptacles, are dumped indiscriminately at convenient spots, presenting unsightly stockpiles to both hospital visitors and people who pass by. The problem is compounded by the informal caterings that have sprung up around the area.
The hospital drainage system is in a very poor state of maintenance. As mentioned above, the storm water drains are clogged with vegetation and all sorts of debris which disrupt the conveyance of the water, resulting in the built up of silt within the channels. The sewerage system is in need of attention with pipes leaking at places. As a result of this, there is a smelly puddle outside ward 4 and several open ground discharges along the system.
The yards, including lawns are not maintained properly and as a result, there is general overgrowth of grass and vegetation, which distorts the landscape and extends to the open storm water drains thus, interfering with the flow of run-off and causing unsanitary conditions to prevail. The trees are not trimmed and their location is not in harmony with either the landscape or the buildings. In fact, some of these trees are just an obstruction to other structures and walkways
The hospital has employed five grounds men complimented on a daily basis by two prisoners. Despite the presence of these people, and as indicated above, the hospital grounds look like they are never attended to.
HCW Storage at Generation Points
The storage of health care wastes at different generation points by medical staff is based on the principle of segregation into primarily three categories of HCW namely, general, infectious, and sharps. In the maternity ward and the theatre a fourth category, the anatomical, is added. Different departments use different storage methods;
Wards – the most common method of general wastes storage is the cardboard boxes. When full, the boxes are emptied into black refuse bags. Sharps are stored in specially designed 20 litre buckets while the infectious category such as dressings, disposable nappies, and pads are stored in 15-20 litre refuse bins lined with red refuse bags. In the maternity ward, 50 litre bins lined with red refuse bags are used for anatomical wastes.
Laboratory and Blood Bank – these departments use autoclavable plastic bags for storage of both general and infectious wastes but separately.
OPD and Casualty – both these departments use 50 litre bins for storage of general wastes while cardboard boxes are used for infectious wastes such as swabs and dressings. The injection room uses 20 litre sharps containers for sharps and 5 litre buckets lined with black refuse bags for swabs and other general wastes.
Theatre – anatomical wastes are stored in 50 litre refuse bins lined with black refuse bags while cardboard boxes are used for infectious and general wastes.
The afore mentioned principle of waste segregation is not strictly adhered to, and different categories of HCW find their way into wrong containers. It is common to find dressings, swabs, and sharps in the container for general wastes and to find components of general waste such as cartons, soft drink cans and bottles, and left over foods among infectious wastes.
HCW Collection from Generation Points
From the wards, theatre, laboratory, and other generation points, HCW is collected by cleaners and transported either by trolleys or hands to designated areas for treatment and final storage before offsite disposal. Infectious wastes and sharps are taken to the incinerator for destruction and the general wastes are taken to a storage area next to the rear eastern gate near the old incinerator to await collection by Maseru City Council (MCC) collection crew for final disposal, as seen in the picture.
[pic]
Figure 4: General waste dumped at Queen II hospital premises
The only form of protective clothing afforded the cleaners apart from coveralls are, the nose masks, the surgical gloves, and in some cases such as those from the theatre and maternity wards. Given the storage situation at generation points, these cleaners are subjected to daily risks of prick injuries with resultant potential infection.
HCW Treatment
Infectious wastes and sharps are destroyed by means of a mechanical incinerator capable of reaching the highest temperatures of 1 3000C when operating under ideal conditions. Two operators who work alternate shifts manage the incinerator. The cleaners deposit wastes on the paved floor of the incinerator enclosure and leave it there for the operator to deal with. Wastes are handled and fed into the incinerator manually.
The operators are equipped with one pair of elbow length rubber gloves, which they share, and like the cleaners, are subjected to the risk of prick injuries. The operators are also often reassigned other duties within the hospital premises, leaving the incinerator area unattended. Given the different household uses that the bucket type sharps containers are put to, this encourages theft of these by both staff and visitors. The sharps are emptied either on the enclosure floor, dumped into the furnace chamber if the door is open, or dumped inside the open storm water drainage channel running past the incinerator area. Two people were actually caught red handed with two containers they had just emptied into the furnace.
The incinerator itself is in a state of disrepair and is not operating effectively as per design. The motor is not running, fuel is fed manually into the furnace chamber to start the fire, and the temperature monitor is not functioning. The operators are not trained, and as such, cannot be trusted to undertake proper and cost effective operation and maintenance of the incinerator. For instance, considerable wastage of fuel was observed on two occasions where the improvised fuel release was left to run unattended until the collecting vessel was overflowing onto the enclosure floor. Poor segregation results in the presence of wrong types of wastes such as cans and bottles which have the potential of hampering the normal operation and efficiency of the incinerator. Although the enclosure has a paved floor, it is not regularly cleaned and this results in occasional spillages and scatterings from overfull receptacles causing unsanitary conditions around the incinerator area.
Collection of HCW from Hospital Premises
The filled black polythene bags and cardboard boxes of general wastes and ash from the incinerator are collected by the MCC refuse collection crew once daily except weekends when they do not come at all. The crew, just like the cleaners and incinerator operators, are at risk of prick injuries and infection due to sharps. The crew is also made to ignorantly handle other infectious HCW without necessary precautions due to failure by the medical staff to observe the segregation principle.
Disposal of HCW
HCW from the hospital is transported by MCC to the Ts’osane dumpsite just on the outskirts of the city. This is a poorly managed crude dump, which is frequented by scavengers from neighbouring villages. The HCW reaching this place is not afforded proper disposal such as that found in a proper landfill hence, the lives of scavengers are put at risk.
Segregation of HCW
For the purposes of the study, HCW was to be segregated according to five categories, namely, sharps, infectious, anatomical, pharmaceutical and general. Sharps would be stored in sharps containers or safety boxes, infectious in 10 or 25 litre containers lined with red refuse bags, anatomical in 10, 25, 50 litre, or larger containers lined with red refuse bags, pharmaceutical in red refuse bags, and general in 50 or 90 litre containers lined with black refuse bags. Only sharps containers or safety boxes and red refuse bags would reach the incinerator while the black refuse bags would go to the final storage area for collection by MCC.
To facilitate this, different departments of the hospital were briefed on the new arrangement prior to distribution of storage receptacles. While most showed willingness to comply, some like the maternity ward resisted outright and declared that they would stick to their normal practice, claiming that this new approach would confuse them. The study team had to compromise and let them continue with their normal practice as long as separation of different categories of wastes could be observed.
The findings revealed that departments, which showed initial resistance, did not abide by the new approach. Wastes from the maternity ward were the most problematic. General waste including leftover foods, cans, bottles, and plastic were always found mixed with human tissues, syringes, swabs, and dressings. Apart from the obvious health risks posed by this practice, it also presented the team with problems of classifying the wastes.
While the theatre complied with the segregation arrangement, the only problem presented by them was non-observance of colour codes with all wastes except sharps stored in black polythene bags. This poses the possible risk of mistakenly taking wastes to wrong destinations with resultant health risks to individuals who handle or come into contact with such wastes.
The rest of other departments performed commendably.
Weighing of HCW
At the weigh station, the wastes were identified according to the five categories and weighed separately. After weighing, the wastes were transferred to their respective destinations, that is, sharps, anatomical, and infectious to the incinerator while general wastes went to the final storage for collection by MCC. As a matter of policy, pharmaceutical wastes (expired medicines and drugs) are returned to the storeroom and can only be destroyed after consultation and in the presence of relevant stakeholders which include Finance and the Treasury.
As mentioned earlier, wastes from the maternity ward were difficult to classify. The team had to use their own discretion to determine the category of each bundle depending on which type between anatomical and infectious wastes formed the bulk of the consignment. General waste found within was classified as either of the two
Table 5: Health Care Waste Generated by Major Facilities in Lesotho. (extrapolated estimates)
|Hospital facility |Number of |Daily waste§ @ |Annual Waste |Extrapolated |Extrapolated annual |Hazardous |
| |Beds |1.44kg/b/d | |daily values @ |values |waste amount|
| | | | |1.068 kg/b/d£ | |@ 25% |
|Mafeteng |200 |288 |104,988 |214 |77964 |22869 |
|Mokhotlong |110 |158 |57,743 |117 |42880 |12578 |
|Butha-Buthe |129 |186 |67,717 |138 |50287 |14751 |
|Leribe |287 |413 |150,658 |307 |111878 |32817 |
|Berea |128 |184 |67,192 |137 |49897 |14636 |
|QE II (Maseru) |450 |647 |236,223 |481 |175419 |51455 |
|Mohales’Hoek |140 |201 |73,492 |150 |54575 |16008 |
|Quthing |148 |213 |77,691 |158 |57693 |16923 |
|Qachas, Nek |145 |209 |76,116 |155 |56524 |16580 |
|Thaba-Tseka |130 |187 |68,242 |139 |50677 |14865 |
|St. James (Mantsonyane) |60 |86 |31,496 |64 |23389 |6861 |
|Maluti (Mapoteng) |150 |216 |78,741 |160 |58473 |17152 |
|Botsabelo (Lepereng) |21 |30 |11,024 |22 |8186 |2402 |
|Itekeng Vocational R. |69 |99 |36,221 |74 |26898 |7890 |
|Mohlomi (Maseru) |150 |216 |78,741 |160 |58473 |17151 |
|Seboche (Butha-Buthe) |72 |104 |37,796 |77 |28067 |8233 |
|Scott (Morija) |102 |147 |53,544 |109 |39762 |11663 |
|St. Josephs (Roma) |140 |201 |73,492 |150 |54575 |16008 |
|Tebellong (Qachas’ Nek) |55 |79 |28,872 |59 |21440 |6289 |
|‘Mamohau (Lejone) |43 |62 |22,572 |46 |16762 |4917 |
|Maseru Private Hospital |32 |46 |16,798 |34 |12474 |3659 |
|Averages |131 |189 |69017 |140 |51252 | |
£ = values have been calculated on the basis of measurements made at Queen II hospital for a period of one month.
§ = calculated on the basis of the number of beds and the average generation rate of 1.44 kg/bed/day, from SA Incinerator Co (Pty) LTD.
Summary of observations at Queen Elizabeth II Hospital:
• HCWM is not assigned any specific authority
• Segregation of HCW is not observed by the medical staff
• Staff engaged in HCW handling is not provided with appropriate protective equipment
• All staff is not trained in HCWM
• HCW is not accorded effective treatment
• There is rampant theft of plastic bucket type medical bins
• Hospital grounds are not maintained in a manner deserving of a health care institution
• There is general poor maintenance of equipment from the incinerator to the sewerage network
5.3 Risk Assessments and Analysis
Most waste generated in healthcare establishments can be treated as regular municipal solid waste. But a varying proportion of HCW requires special attention, including sharps (e.g. needles, razors, and scalpels), pathological waste, other potentially infectious waste, pharmaceutical waste, biological waste, and hazardous chemical waste. Collectively, these wastes are known as “special healthcare waste”. In addition, all waste generated under certain circumstances, such as in isolation wards and microbiological laboratories, requires special attention. Other waste streams generated by HCW could include packaging, reusable medical equipment, and secondary waste created through disposal technologies. The mismanagement of healthcare waste poses risks to people and the environment. Healthcare workers, patients, waste handlers, waste pickers, and the general public are exposed to health risks from infectious waste (particularly sharps), chemicals, and other special HCW. Improper disposal of special HCW, including open dumping and uncontrolled burning, increases the risk of spreading infections and of exposure to toxic emissions from incomplete combustion. For these reasons, occupational health and safety should be a component of HCW management plans.
Transmission of disease generally occurs through injuries from contaminated sharps. Infections of particular concern are Hepatitis B (HBV), Hepatitis C (HCV), and the human immunodeficiency virus (HIV). HBV, for example, can remain infectious for a week, even dried at room temperature, and the probability that a single needle stick will result in sero- conversion is approximately 30 percent. For HIV and HCV, the probability that a single needle stick will result in sero-conversion is 0.3-0.5 percent and 2-5 percent, respectively (WHO, 1997). In the healthcare sector alone, the World Health Organization estimates that unsafe injections cause approximately 30,000 new HIV infections, 8 million HBV infections, and 1.2 million HCV infections worldwide every year. Toxic risks arise among others from reagents (particularly laboratory reagents), drugs, and mercury thermometers.
Furthermore, sensitivity is needed in the management of special HCW when dealing with biological waste. While the Basotho cultures bury the dead, they have definite views on the disposal and burial of body parts. It is important to consider cultural factors in the disposition plans of special HCW. Additionally, appropriate consideration of local community perception in the proposed waste management plan for all HCW is integral to a sustainable disposition plan.
Normally nurses and the cleaning staff and grounds workers are responsible for day-to-day management of HCW. The list is however longer; engineers, inspectors and drivers are also involved and may be equally exposed. Proper HCWM extends beyond the health facility site. Removing untreated potentially infectious HCW from the facility further exposes the public to the risk; hence on site treatment should be a better option.
6.0 Determination of Technology
Using South African incinerator company waste generation guideline, which is probably on the higher side, major hospitals in Lesotho produce about 1,290 tons of waste per year. According to WHO guidelines, about 75% to 90% of this can be classified as general waste that can be disposed of/treated like municipal waste. This leaves 25% to 10% that is classified as medical waste (special and sharps), hazardous waste that poses a variety of potential health risks and thus need special attention.
Different technologies are engaged at all levels /stages of HCWM.
6.1 Handling, Storage and Collection
Packaging and storage of special healthcare waste consists of primary packaging at the source and secondary packaging for transportation. For primary packaging, all special healthcare waste should be packed in leak-proof and disposable bags or containers. In addition, containers for sharps must be puncture proof and glass containers are regarded unsuitable. A color code of either yellow or red should be chosen for all special HCW. For pathological waste, the opposite (and non-transparent) color should be used. In the case of secondary transport packaging, leak-proof solid containers mounted with wheels should be used for easy transport. Color-coding should follow the primary packaging color code. For environmental protection reasons, non-PVC products are preferred. In-house storage may consist of two levels:
1) A well ventilated room at or near the ward, where waste collectors pick up the waste, and
2) A centrally located air-conditioned storage room, where temperatures can be kept low, until waste is picked up for treatment.
In most Health Centers there are rooms adjacent to wards that can be used for purposes of storage however there are no centrally located storage rooms
World Health Organization recommended colour-coding is as follows;
• General Health Care waste should be put in black bags
• Potentially infectious HCW/hazardous HCW should be put in yellow bags
• While sharps are put into rigid containers which are also yellow or with yellow stickers to indicate the risk level
To reinforce the color-coding system, all bag holders (which should be preferably the same as ‘pedal bins’) and transporting trolleys should be black for general waste and yellow for hazardous waste. Separate trolleys should be used for general waste and potentially infectious waste.
At all times, personnel handling HCW must be protected, with appropriate personal protective clothing; Mop caps, heavy duty gloves, acid resistant coverall and plastic aprons, safety goggles and safety shoes.
6.2 Treatment
Autoclaving involves the heating of waste material, with steam, in an enclosed container at high pressure. At the appropriate levels of time (> 60 min), temperature (>121°C), and pressure (100 kPa) effective inactivation of all vegetative microorganisms and most bacterial spores can be achieved. Preparation of material for autoclaving requires segregation to remove unsuitable material and shredding to reduce the individual pieces of waste to an acceptable size.
Small autoclaves are common for sterilization of medical equipment but a waste management autoclave can be a relatively complex and expensive system requiring careful design, appropriate segregation of materials, and a high level of operation and maintenance support. The output from an autoclave is non-hazardous material that can normally be land filled with municipal waste. There is also a wastewater stream that needs to be disposed of with appropriate care and controls. Furthermore, large autoclaves may require a boiler with stack emissions that will be subject to control.
At present, the use of autoclaving, chemical disinfection or any other non-destructive technology like microwave or radio wave irradiation is not allowed for the treatment of special HCW such as organs, tissues, or amputated human body parts. Incineration or burials are the only accepted techniques for the treatment of such special type of HCW. Required electricity and water as well the secondary waste stream imply additional costs.
Microwave and Radio wave Irradiation involves the application over the wastes of a high energy electromagnetic field that provokes the liquid contained within the waste, as well as the liquid cell material of microorganisms, to oscillate at high frequency, heat up rapidly, and eventually cause the destruction of all infectious components of the waste. The technique takes place in enclosed containers at atmospheric pressure and temperatures below the normal water boiling point. The waste passes through a preparative process of segregation to remove undesirable material, and then it is triturated, pulverized, and compressed prior to its disinfection. Similar to the autoclaving technique, the output from a microwave or radio wave facility is considered non-hazardous and can be land filled together with municipal waste.
Since the technology does not involve the application of steam, there is a minimal generation of wastewater stream, and with the appropriate conditioning it can be recycled to the system. Since electricity is the main source of energy for operating this technology, gas emissions are also minimal compared to incineration or even autoclaving, which requires the combustion of fuel for the generation of steam. At the level of high volumes of waste, the technology is inherently expensive and needs good infrastructure and its overall effectiveness is highly dependent on the sophistication.
Chemical disinfection is used routinely in healthcare to kill microorganisms on medical equipment. It has been lately extended to the treatment of HCW. Chemicals (mostly strong oxidants like chlorine compounds, ammonium salts, aldehydes, and phenolic compounds) are added to the waste to kill or inactivate pathogens. This treatment is most suitable for treating liquid wastes such as blood, urine stools or hospital sewage, but solid and highly hazardous HCW like microbiological cultures, or sharps must undergo a relatively complex and expensive preparative process of segregation shredding, and milling prior to the application of the chemical reagents. This technology requires special treatment of hazardous wastewater streams.
In consideration of Waste Management situation in Lesotho as discussed in Section 1.4, autoclaving, micro waving and radio wave irradiation cannot be options for Lesotho. These are also expensive (capital intensive) and sophisticated in terms of skill/knowledge requirements. In the light of weak chemical management infrastructure, chemical disinfection in HCW treatment is not recommendable (no capacity for waste water streams treatment).
6.3 Incineration
Incineration is not the same as burning, which is what is being practiced using mal-functioning incinerators. Proper incineration is a highly advanced technology that can adequately treat all types of special healthcare waste. The key parameters of controlled incineration are summarized as “TTT”: combustion at a sufficiently high temperature (between 1,000°C and 1,200°C in the combustion chamber) for a long enough time, in a combustion chamber with sufficient turbulence and oxygen for complete combustion to be achieved and problematic gases to be minimized.
Incinerators require skilled operators, extensive flue gas emission controls and, frequently, imported spares and supplies. Properly controlled incineration is relatively expensive. Incineration of wastes generates residues, including air emissions and ash. Environmental controls on incinerators in developed countries have been tightened in recent years, principally because of concerns over air emissions of pollutants such as dioxins and furans as well as heavy metals.
The technology of small-capacity incinerators, for use by a single medical facility, is often rudimentary. These installations are not recommended, however, since they may constitute a serious air pollution hazard to the surrounding area. World Health Organization recommends closing down small incinerators that are not operating satisfactorily.
Incineration is an option for certain types of HCW (and is the preferred method for some substances such as cytotoxins and other pharmaceuticals) but it needs to be carefully operated and controlled. Regulatory agencies in the United States and the European Union have adopted emissions limits for medical waste incinerators that include, among others, values for dioxins. It is recommended that incinerators installed under any major project pay attention to national regulations and/or look to the examples set in other countries such as in the EU Member States. Lesotho has no limits yet, but a signatory to Stockholm convention and as such should follow the guidelines thereof. Therefore, any installation of incineration processes has to take into consideration emission factors.
The recommended operating/burning time for normal conditions of the SA incinerators is 6 (six) hours maximum per day. On basis of the daily generation averages of 189 kg and 140 kg, burned over a period of 6 hours, the rate of burning is 31.5 kg/h and 23.3 kg/h. The General refuse equivalent of hospital hazardous waste (based on maternity value) is 1.3. The implication is that the required incinerator sizes would therefore be 40.95 kg/h and 30 kg/h respectively. Both these values fall between the 50 LA and the 100 LA models of SA Incinerator Company. This model is the one already installed in health facilities that have incinerators in Lesotho. An exception is the Queen II hospital. For QII using extrapolated waste amount of 481 kg/day of all wastes, operating over 6 hours gives a value of 104 kg/h, which corresponds to model 250 LA.
[pic]
Figure 5: The incinerator at Queen Elizabeth Hospital, the largest Hospital in Maseru.
The SA Incinerator company makes incinerators in which the burning process is said to take place in compliance with the South African Air Pollution Prevention act of 1965. The design is based on the Los Angeles Air Pollution Control District Authority. The important features of these incinerators are:
• Multiple chamber design
• Monolithic construction
• Built-in emission control
• Heated refractory screen
• Grit setting chamber
• Stainless steel arrestor
• Door operated draught breaker
• Heated primary and secondary air
• Automatic temperature control is available for oil and gas fired units.
Most of the spare parts are standard and can be obtained from local electrical or hardware shops as well as from SA incinerator Company (Pty) Ltd in Johannesburg, South Africa.
There are four options that can be considered for incineration technology citing for Lesotho:
Option A: One large capacity incinerator – centrally located and run by the municipality, to treat all hazardous waste of the country.
Wherever it could be located it has implication on Very high transport costs for all centres, distance and secure vehicular requirements and thus no incentive for that kind of treatment. The capital cost for such a big capacity may also be high.
The spin-offs of this arrangement are that; It would be accessible to all other hazardous waste generators in the country. Air pollution would be localized and emission controls could be manageable.
Option B: Demarcating the country into three zones (North, Central and South) and installing three medium capacity incinerators to include municipal hazardous waste.
The major advantage of this option against option A would be lowered transportation costs. It is still however undesirable to transport untreated waste over distances due to the risk it poses during possible accidents and this would require increased management input.
Option C: Small capacity incinerators at the central hospital of the HSA- for use of all health centres in that HSA.
This situation has been practiced and is still partially operative. Risk of exposure to the general public is minimized. It has the highest probability of success and cost containment. Sustainability of this option depends only on proper and timely maintenance of the incinerators.
Option D: All Health facilities equipped with appropriate capacity incinerators.
This may be an over investment for low benefits. Inconvertible fraction of waste is not enough to warrant this capital and operation cost.
Incineration is known to produce various air polluting gases, the most dangerous of which are the Persistent Organic Pollutants, namely, Dioxins and Furans. All signatories to the Stockholm Convention have pledged to reduce their annual emissions of these POPs and to use the Best Available Techniques in doing so. Incineration is still the Best Technology in destruction of hazardous waste. The current waste management practices in Lesotho indicate that the emissions without incineration are much higher than with incineration. However emphasis is put on incineration with GOOD Air Pollution Control system. This situation is indicated by the case study analysis made in annex C.
6.4 Land filling
Land deposition of HCW is performed in the same manner as solid industrial wastes; that is, in a pit excavated in mature municipal waste at the base of the working face and immediately covered by a two-meter deep layer of fresh municipal waste. This is done at the same sanitary landfill where municipal waste is disposed. Alternatively, a specially constructed small fenced landfill pit or bounded area could be prepared on part of the site to receive only HCW. It should be covered immediately with soil after each load. For added health protection and odour suppression, it is suggested that lime be spread over the waste. In both cases it is essential to cover the HCW layer well enough to prevent animals or scavengers from re-excavating it.
Land deposition or Land filling is considered as a “bottom of the list” option for disposal of untreated HCW, and is only recommended when the economic situation of the country does not permit access to environmentally safer technologies, such as the ones previously described, such as incineration.
Lesotho is already in shortage of land, hence land depositing of HCW may not be an option for all health facilities. This is currently being practiced in several HC centres around the country, though not in an appropriate manner as described above. This practice poses the risk of contamination to ground water as it is done indiscriminately The best option is the construction of central sanitary landfill in each district. After incineration of special HCW the ash will be disposed together with the general waste, this then calls for the best collection management. Options within the context of Lesotho are discussed in the next section.
6.5 Other technical issues:
Transport of special healthcare waste on public roads is inevitable under any system designed to treat and dispose of special healthcare waste outside the generating premises. Trained staff in a dedicated vehicle with closed containers should as a minimum, carry out transportation of special healthcare waste. Recommended design criteria for special healthcare waste transportation vehicles are provided in the WHO handbook. These would be used to set up standards and guidelines for licensing and monitoring.
Operation and maintenance of equipment and facilities is essential for proper waste management. Good operation and maintenance requires trained and motivated staff, an adequate supply of consumables and spares, and a sufficient ongoing budget. Assessment of these matters must be a fundamental part of any decisions on choice of waste management treatment technology.
All government hospitals are already equipped with incinerators, SA Incinerator types, models 50LA, 100LA and 1000LA. All of these are currently not working or not being used for various reasons including: No fuel, breakdown, need repairs and unavailability of parts, this was explained by one operator saying that the Hospitals have a bad paying record hence suppliers have become reluctant to supply without payment. This is the simple situation that needs to be rectified.
7.0 Determination of Disposal Sites
The disposal sites for Health care waste cannot be stand-alone sites unless they are within the premises of the health facility, a very unsustainable situation. To this end, the overall country waste management plans and programmes need to be evaluated.
Historically, according to the Sanitary Services and Refuse Removal regulations (1972), sanitary and refuse removal services in Lesotho were limited to all districts headquarters and four other major settlements, Matsieng, Morija, Roma and Maputsoe. Waste management was solely a responsibility of the Ministry of Interior, until the commencement of the Urban Government act (1983), which became operational only in 1986, through the legal notice No 44 of 1986. Services were then limited to institutional housing premises, particularly government ones, this tendency is still the dominant one in most districts.
After 1986, waste management became part of the broader environmental concern, with policy aspects entrusted to the then non-constituted National Environmental Council (NEC), later with National Environment Secretariat (NES). Specific functions of the provision of sanitary services and refuse removal in urban areas were allocated to what would be urban governments (urban councils and boards) as identified in section 5 of Schedule 1 of the Urban Government Act.
Unfortunately the Act has only been partially implemented. Only Maseru has to some extend succeeded to establish an urban government. In all other major settlements, the Ministry of Local government is still responsible for sanitary and refuse removal services through the offices of resident town clerks.
Although the Urban Government Act empowers the Minister responsible for Local Government to establish local authorities for efficient control and service delivery in urban areas, such powers have only been exercised in Maseru. In all other gazzeted towns, town clerks have limited duties such as:
• Collection and removal of waste
• Street cleaning
• Maintenance of urban roads
• Supervision of urban markets, abattoirs, vendors, etc. and
• The issuance of urban sites and building permits
Town clerks and their staff form part of the District Secretary’s staff. They generally lack authority to make decisions, and in the execution of their duties, do not follow any formal work plans. Due to limited financial, human and equipment resources their overall functioning is crippled to the level of non-existence in some towns.
In this state of affairs, waste has to be disposed of, be it harmless or hazardous. Hence the town clerks chose the disposal sites on the basis of cultural norm, dongas or disused quarries. There are no proper sanitary landfills but open dumpsites. Disposal is performed as uncontrolled open dumping on sites, which are normally situated on the borders of the town. In most cases these dump sites are along or near natural watercourses, aquifers and too close to settlements. Health Care Facilities are some of the important institutions in terms of waste generation for National Waste Management Planning. Local government authorities should consider these areas equitably like CBD – commercial area and domestic areas, where they collect. As it was pointed out in Section 1.4, waste management in Lesotho has not taken off to any planned level as yet. Proposals are underway to build a new landfill close to Maseru that would cater for the greater Maseru Town and neighboring peri-urban towns.
The key actors in these endeavors have been Environment and Local Government; Health has not substantially indicated the real need – probably due to the trust that the counter ministries will do their part. It has become evident, and is in effect imperative that Health participation be at even a higher level than the few role players.
Health Care Waste Management is not only a matter of Environmental Pollution control, but also even more a matter of disease control, and better health for all.
Table 6: Roles and Responsibilities of various actors in Waste Management
|Institutions |Role/responsibility in Relation to Waste management |Limitations in Health Care Waste management |
|Central Government | | |
|MTEC | | |
| |Policy and advisory role on general Environmental issues, |Lesotho Environment Authority not yet established, |
| |including waste management |therefore Lesotho Environment Act not yet |
| | |operational. |
|MoLG |Implementation of Local Government and Urban Government | |
| |Act, including waste removal and sanitation services. |Lack of financial resources for waste management. |
| | | |
| |Monitoring of economic activities towards good health | |
|MoHSW |maintenance. Ensuring that no nuisance exist in public |Lack of sufficient personnel or unit dedicated in |
| |areas. |waste management. |
| | |Unclear role of Environmental Health Division. |
|Regional | | |
| | | |
|Town Clerks |Management of waste in all urban areas other than |Lack of financial resources and personnel for waste |
| |municipalities. |management, sanitary landfills, plant and equipment. |
| | | |
|Urban Councils |Management of waste in municipalities (currently only |Lack of financial resources for waste management, |
| |Maseru city is a municipality) |sanitary landfills, plant and equipment. |
Each district center has a designated dumpsite, whose distances range between 500m and 1.7 km from town boundaries.
7.1 National Official Dump Sites
The requirement of terms of reference under the Determination of Disposal Sites is that:
“If site for disposal exists, collect all existing plans for suitable sites to be considered for the locations of the treatment facilities and review general transport and traffic systems relative to appropriate sites.”
There are disposal sites all over the country, those that are sporadically used and those that are used in a more official manner. These are the ones so called ‘official dumpsites” These sites were selected by default in most districts. They are just the convenient places to dump in the absence of proper landfills. There were no standard criteria used in their determination, as a result, they are all known to be highly unsuitable by all standards.
These site are discussed below, mainly indicating their unsuitability, on the basis of simple preliminary guideline used by the National Environment Secretariat (Annex B)
MOKHOTLONG
The dumpsite covers an area of about 2000 m2, situated along a stream that connects to Mokhotlong River, about 30 m downstream. It is within a soft-top soil valley, hence a high risk to both ground and surface waters. The health facility is about 1.5 km uphill, well out of town population. However, there is a public route adjacent to the site where villagers pass into town. Since the site is not fenced or secured; no management of any sort, scavenging is highly probable. For the site to be maintained as a dumpsite, the ground will have to be well lined and a retention pond be constructed downstream. There is enough material alongside for construction and burying during operation. However the site is undesirable since it is very close to natural water source (the nearby stream and Mokhotlong river).
THABA-TSEKA
Waste is dumped at an open space that is located above a valley whose water joins the main stream. All sorts of waste is dumped there including medical waste. This is an open space covering an area of about 2000 m2. The top soils are loam, rich for cultivation. There is no reparation done for disposal, this just a large area that is covered with scattered waste. There is also no coverage of dumped waste hence waste is easily blown by wind.
[pic]
Figure 6: The waste dumping site at Thaba-Tseka.
QACHA’S NEK
Excavated dyke (bore pit) was formerly used as an illegal dumping site, but has now been made official by the office of Town Clerk. All sorts of waste are dumped there including medical waste. The dumpsite is too close to the houses occupied by prison warders. This therefore may lead to scavenging. Waste is dumped throughout the quarried dyke and not at the specific place. The site is at the high point relative to the town, which may increase the risk of ground water contamination down stream.
BUTHA-BUTHE
This is the one dumpsite whose location is suitable since it is far from the villages and the town center. It had been properly fenced during the LHDA operations; the fence had been vandalized however. The area was also a gravel quarry; hence there is abundant material for landfill operation. This dumpsite only requires good management.
HLOTSE
The dumpsite in Hlotse is just an open space with no clearly defined boundaries. However, the area that is being used currently is about 3000m2. It is situated on a hillside about 1Km from Hlotse river. The site is about 2Km from the village of Sebothoane, however there are three households located 500m below the site. The waste disposed at this site comes from the Town of Hlotse and the surrounding residential areas. The furthest waste generation point (end of Mankoaneng Village) is about 5Km away and the nearest (Government Garage) is 500m away.
Though the site is on a hillside sloping to Hlotse River, it is located on flat narrow but long strip of land. There is no flooding occurring in this area. The site is about 1.5Km from Mandela road and the flatness of the site allows the easy access of vehicles to the site.
MAPUTSOE
The current dumpsite of Maputsoe is a rather shallow cleavage that resulted from quarry mining. It is on a small hill about 200m from Mokota-koti River and half a kilometer from Main North 1 road. The site for disposal is not fenced, therefore its boundaries are not well defined. As a result, waste is dumped not at one point, but anywhere around the cleavage. The site is always full of scavengers who select good off-cuts to us them in activities that will earn them income. About 200m away, on the north side of the site is a secondary school, which is also not fenced. The community of Ha Nyenye is along Main North 1 road on the east of the site. On the northeast of the site, there are numerous textile industries. On the West side there are WASA stabilization ponds, which are situated along Mohokare River.
The high proportion of the waste found on this site consists of off-cuts from the industries. Also found there are cans and bottles of beverages probably from the hotel. However this is supposed to cater for the whole town of Maputsoe including the surrounding residential areas and the near by villages like St. Monica’s. The business center of Maputsoe (where all healthcare facilities are located) is about 5Km and furthest residential area (Ha Nyenye) is about 7Km away.
There have been a number of complaints lodged to the town clerk, especially for the nearby school, about the waste that is blown around. They do not object to use of the site for disposal, but they would like it to be developed as it is currently unsightly.
TEYA-TEYANENG
The old dumpsite is right in the middle of a village. This was relocated without proper rehabilitation. Although it was said that the new dumpsite was in use, very little waste was observed at the place and waste was not put in the pit rather it was dumped at the mouth of the pit. Because of this level of activity, at this site, it could not be conclusive where dumping is actually done. The new site is about 2 km out of town, is adequately sited away from population, there is enough earth material for covering waste. This only needs to be developed into a proper landfill and be managed properly.
QUTHING
The dumpsite is properly located being far from the neighbourhood and in an unused quarry; the problem is that dumping is done outside the pit. Just in an open space. The dumpsite is not restricted and as a result the dumping is uncontrolled. Site is located in an area that has been allocated for residential development, and sites have already been allocated.
MOHALE’S HOEK
In Mohales’ Hoek there is no official disposal site; people dump waste just about anywhere. But the most victimized place is the stream that runs between the taxi rank and the town and it goes all the way to Makhaleng River. The area is so close to the hospital and the public traffic into town.
MAFETENG - 10
The official disposal site of Mafeteng is about 2000 m2 located in the area commonly known as “Sepetlele”. It is situated on a gentle slope along Lekoantlana River that leads to Mohokare River, and alongside WASA stabilization ponds. It is half a kilometer below Mafeteng hospital. The nearest village, which is across the river, is about 1km away. People from the neighbouring villages collect water from the same river.
This site carries waste collected from the business community of Mafeteng, which is located at distance of 3km from the site. It also carries waste from the residential areas, the furthest being at a distance of 5km away. This site was selected by the town clerk in collaboration with the Department of Environmental Health, the Urban Board, and representatives of the business community and also with representatives of the residential community. Thus, this site has been accepted by the whole community of Mafeteng Town.
MASERU –11
In Maseru town there is one official dump-site located within the village of Ha Tŝosane. It caters for all waste collected from the city centre, the industrial areas and the residential areas that get refuse removal services. Though this site is protected with fencing and has a guard, one will find scavengers collecting metallic substances that are sold for recycling to make a living. There is a continuous cloud of smoke coming from burning of waste and spontaneous combustion due to methane production . This smoke decreases visibility in Ha Tsosane area, particularly in winter.
The location of the site is critical as it is on a sloping area within a catchment of Maqalika Dam which supplies domestic water in the whole of Maseru town. It is also within the community with several houses just a few meters away. Apart from that there are possibilities of groundwater contamination as the site itself is a cleavage that resulted from quarry mining.
[pic]
Figure 7: Emissions from the uncontrolled burning of all types of waste at Tsosane dumpsite in Maseru.
7.2 Healthcare Waste Water
There are four streams of healthcare wastewater and these are from Out Patients Department (OPD) and wards, Pharmacy, X-ray section and from the Laboratory. Wastewater from OPD and wards can be expected to be of similar quality to domestic wastewater, but it may contain hazardous components. The concern is on microbial pathogens introduced into the wastewater by patients being treated for enteric diseases. This is also the case with laboratory wastewater where these pathogens can be introduced by samples taken from patients.
Chemicals in wastewater are of lesser concern as wastewater from other points inside and outside the health facility compound dilutes them. However, there are some chemicals that will still pose risks to the environment even if their concentration in wastewater is lower. For example, silver which is introduced to wastewater stream by development of films used for X-rays will accumulate in bodies of aquatic organisms even when found in low concentrations in water. In the same way Mercury that comes from dental amalgams and broken thermometers find way into water streams. This calls for special attention to be paid to such chemicals.
Quality of Healthcare Wastewater
There has been no monitoring on quality of wastewater from healthcare facilities in Lesotho. But when using the current practice of waste management in different sections of the facilities (OPD and wards, pharmacy, laboratory and X-ray) as the determinant of the polluter sections, OPD/Wards and X-ray sections were found to be the major polluters. Lesotho is prone to outbreaks of enteric diseases like typhoid and diarrhea which introduce enteric pathogens in wastewater. X-ray section also introduces into the sewer line the chemicals used to develop the films and which contain silver from these films.
Pharmacy is assumed to be introducing minimal pollution to wastewater as all the pharmaceutical waste (including liquid medication) is incinerated. The laboratory is introducing both the enteric pathogens and chemicals to wastewater but their concentrations in wastewater are low because only small quantities of samples and chemicals or solvents are used. And most of the waste from this section (including the analyzed and unanalyzed samples and outdated chemicals) is incinerated.
Current Methods of Treatment and Disposal
As mentioned earlier, WASA is the only institution in the country that is mandated to provide services of sewage and wastewater collection and treatment. But due to the difficult terrain of the country, sparse location of settlement areas and lack of sufficient finances, most settlement areas do not have access to these services. Thus, most of the health facilities in the country are not connected to WASA sewer lines and have therefore resorted to use of septic tanks and pit-latrines for disposal of wastewater.
According to WHO guidelines (WHO, 1999) healthcare wastewater may be discharged into the municipal sewers if
- These facilities are efficiently operated and can remove 95% of bacteria as well as toxic chemicals, pharmaceuticals, radionuclides, cytotoxic drugs and antibiotics in sewage; and if
- The sludge resulting is treated by anaerobic digestion to ensure removal of helminthes and other enteric pathogens.
- Or in a case where the public sewer does not meet these standards, the wastewater should be pretreated.
Unfortunately WASA facilities are simple oxidation ponds that do not meet the above-mentioned standards and on the other hand the pre-treatment facilities that are required for this kind of wastewater are highly capital intensive and impose high costs of operation. The only alternative is to adopt a system that will prevent introduction of pollutants of concern into healthcare wastewater. This system should also apply to all health facilities that are not connected to WASA.
Management Plan
To prevent introduction of unwanted pollutants in healthcare sewage, the following tasks will have to be implemented:
High Capacity Health Facilities and Other Facilities in Urban Areas
- Excreta from patients with enteric diseases , during epidemics may be collected in buckets for chemical disinfection before they can be disposed into municipal sewers
- Excreta from patients being treated with cytotoxic drugs may be collected separately for incineration
- Pharmaceutical and laboratory chemicals should be incinerated (with lids of their containers open to prevent explosions) instead of disposing them into the sewer lines.
- All infectious samples from the laboratory should be incinerated.
- The fixer from the X-ray section should be collected and sold to companies that recover silver, while developer should be sprayed in incinerators for incineration.
- Wastewater from different streams of the healthcare facility should be monitored regularly for improvement of its quality.
Small Capacity Health Centres in Rural Areas
The assumption is that these facilities will not run laboratories and X-ray sections, and will also not treat patients who require cytotoxic drugs, instead they will refer them to hospitals as is the situation currently. These facilities use pit-latrines and septic tanks in which the infectious anatomic waste and excreta will later be buried, and these methods of disposal are sufficient to contain pathogens and prevent spread of disease, provided they are appropriately sited and well constructed. In this case the only water contaminants of concern will be from the pharmaceutical products. Therefore all pharmaceutical waste will be collected and transported to the hospitals servicing the HSA for incineration.
8.0 Private Sector Participation
Private sector participation in healthcare waste management is possible at different levels. At the simplest level, the private sector may be subcontracted solely to provide waste transportation services to individual healthcare facilities. At the other end of the spectrum, the private sector may sign a contract to Build, Operate, and Transfer (BOT) or Build, Own, and Operate (BOO) an entire HCWM treatment or disposal facility.
The private sector can play a significant role in providing waste treatment and disposal services if the contract establishes a clear set of rules about division of responsibilities between the parties involved (i.e. regulatory authority, healthcare facility, and private operator). The essential conditions for private sector participation are transparency, competition, and accountability. Adequate budget provision is also required at the healthcare facility or the local authority level to pay the private operator.
In the three countries described below, private contractors play differing roles in HCW management:
Malaysia:
Following a strategy for healthcare waste management developed by the Ministry of Health, Peninsula Malaysia is divided into three HCW management zones. Each zone has contracted a concession to a private company for 15 years. Within the concession zone, the private contractor is obliged (and restricted) to provide bins and bags for collection, internal collection and storage, external transport, and a central localized incinerator for special HCW generated at MoHSW hospitals. The three contractors can compete throughout Malaysia for handling of special HCW from private hospitals. The contractors must meet Malaysian standards for segregation, transportation, and treatment. The most stringent standard is treatment--all special healthcare waste must be incinerated and incinerator emissions must meet standards equivalent to those of the European Union (EU).
Republic of South Africa:
The province of Kwa-Zulu/Natal (eastern part of South Africa) has one centrally located incinerator for treatment of all special HCW generated in the province. The incinerator is located at the largest landfill of Durban and is operated by the city of Durban. Transportation of special HCW from healthcare facilities to the incinerator is carried out under individual contracts between each hospital and a private licensed contractor.
Mexico:
Mexico City has developed a free market for handling of healthcare waste. The market for HCW management is open to any private licensed contractor. So far, at least fourteen contractors are handling HCW in Mexico City’s metropolitan area, either through autoclaving, radio wave irradiation or incineration. Contracts with hospitals range from one to five years in duration.
Lesotho can adopt any of the above modes of private participation; however, there exist no systems as yet for such participation. First, there should be an established proper disposal sites, then systems of licensing and monitoring. Local cleaning companies are still focused on office cleaning and gardens; there are no serious operators in hazardous waste management. This then drives the privatization process towards foreign companies as has been done in communications and utilities sectors.
8.1 Public-Private Partnership Options for Lesotho
On the basis of the above experiences and the economic driving forces, it is highly commendable to link all potentially viable activities to both public and private sector. The public sector has already taken strides in setting down the basis for this partnership. This basis is seen in various economic developmental initiatives, namely, Vision 2020, PRSP and millennium Goals.
Lesotho Vision 2020
In 2000, the country took a policy decision to formulate a vision to provide for a long-term perspective within which national short to medium-term plans could be formulated. The vision statement reads:
“By the year 2020 Lesotho shall be a stable democracy, a united and prosperous nation at peace with itself and its neighbours. It shall have a healthy and well-developed human resource base. Its economy will be strong; its environment well managed and its technology well established”
Section 3.2.6 of the vision document acknowledges that the country is faced with the challenges of implementing the ratified conventions and treaties for sustainable development. To this end, strengthening institutions responsible for natural resources management, developing and effectively implementing land management systems as well as strengthening overall environmental management, advocacy and awareness among Basotho, are seen as vehicles to realizing “a well managed environment”
The Implementation and monitoring Matrix identifies eight strategic actions towards this endeavor. These are to:
• Strengthen coordination of institutions responsible for natural resource management
• Protect air, soil and water quality
• Develop and implement proper land management systems
• Preserve and conserve biodiversity and heritage
• Improve institutional capacity to implement the Environment Act
• Reduce over-harvesting of natural resources
• Improve effluent and solid waste management systems
• Promote use of renewable energy resources.
Poverty Reduction Strategies
The government of Lesotho, through a long consultative and participatory process developed a Poverty reduction Strategy. It commits itself, over the next three years to begin systematic implementation of the most important priorities.
The overarching development goals of the PRSP is to provide a broad based improvement in the standard of welfare for the current generation of Basotho, without compromising opportunities for future generations. The PRSP is built on three inter-connected approaches, namely
• Rapid employment creation through establishment of an operating environment that facilitates economic growth.
• Delivery of poverty-targeted programmes that empower the poor and vulnerable and enable them to secure access to income opportunities; and
• Ensuring that policies and legal frameworks are conducive to full implementation of priorities, that bureaucratic constraints are removed, and that the productivity of the public sector improves.
The process has identified eight (8) priority areas and two critical crosscutting issues. Topped by employment creation, the seventh is to manage and to conserve the environment, and the government is committed to implement specific strategies in this area, which include:
• Promotion of environmental conservation with improved production
• Strengthening management of solid and waste water as well as air pollution
• Strengthening curriculum and media programmes on environmental education
• Reduction of loss of bio-diversity by implementing the Maloti-drakensberg Transfrontier park
• Addressing range management issues by establishing and/or revitalizing grazing associations in collaboration new local government authorities
• Improving the legal, policy and institutional framework, giving particular attention to the capacity of National Environment Secretariat (NES) and implementation of Environment Act 2001.
The Millennium Development Goals
Lesotho is a signatory to the Millennium Declaration, along with all members of the Unite Nations. It has renewed its commitment to freeing all people from the abject and demoralizing condition of extreme poverty and to promote human development.
The eight goals and their national targets may be outlined as follows:
Goal 1:Combat HIV/AIDS
The overall target is to halt and begin to reverse the spread of HIV and AIDS by 2007
Goal 2: Eradicate extreme poverty and hunger
In this goal the targets are:
• To halve, between 1990 and 2015, the proportion of people whose income is less than one dollar a day And
• To halve the proportion of people who suffer from hunger between 1990 and 2020
Goal 3: Achieve universal primary education
To ensure that children everywhere (boys and girls alike) will be able to complete a full course of primary schooling by 2007 is the major target.
Goal 4: Promote gender equality and empower women
The elimination of gender disparity in primary and secondary education preferably by 2005 and to all levels of education by 2015 is the target.
Goal 5: Reduce child mortality
The target here is to reduce the under-five mortality rate by two thirds between 1990 and 2020.
Goal 6: Improve maternal health
Reduction of maternal mortality ratio by two thirds between 1990 and 2015 is the target.
Goal 7: Ensure environmental sustainability
Here the target is to integrate the principles of sustainable development into country policies and programmes and to reverse the loss of environmental resources. And
To halve the proportion of people without sustainable access to safe drinking water and basic sanitation by 2015.
Goal 8: Develop a global partnership for development
There are several targets in this goal, all of which center around bilateral and multilateral agreements in trade, health and economy.
The country has integrated these targets within the broader strategies as found in the Vision 2020 and the Poverty reduction strategy paper.
The becoming Health Care Waste Management plan is one opportunity for the country/government to show the commitment to these initiatives through strong private sector participation and involvement. There are two levels at which private sector could participate.
1. Paying for their pollution contribution, in order to capacitate the local authorities in provision of waste management services.
2. Providing services in waste collection, awareness and training as well as disposal, and even managing the landfills.
The private sector in Lesotho, particularly in the area of waste management is very underdeveloped. As a result, the real possibility of participation as service providers was not easily accessible for assessment.
Within this analysis, the three principles are engaged, namely Polluter Pays Principle, Best Practices and Cost Recovery.
The situation in Lesotho is such that, due to increasing poverty level and unemployment, the majority of the people are unable to afford health care. Even in this state of subsidy, several patients cannot get treatment beyond simple dressing and drugs. The generation of waste during the Health care delivery should be a cost to the receiver of service. The implication is an increment in the already unaffordable charges. One way or another, imagining a situation where each patient is given the responsibility of disposing of his/her waste in an environmentally sound manner, there would be costs on their part. This justifies that a sound waste management system has to be paid for. The question is what should be the share of cost from patients, in terms of charges relative to the share of the institution, which is not also a public entity.
The other supporting side to public-private involvement is the job creation aspect of it. “there is cash in trash” The overall solid waste management of Lesotho should overhauled to allow re-use and recycling of suitable materials. Organizations for collection, segregation and recycling should be set up through government initiatives to kick start public participation. There are several Non-Governmental Organizations that should be engaged in all these endevours.
8.2 Cost-Benefit Analysis
Implementing a national strategy is a gradual process that often requires a minimum of one to two years.
An often-important role for national authorities is to provide technical and financial assistance to lower-level authorities in implementing the national strategy. The Ministry of Environment and Ministry of Health may also help finance new waste regional treatment facilities when new healthcare waste management regulations are introduced. But these ministries are less likely to provide national subsidies for operation and maintenance of regional treatment facilities. Those generating the waste, i.e. the healthcare facilities, should absorb these costs based on the “polluter pays” principle. However, it should again be noted that recovering the full cost of treatment and disposal might create incentives for indiscriminate disposal. Therefore, enforcement of regulations is also essential, and financial incentives for healthcare facilities to improve their HCW management may be warranted.
In Lesotho, the most polluters are the government institutions. This scenario can work both positively and negatively to the overall HCWM objective.
Positive in the sense that HCWM can be intrinsically included in the Health sector budgetary allocation, in which case the plan would then be implemented without any capacity hiccups.
Negatively, if the government does not specifically allocate funds for HCWM, while the health centers are still operating and polluting, under current conditions where implementing agencies, like local government are not capacitated and payments due are ignored by health.
In the final analysis, the real benefit of proper HCWM shall be evident in the general national waste management mobilization. The cost to the nation can be absorbed in taxes, otherwise the level of willingness to pay for waste in this country is still very low.
9.0 Training Needs and Awareness Assessment and Programs
9.1 Health Centers
On consultation with different health facilities, gaps of knowledge in medical waste management were identified in different cadres of facilities personnel. All of the identified gaps seem to be common in all health facilities, therefore the proposed training and awareness activities are meant for all facilities, though the training may differ for different cadres.
9.1.1 Health Center Management
The management of health center is responsible for planning, budgeting, mobilization of resources and to ensure that all departments of the center are operational. In hospitals they key people in management are the District Medical Officer (or otherwise known as Superintendent), the Senior Nursing Officer (otherwise known as Matron) and the Administrator. For other centres, the key people are the manager of the hospital (who can be the church leader or the practice owner) and the nursing clinician or nursing sister. From the survey, it has been found that the centers have no budget for waste management, any resources required for this activity are bought from operational costs budget.
Most of these people understand to a moderate level, the risks that medical waste can have on environment. However they have constraints in appropriate management of this waste which include among others:
- Lack of finances for purchasing and maintenance of appropriate equipment,
- Lack of staff trained in waste management and its technology
- Prioritization of other medical resources like medications,
- Pressure of attending too many patients and finding segregation a time consuming activity.
As a result, the management of health facilities need to be given training on why waste management should also be given a high priority and the resources and skills required for a center to manage its waste appropriately.
9.1.2 Medical Staff
Medical staff constitutes medical doctors, nurses, nurse assistants, pharmacists, technicians, laboratory technicians, dentists and other health center staff that generate medical waste. And this is the group of hospital staff that knows the risks linked to medical waste and has been trained on how to handle it at generation point. Despite this knowledge, they do not practice the principle of segregate of waste at source, and this shows that they lack knowledge of appropriate waste management in a broader picture.
Therefore they need to be given on-site training on segregation of waste at source and treatment of hazardous waste. They should also be given a general knowledge of appropriate medical waste management as well as the risks of inappropriate management including cost implications. This information can be given during the staff professional workshops and through the pamphlets and posters.
9.1.3 Waste handlers
This is the group of staff that did not get formal education on management of medical waste and risks associated with it. However, they are the ones given the responsibility of managing and handling this waste. While they do not have sufficient knowledge for this responsibility, they also do not have appropriate resources like equipment and protective clothing for handling this kind of waste. In Lesotho the waste handlers in health centres are;
- The cleaners who remove waste from its point of generation
- The porters who sometimes transport it to point incineration or disposal and
- The laborers who operate incinerators and dispose the resulting waste
According to WHO [1999] the minimal training for waste management operators should include:
- information on the risks associated with the handling of health-care waste;
- procedures for dealing with spillages and other accidents;
- instructions on the use of protective clothing
In addition to this, the waste handlers in Lesotho should be trained on appropriate ways of handling waste, and the points to be emphasized are shown in Box 1 below.
Box 1. Training of waste handlers; points to be emphasized. (Extracted from Pruss,1999).
| |
|Check that waste storage bags and containers are sealed; no bags should be removed unless properly labeled and securely sealed to |
|prevent spillages. |
| |
|Bags should be picked by the neck only. They should be put down in such a way that they can again be picked up by the neck for |
|further handling. Manual handling of waste bags should be minimized whenever possible. |
| |
|Waste bags should not touch the body during handling and collectors should not attempt to carry too many bags at one time – |
|probably no more than two. |
| |
|To avoid puncture or other damage, waste bags should not be thrown or dropped. |
| |
|Sharps may occasionally puncture the side or bottom of a polypropylene container; the container should therefore be carried by its |
|handle and should not be supported underneath with the free hand. |
| |
|Bags for hazardous health-care waste and for general waste should not be mixed, butt segregated throughout handling; hazardous |
|waste should be placed only in specified storage areas. |
| |
|Appropriate cleaning and disinfection procedures should be followed in the event of accidental spillage; any such incident should |
|be reported immediately to the responsible member of staff. |
| |
|Adequate protective clothing should be worn during all waste handling operations. |
| |
Table 7: Training for Health Centres
|Group |Duties |Type of Training/ Awareness |Method of Training |Training/Service Providers |Frequency of training/awareness |
| |
|Management |
|Planners, |To Plan and budget for the health |Justification for appropriate medical|Training Workshop |NHTC |Every year |
|Administrators, |centres |waste management | | | |
|Financial Controllers |To allocate finances to different | | | | |
| |departments of the health centres | | | | |
| | |Resources and other requirements for |Training Workshop |Consultant |Every year |
| | |appropriate medical waste management | | | |
|District Medical |To over see that all health service |Courses given to planners, administrators and financial controllers |
|Officers, Senior Nursing|divisions at health centers are | |
|Officers |functional | |
| | |Appropriate management of different |For nursing officers this should be part |NHTC |Once |
| | |types of medical waste |of their curriculum | | |
| | | | | | |
| | | |Refresher course for both Medical | | |
| | | |officers and Nursing officers | | |
| | | | | | |
| | | | |NHTC |Every 5 years |
| |
|Medical Staff |
|Doctors |To carry out surgeries and some |Segregation and handling of medical |On site training, |NHTC |Every 5 years |
| |dressings |waste | | | |
| | | |Pamphlets, posters |Health Education |Every 5 years |
|Nurses |To attend to the patients and carry |Segregation and handling of medical |It should be part of their training |NHTC |Once |
| |out all necessary activities like |waste |curriculum | | |
| |injection, dressings, midwifery, etc. | |On site training | | |
| | | | |Consultant |Every 5 years |
| | | |Pamphlets, posters | | |
| | | | |Health Education |Every 5 years |
| | |Treatment of Medical waste |Workshop and on-site training |Consultant |Every 5 years |
|Pharmacy Technicians |To dispense medications |Segregation and handling of |It should be part of their training |NHTC |Once |
| | |pharmaceutical waste |curriculum | | |
| | | |Pamphlets, posters | | |
| | | | | | |
| | | | |Health Education | |
| | |Treatment of different types of |Workshop and on-site training |Consultant |Every 5 years |
| | |pharmaceutical waste | | | |
| | | |Pamphlets, posters | | |
| | | | |Health Education |Every 5 years |
|Laboratory Technicians |To carry out medical laboratory |Segregation and handling of |It should be part of their training |NHTC |Once |
| |analyses |laboratory waste |curriculum | | |
| | | |Pamphlets, posters | | |
| | | | |Health Education |Every 5 year |
| | |Treatment of different types of |Workshop and on-site training |Consultant |- Every 5 years |
| | |laboratory waste |Pamphlets, posters | | |
| | | | |Health Education | |
| |
|Waste Handlers |
|Cleaners |Removal of waste for its generation |Risk linked to medical waste |Workshops |Consultant |Every 5 years |
| |points | |Pamphlets |Health Education |Every 5 years |
| |Transportation from source or storage | | | | |
| |to incineration | | | | |
| |Removal from incinerator to storage or| | | | |
| |disposal site | | | | |
| | |Appropriate management of different |Workshops |Consultant |Every 5 years |
| | |types of medical waste |Pamphlets |Health Education |Every 5 years |
| | |Handling of waste at different |On-site training |Consultant |Every 5 years |
| | |stations/points | | | |
| | | |Pamphlets |Health Education He |Every 5 years |
|Incinerator Operators |Collection of waste from storage |Same training as given to cleaners |
| |Operation of the incinerator | |
| |Removal of burned waste from | |
| |incinerator to storage or disposal | |
| |point | |
| | |Appropriate operation and Maintenance|On-site training |Incinerator supplier |On recruitment or Annually or as |
| | |of Incinerators |Pamphlets |Incinerator supplier |the necessity arises |
| | | | | | |
|Other laborers handling |Removal of waste from different points|Same training as given to cleaners |
|waste |Disposal of waste | |
| | |Burial disposal Method |Onsite training |- Consultant |Every 5 years |
| | | | | | |
9.2 Communities
From the survey done on communities and the scavengers themselves, it has been found out that their level of knowledge on risks that medical waste exposes them to risk is very limited. They understand that they may get infected with HIV and AIDS if their bodies get in contact with blood. However, they do not know the risks associated with other medical waste like expired medicine, x-ray negatives, etc, and they also do not know how medical waste that comes from households should be managed.
The lack of adequate knowledge places people at high risk, and this calls for their education on risks and management of medical waste. According to Pruss (1999) the objectives of public education on health-care waste are:
- To prevent exposure to health-care waste and related health hazards; this exposure may be voluntary, in the case of scavengers, or accidental as a consequence of unsafe disposal methods.
- To create awareness and foster responsibility among hospital patients and visitors to health-care establishments regarding hygiene and health care waste management.
- To inform the public about the risks linked to health-care waste, focusing on people living or working in close proximity to, or visiting health-care establishments, families of patients treated at home and scavengers on waste dumps.
Within the MoHSW, there is a department of Health Education that is responsible for awareness building to the public and personnel of health sector on all issues of health. This is the department that should be given responsibility of raising awareness to the public about risks of medical waste. There is also PHELA, (meaning LIVE) an NGO that uses mass media to promote positive behavior towards health related issues in Lesotho. These two institutions can use joint efforts to educate the public and the health workers on appropriate management of medical waste.
Due to difference of people in levels of literacy, accessibility of their location and their access to mass media, as well as preferences to the type of media, different methods have to be used to reach all people in awareness building. The suggested methods are presented in Table 8 below.
Table 8: Methods to be used to raise awareness to different target groups.
|TARGET GROUP |METHOD OF AWARENESS BUILDING |RESPONSIBLE AND PARTICIPATING INSTITUTIONS |
|Population in Urban Areas |Radio, TV, Pamphlets |Health Education, Phela, |
|Peri-Urban Areas |Radio, TV, Written materials, Public |Health Education, Phela, Chieftainship |
| |Gatherings | |
|Population in Rural Areas |Public gatherings, Radio, Pamphlets |Health Education, Chieftainship, |
|Herd boys |Public gatherings |Health Education, |
|Students |School Curriculum, |Ministry of Education, Health Education, |
| |Written Materials |NCDC |
|Population within hospital areas and |Billboards erected at storage and disposal |Health Education, MoLG |
|disposal sites |areas | |
9.3 Institutions and Agencies
There are institutions that are major stakeholders in medical waste management as they have roles to play in management of waste in general.
Table 9. Institutions to be trained for participation in Medical Waste Management.
|Institution |Role in Waste Management |Section to be Trained |Training |
|Ministry of Tourism, Environment and |External monitoring, |All officers in EIA and Pollution |Administration and enforcement in HC |
|Culture |Advisory, Enforcement |control Division |Waste management |
|Ministry of Local Government |Implementers of waste management |Environmental Health Officers, Town |Best Environmental Practices, and |
| | |Clerks, Waste Collectors, Planners |procedures, Best Available Technologies|
| | | |in HCWM, admin and enforcement |
|Ministry of Natural Resources – Energy |Monitoring water quality |Water Quality Analysts |Inspection and monitoring for HCW |
|and Water Affairs | | |pollutants |
|Ministry of Labour and Employment |Monitoring occupational health and |Inspectors |Best practices and procedures in Health|
| |safety | |Care delivery. Administration and |
| | | |enforcement of regulations |
|Ministry of Finance and Development |National planning and development |Planners, |Integrating environmental management in|
|Planning |activities |Financial Controllers |national development programmes |
|Non-Governmental Organizations |Monitoring, Awareness raising and |All relevant and functional NGO’s |Participatory methods in Environmental |
| |public participation | |management. Rights and responsibilities|
| | | |of the public. |
10.0 Summary of HCWM Plan for Lesotho
10.1 Preconditions and Reservations
The described Health Care Waste management Plan shall be recognized as a proposal, which recognizes that HCW should be managed within the scope of National Waste Management Strategies, because Health care facilities are important category of institutions generating hazardous waste.
Secondly, The plan is based on the three initial components being undertaken and consensus reached among all stakeholders regarding;
• National Health Care Waste Management Workshop, should start the process
• National Health Care Waste management Committee is established,
• Three major role players, namely Ministry of Health and Social Welfare, Ministry of Tourism, Environment and Culture and Ministry of Local Government should commit to fund the plan and support the HCWM committee and
Thirdly, the National Waste Management Plan and Strategies should be publicized and implemented by the three major role players, where at least three sanitary landfills are constructed, North, (Butha Buthe), Central (Maseru) and South (Quthing), within the first implementation year..
10.2 Segregation and Handling
A three-bin system shall be adopted and implemented, with appropriate colour coding. The Black and yellow waste bags shall be located in separate places away from patient areas. Medical staff shall separate all waste into three categories as illustrated in the table below (showing examples of the three categories).
Table 10. Examples of typical items in separate waste containers
|Potentially Infectious Waste Bags |General Waste Bags |
|Waste materials contaminated or possibly contaminated with|Used sharps containers |Waste materials not contaminated with body fluids |
|body fluids | | |
|Gloves, gowns, masks, |Needles |Packages, boxes |
|Gauze, dressings, swabs |Needles and syringe assemblies |Wrappings |
|Spatula |Lancets |Newspapers, magazines |
|Urine, blood bags |Scalpels, blades | |
|Sump tubes |Scissors, sutures |Disposable plates, cups, utensils |
|Suction canisters |Specimen tables |Food, food packaging, drinks containers, |
|Disposable bowls and containers used for medical purposes |Broken glass, ampoules |Tissue, paper towels |
|Haemodialysis tubing |Intravenous catheter |Flowers |
|Intravenous (IV) lines, bags |Glass slides, cover slips |Intravenous bottles, packs |
|Foley catheters | | |
|Sanitary napkins | | |
|Incontinence pads | | |
|Pre-treatment highly infectious waste from medical | | |
|laboratory, isolation patients | | |
|Nappies, diapers | | |
|Human and animal tissue, Placentae | | |
|Body parts (where permitted by local laws and customs) | | |
All waste handlers at all levels, cleaners, porters and gardeners and incinerator operators shall wear appropriate protective clothing when handling all waste at all times.
There shall be designated personnel in each unit, who shall be responsible for monitoring these processes. S/he shall seal all bags when full or before removal and supervise the removal to the temporary storage or treatment area.
Economic analysis
A major cost implication as far as segregation and handling are concerned centers around appropriate personal protective clothing of waste handlers and appropriate storage. Provision of these requirements is not an externality to the proper Health care. Thus, as an operational expense, they should be integrated in the financing mechanism of the sector.
10.3 Collection and Disposal
An establishment of the basic system for collection and disposal of HCW in the three distinctive areas of Lesotho is illustrated on the basis of major essential components. Focus is also put on economic and financial consequences related to implementing such a system.
10.3.1 All areas
System elements
All major hospitals and filter clinics within each HSA (those with beds) will be equipped with small capacity incinerators, except the Maseru HSA, which requires a medium capacity one. Special Health care Waste (Infectious waste) and sharps from all other health facilities will be treated at these centers and ash disposed of appropriately where general waste is being disposed of.
Economic analysis
Since the current condition of the incinerators is uncertain the overall investment can only be worked on procurement of new equipment. A further consideration is that the cost of repairs of existing incinerators would not exceed procurement of a new one. A further evaluation of this option would be required before procurement is done.
Calculations based on extrapolated waste quantities, and the recommendation of the SA Incinerator Company, appropriate incinerator capacities have been worked. The total investment for this level shall not exceed M 2,054,950.00 and shall be borne by the health sector.
10.3.2 Urban Areas
System elements
Health care waste should be collected in rigid two wheeled containers with a lid (about 80 to 240 liters depending on the health center generation rate). Black and yellow plastic bags should be sealed prior to movement to temporary storage. Three containers of these types are required for all generation points, such as Wards, Pharmacy, Theaters, OPD and Emergency Rooms. This is to avoid filled bags to be piled on the floor where they could be knocked and split open. The wheeled containers allow transportation of waste from the medical area, directly to incineration area for hazardous waste and to temporary central storage for general waste.
Infectious waste should be sent to incineration every 24 hours or at least every 48 hours in case of unforeseen delays.
Every Health Care facility should have adequate storage facility for Health Care Waste that need to be disposed. This should be in the form of at least four wheeled 1.1 m3 euro bins or skip with lids that can easily be carried by a truck or tractor to the final disposal site. The central storage should not store infectious waste or sharps; only the ash and general waste and this should be collected and emptied at least once a week.
Under these conditions, collection can be made by a mid sized compactor vehicle or a tractor manned with three runners and one driver.
The final disposal of the waste will take place at the new established sanitary landfill.
Economic analysis
The small bins are no longer recommended because of the increasing misuse by the staff. Even the sharps containers are emptied and used in homes for various domestic purposes including fetching water. The two-wheeled bins shall serve the dual purpose of storage and transportation, which shall minimize the risk during transfer of full plastic bags.
The major investment component here is that of external waste disposal. This part is the responsibility of the local authorities; however, their capacity in real terms is not sufficient. The Local government has to be helped to put together all these elements. The overall investment covering the cost of additional vehicles for collection and the construction and management of 10 landfills is estimated a M155, 640,000.00
10.3.4 Peri-Urban Areas
System elements
There is generally one hospital and one clinic in each peri-urban area, e.g. Morija, Roma, Mapoteng etc. These are generally accessible by vehicles and there is no collection service by local authority, hence collection by a private contractor seems a more immediate solution. This can be done with a standard sized van manned with two runners and a driver. The waste can be taken either to the local authority central collection point, equipped with a container or skip of about 2.5 m3 or direct to the landfill once every two weeks.
A central collection point that caters for other collection points for local authority is recommendable. This can be a transfer station, from which a vehicle equipped for transportation of the container to the sanitary landfill takes place every two weeks.
10.3.5 Rural Areas
System elements
The rural areas of Lesotho can be difficult to access and health centers are sparsely distributed, far from the parent hospitals. Since Incineration will be done at central hospitals only, and clinics do not regularly generate appreciable quantities of infectious waste, a different treatment is warranted. Sharps shall be stored in sharps containers in a secure and adequate storage and transferred to the central hospital once a month, by a hospital vehicle that takes those monthly rounds or by the flying doctors service. Infectious waste other than sharps can be buried in a well-lined and ventilated “septic tank” kind of a pit, where natural degradation can occur. This shall be secured and be a restricted access area.
|Table 11. Summary of Waste Management Plan for 3 years time-frame. |
|GOAL: NATIONAL HEALTH SERVICE THAT SUFFICIENTLY AND EFFECTIVELY EMPLOYS ENVIRONMENTALLY SOUND, TECHNICALLY FEASIBLE, ECONOMICALLY VIABLE AND SOCIALLY ACCEPTABLE SYSTEMS FOR MANAGEMENT OF HEALTH |
|CARE WASTE IN LESOTHO |
|OBJECTIVE 1: To Enhance the Legal and Policy Framework to Cover Medical Waste Management Adequately | |
|Activities |Responsible |Time Frame |Indicator |Assumptions |Budget (Maloti) |
|1.1 Workshops and meetings for review of the relevant Acts and Policies |Pollution Control |x | | |Attendance and contribution from |Cooperation from all|70,000.00 |
|held |(MoHSW); | | | |relevant departments; Workshop |stakeholders; | |
| | | | | |reports; | | |
| | | | | | |Agreement on roles | |
| | | | | | |for each | |
| | | | | | |stakeholder; | |
|1.2 Necessary amendments and regulations on medical waste management |Pollution Control |x | | |Documents and reports on amendments | | |
|developed |(MoHSW); | | | |and regulations | | |
|1.3 Proposal on amendments and regulation presented in the houses of |Pollution Control |x | | |Amendments and regulations adopted by | | |
|Cabinet and Parliament and the Senate |(MoHSW); | | | |Cabinet and Parliament; Documented | | |
| |Principal Secretary | | | |amendments and regulations available | | |
| |(MoHWS); | | | | | | |
|1.4 Medical waste Management Guideline for different types of health |Pollution Control |x | | |Documented guidelines available in | | |
|facilities developed from National Laws and policies |(MoHSW); | | | |health facilities | | |
| |Environmental Health | | | | | | |
| |(MoHSW); | | | | | | |
|OBJECTIVE 2: Training and Awareness for Health Facilities Personnel and Relevant Institutions |
|Activities |Responsible |Time Frame |Indicator |Assumptions |Budget (Maloti) |
|2.1 Training institutions sourced |Pollution Control |x | | |Documented Agreement between MoHSW and|Approval of budget; |2, 559,160.00 |
| |(MoHSW); | | | |training institutions | | |
| | | | | | | | |
| | | | | | |Cooperation and full| |
| | | | | | |participation of | |
| | | | | | |relevant | |
| | | | | | |stakeholders and | |
| | | | | | |private surgeries; | |
|2.2 Training schedules developed |Pollution Control |x | | |Documented training schedule | | |
| |(MoHSW); | | | | | | |
|2.3 Institutions and personnel to be trained selection |Pollution Control |x | | |Official lists of selected | | |
| |(MoHSW); | | | |participants from health facilities | | |
| | | | | |and other stakeholder institutions | | |
|2.4 Training implemented according to schedules |Pollution Control | |x |x |Training implemented according to set | | |
| |(MoHSW); | | | |schedule | | |
| |Planning Department | | | | | | |
| |(MoHSW); | | | | | | |
|2.5 Written awareness materials produced and distributed |Environmental Health | |x |x |Availability of awareness materials in| | |
| |(MoHSW); | | | |all health facilities | | |
| |Health Education | | | | | | |
|OBJECTIVE 3: To Mobilize all the Required Equipment and Protective Clothing and to maintain the High Standards of Treatment |
|Activities |Responsible |Time Frame |Indicator |Assumptions |Budget (Maloti) |
|3.1 Suppliers of the required equipment and protective clothing sourced |Pollution Control |x | | |Quotations from suppliers |Budget approved; |Incinerators |
| |(MoHSW); | | | | | |investment: 2, |
| | | | | | |Availability of |465,940.00 |
| | | | | | |funds for CHAL and | |
| | | | | | |private facilities; |Protective clothing and|
| | | | | | | |handling equipment: |
| | | | | | | |33,490,472.00 |
|3.2 All equipment listed mobilized |Pollution Control | |x |x |Required equipment available in all | | |
| |(MoHSW); | | | |health facilities | | |
| |Health facility | | | | | | |
| |Administration; | | | | | | |
|3.3 All required protective clothing mobilized |Pollution Control | |x |x |Protective clothing available in all | | |
| |(MoHSW); | | | |health facilities | | |
| |Health facility | | | | | | |
| |Administration; | | | | | | |
|3.4 Personnel for operation and maintenance of the technology mobilized |Pollution Control |x | | |Personnel working and their contracts | | |
| |(MoHSW);Health facility | | | |documented | | |
| |Administration; Public | | | | | | |
| |Health | | | | | | |
| | | | | | | | |
|OBJECTIVE 4: To Adopt an Environmentally Sound Way of Waste Management that prevents spread of Diseases by waste from health Facilities |
|Activities |Responsible |Time Frame |Indicator |Assumptions |Budget (Maloti) |
|4.1 All solid waste segregated according to a three-bin system at all |Matrons; |x |x |x |No waste found mixed in bins |Availability of |Landfill investment: |
|points of their generation |Superintendents; | | | | |sanitary landfills |137,500,000.00 |
| |Environmental Health | | | | |in all towns; | |
| |(MoHSW) | | | | | | |
| | | | | | | |Landfill operation: |
| | | | | | |Availability of at |13,750,000.00 |
| | | | | | |least one | |
| | | | | | |operational |Waste collection plant |
| | | | | | |incinerator in each |and equipment 5,390,000|
| | | | | | |HAS; | |
| | | | | | | | |
| | | | | | | | |
| | | | | | |Availability of | |
| | | | | | |transport; | |
|4.2 All infectious waste including sharps in urban and peri-urban |Environmental Health |x |x |x |Infectious waste and sharps fond only | | |
|facilities incinerated before disposal |(MoHSW) | | | |at their point of generation and the | | |
| | | | | |site of incinerator; This waste not | | |
| | | | | |stored at the latter for more than 24 | | |
| | | | | |hours | | |
|4.3 Al infectious waste in rural facilities is disposed in well-lined |Environmental Health |x |x |x |Infectious waste not found in any | | |
|pit for degradation |(MoHSW) | | | |place other than at its point of | | |
| | | | | |generation and in the pit | | |
|4.4 All used needles from rural facilities incinerated in hospitals in |Environmental Health |x |x |x |No used sharps are found in any place | | |
|each HAS |(MoHSW) | | | |other than in their store room sealed | | |
| | | | | |in their containers | | |
|4.5 For urban and peri-urban facilities, all generated waste and ash |Town Clerks; MCC; Health|x |x |x |No illegal dumping of general waste | | |
|from the incinerators is disposed in appropriate disposal sites |facility Administration;| | | |and ash from health facilities; | | |
| | | | | |Records of waste collection and | | |
| | | | | |disposal | | |
|4.6 General waste from rural facilities buried |Environmental Health |x |x |x |No illegal dumping of general waste | | |
| |(MoHSW) | | | |outside the facilities | | |
|4.7 activities on management of medical solid waste in health facilities|Environmental Health |x |x |x |Documented reports on monitoring | | |
|monitored |(MoHSW); NES | | | | | | |
|OBJECTIVE 5: To Employ a System of Medical Wastewater Management that Ensures that no Chemicals and Pathogens from Health Facilities are Introduced into the Sewage System |
|Activities |Responsible |Time Frame |Indicator |Assumptions |Budget (Maloti)|
|5.1 Excreta from patients with enteric diseases collected and |Senior Nursing Officer; |x |x |x |No enteric pathogens found in health |None |Budget of this |
|incinerated | | | | |facilities waste water | |objective covered in |
| | | | | | | |objective 3 |
|5.2 Excreta form patients on cytotoxic drugs collected separately and |Senior Nursing Officer; |x |x |x |No cytotoxic drugs found in health | | |
|incinerated | | | | |facilities waste water | | |
|5.3 All pharmaceutical waste collected and incinerated |Environmental Health |x |x |x |No heavy chemical loading of | | |
| |(MoHSW) | | | |pharmaceutical waste found in | | |
| | | | | |wastewater from health facilities | | |
|5.4 all laboratory samples and chemicals incinerated |Environmental Health |x |x |x |No enteric and heavy chemical loading | | |
| |(MoHSW) | | | |of laboratory chemicals found in | | |
| | | | | |health facilities wastewater | | |
|5.5 The fixer from X-ray section collected for recovery of silver; and |Environmental Health |x |x |x |Records of collection of fixer by the | | |
|the developer incinerated |(MoHSW) | | | |company that recovers silver; no | | |
| | | | | |heavy chemicals loading in waste water| | |
| | | | | |due to develop | | |
|5.6 Quality of waste water from health facilities monitored |Health Facility |x |x |x |Records of monitoring | | |
| |Laboratory; WASA; | | | | | | |
| | | | | | | | |
|OBJECTIVE 6: To Educate and Build Awareness to the General Public | | |
|Activities |Responsible |Time Frame |Indicator |Assumptions |Budget (Maloti) |
|6.1 Designs of written materials and schedules of other methods of |Health Education; |x | | |Minutes of meetings; Contract/order |Budget approved; |1,432,526.00 |
|awareness agreed upon |Environmental Health | | | |to the designer | | |
| |(MoHSW) | | | | |Cooperation from all| |
| | | | | | |role players in | |
| | | | | | |education and | |
| | | | | | |awareness raising to| |
| | | | | | |the communities; | |
|6.2 Written materials produced and distributed |Health Education; |x | |x |Materials available in target | | |
| |Environmental Health | | | |communities | | |
| |(MoHSW) | | | | | | |
|6.3 Schedule of mass media and public gatherings methods and awareness |Health Education; |x |x |x |Public gatherings held; relevant | | |
|implemented |Environmental Health | | | |officers interviewed on talk shows | | |
| |(MoHSW) | | | | | | |
| |
|OBJECTIVE 7: Develop specific Financial Resources to Cover the Cost of the Management of Health Care Waste |
| |
|Activities |Responsible |Time Frame |Indicator |Assumptions |Budget (Maloti) |
|7.1 Set up specific HCWM budget lines in accountancy system |Financial Controllers |x | | |Budgets lines in place and funds |None |These activities do not|
| | | | | |allocated | |require special budget |
|7.2 Evaluate all options in the plan and determine cost recovery |Environmental Health |x | | |Best option identified | | |
|mechanism that is centralized |(MoHSW); Accountancy | | | | | | |
|7.3 Memorandum of agreement for cost recovery between appropriate |Principal Secretary |x | | |MOA signed | | |
|institutions |(MoHSW); District | | | | | | |
| |secretary; | | | | | | |
|7.4 Develop and implement effective billing, collection and exemption |Financial Controllers |x | | |Systems in place | | |
|system | | | | | | | |
|7.5 Develop and implement a new fee schedule incorporating real cost |Financial Controllers |x | | |Fee schedule in place | | |
|recovery | | | | | | | |
11.0 Monitoring Plan
To ensure that objectives of the Medical Waste Management Plan are achieved, the implementation of the plan has to be monitored by either internal or external bodies to the Ministry of Health and Social Welfare. In some cases it will be both. The monitoring body will determine the tools of monitoring. This monitoring will assist the Ministry to identify the strengths and weaknesses of the plan itself and the programmed implemented under it. Where the weaknesses exist, the plan will be revisited and improvements will be made.
Table12: Monitoring Plan for Implementation of HCWM Plan.
|Objective1: To Enhance the Legal and policy Framework to Cover Medical Waste Management Adequately |
| |
|This objective has to be monitored to investigate if the issue of Medical Waste Management is adequately addressed by the relevant policies and|
|legal mandates in the country. The monitoring will also look into clarification of roles of different institutions in medical waste management|
|and see if these have been well defined and if all involved institutions are content with their responsibilities and committed to implement |
|their due duties. |
|Monitoring Bodies |Private Consultant |
|Parameters/Factors to be analyzed |Whether all relevant stakeholders have been involved and they participated fully. |
| |Proposed amendments and regulations have to be analyzed to assess their applicability in implementation |
| |of medical waste management. |
|Frequency |The monitoring has to be done after the amendment to the policies and laws as well as the regulations |
| |have been developed, and its repetition will depend whether the objective has been reached. |
|Objective 2: Training and Awareness for Health Facilities Personnel and Relevant Institutions |
| |
|Monitoring of this objective will be meant to assess whether the education given to the personnel of MoHSW and other institutions has sunk and |
|to investigate its effectiveness in roles played by each cadre in HCW management. |
|Monitoring Body |Development and Training (MoHSW) |
| |Health education |
|Parameters/Factors to be analyzed |Content of the training and awareness materials |
| |Attendance of personnel and institutions in training |
| |Motivation and commitment of personnel and institutions towards implementation of their roles in |
| |appropriate HCW management. |
|Frequency |6 months after the training or awareness campaign |
|Objective 3: To mobilize all the Required Equipment and Protective Clothing and to maintain the high standards of treatment technology |
| |
|The purpose of monitoring under this objective will be to find out if the necessary equipment and protective clothing is available and if the |
|equipment is operated and serviced to maintain its highest standard of performance. |
|Monitoring Body |Environmental Health |
| |OSH (Ministry of Labour and Employment) |
|Parameters/ Factors to be analyzed |Whether every staff member has and uses the necessary protective clothing |
| |Availability of recommended technologies in relevant health facilities |
| |Conditions of the technologies and whether they are appropriately operated |
|Frequency |Every month |
|Objective 4: To adopt an environmentally sound way of waste management that prevents spread of diseases by waste from Health facilities. |
| |
|Monitoring activities under this objective will investigate whether recommended methods of management of infectious and general waste from |
|health facilities are practiced. |
|Monitoring Body |Environmental Health |
| |NES |
| |MoLG (MCC and Town Clerks) |
|Parameters/ Factors to be analyzed |Whether waste is segregated at generation points |
| |Conditions and period of its storage |
| |Handling of waste |
| |Whether incinerators operate at recommended temperatures |
| |Presence of needles and other infectious waste in disposal sites |
|Frequency |Monthly for Environmental Health |
| |Bi-monthly for NES, MCC and offices of Town Clerks |
|Objective 5: To employ a system of Medical Wastewater Management that ensures that no chemicals and pathogens from health facilities are |
|introduced into the sewage system. |
| |
|The purpose of monitoring under this objective will be to find out if wastewater from health facilities contains enteric pathogens and |
|chemicals, and to find out their source. |
|Monitoring Body |WASA |
| |DWA |
| |Hospital Laboratory |
|Parameters/ Factors to be analyzed |Analyze |
| |Presence of enteric pathogens and |
| |COD |
| |from health facilities. |
|Frequency |Every month for the hospital laboratory in the first year, and bi-monthly afterwards |
| |Quarterly for WASA and DWA |
|Objective 6: To Educate and Build Awareness to the General Public |
| |
|The monitoring will assess level of awareness of people on risks associated with medical waste after awareness campaign. |
|Monitoring Body |NGO’s |
| |Health Education |
| |Private Consultant |
|Parameters/ Factors to be analyzed |Content of awareness methods |
| |Suitability of each method used to a target group |
| |Effectiveness of the method used to a target group |
| |Opportunities for improvement of methods |
|Frequency |A year after the campaign has started |
|Objective 7: Develop specific financial resources to cover the cost of the management of Health Care waste |
| |
|For effective implementation of this objective, the monitoring will investigate if a specific budget for HCW management has been drawn and |
|whether other financial sources apart from the Government have been tapped. As NES is a focal point for accession of funds from some |
|organizations (e.g. Conventions), they will have to be involved in monitoring so see how the funds have been used. |
|Monitoring Body |NES |
| |Financial Controller (MoHSW) |
|Parameters/ Factors to be analyzed |Available funds and their source |
| |How funds have been used and the gaps |
| |Attempts made to source funds and the responses |
| |Other potential financial sources |
|Frequency |At the end of every governmental financial year. |
Evaluation of Financing Possibilities
Looking into the financing of the activities and components of the overall Health Care Waste Management in Lesotho, the total National Investment can be estimated at M 176,059,768.00. This value is inclusive of the minimum requirements for efficient collection in major towns and peri-urban areas, over a period of a year.
The three major role players are implicated and can be expected to finance the system.
Ministry of Tourism Environment and Culture, whose major roles should be Monitoring, enforcement and Public Awareness programmes, would provide infrastructure and resources for these roles. .
Ministry of Local Government should procure the Hardware component (landfills and collection trucks and storages). They shall remain in Operation and Maintenance as well as Personnel management (collectors and drivers and landfill managers)
Ministry of Health and Social Welfare, as a committed member should start with proper Segregation and provision of all requirements thereof (containers and storages). They should commit to treatment with the high standard incineration process. The Ministry should further ensure equitable User charges and set up an efficient collection system in order to recover some costs. Training of all cadres of workers should be regular component of the medical programs.
Financing options; (capital costs)
The current sector budget of M 327 million is undoubtedly very low for operations of a good health care system. The management, workers at all levels and the accounting section of the ministry estimate that at least M600 million is required to run the sector. The improvement of HCWM poses yet another financial requirement, not only to the sector but also to the nation at large.
The Government of Lesotho should approach its development partners for assistance in the form of Loans or Grants. Lesotho is eligible for HCWM assistance through WHO.
The sale of long term Bonds is another option that the government should try to raise funds for such capital works.
Operating and maintenance costs can be financed through general revenues or grants from the central government. For cost recovery, mainly on the part of local Government, financing should be based on user charges. The current charges should be reviewed to reflect the actual cost of the service, both at Local Government and Health delivery.
Conclusions and Recommendations
The observations at the main hospital in Maseru are:
• HCWM is not assigned any specific authority
• Segregation of HCW is not observed by the medical staff
• Staff engaged in HCW handling is not provided with appropriate protective equipment
• All staff is not trained in HCWM
• HCW is not accorded effective treatment
• There is rampant theft of plastic bucket type medical bins
• Hospital grounds are not maintained in a manner deserving of a health care institution
• There is general poor maintenance of equipment from the incinerator to the sewerage network
Lesotho’s economy is still low to sustain a full-fledged waste management expenses. Due to unemployment and general poverty, people cannot afford to fund waste management. The successful implementation of HCWM shall require a more efficient economy.
Institutional collaboration is very poor among government ministries and departments, as such crosscutting programs like waste management, which are heavy on individual authority in charge are not fully functional. Collaboration should be improved and roles clearly defined down to financial responsibilities.
Communication channels and responsibilities are often neglected as a result of unclear roles (undefined) and the general attitude of hoarding program by the management in public service, in general. All programs within the sector should be publicized in the sector newsletter so that information reaches everybody and the public knows their roles.
Healthcare Waste Management is relatively poor in Lesotho and does not seem to receive any attention as a serious infection prevention program.
There is no legislation that governs HCW directly, except for the new Environment Act, which encompasses it in hazardous waste. Regulations and guidelines are non-existent.
Generally, the National Waste Management is inadequate to address the requirements o environmentally sound disposal of HCW.
Little support, especially in terms of resources to the healthcare workers has led to low morality and demotivation among workers at all levels.
Misadministration, such as late payments to non-payment of bills has crippled many operations of the healthcare system and still remains a serious threat to smooth operation.
Investment in HCW management should be regarded a national issue, not health sector issue. Hence collaboration between the major role players namely; MoHSW, MoLG, MTEC, and MoFDP must be strengthened with a view of harmonizing responsibilities and priorities.
It is further recommended that;
- MoHSW, MoLG, and MTEC share the funding of the capital costs of this plan, preferably at the ratio of 2:2:1 respectively. Other related operational costs can be funded within the recurrent budgets of individual ministries. The budget for these three ministries need to be thoroughly reviewed whereas budget lines pertaining to HCWM will be established.
- For purposes of accountability, the department of Environmental health should be assigned the responsibility of ensuring that all healthcare facilities implement the proposed HCWM plan. And for support to this department, the two committees – National HCWM Committee and HSA HCWM Committees - have to be established.
- The approved plan, through the national HCWM committee and HSA HCWM Committee should be made available and disseminated to all units of HHC facilities, including practices.
- Regulations on Hazardous waste and technical guidelines should be developed to address day-to-day operational issues.
- A system for evaluation, licensing and monitoring of private sector participation in hazardous waste management should be developed to enable considerable participation of private sector.
REFERENCES AND BIBLIOGRAPHY
1. DANCED, Pre-feasibility Study on Solid Waste Management in Lesotho, 2000
2. DANCED, Proceedings on workshop for Decision and Policy Makers Regarding Solid waste Management, 2000
3. Lesotho government, Building Control Act, 1995, Government Printing, Maseru, 1995.
4. Lesotho Government, Environment Act No.15 2001, Government Printing, Maseru, 2001.
5. Lesotho Government, Health and Social Welfare Policy, 2004, Government Printing, Maseru, 2004.
6. Lesotho government, Labour Code (Chemical Safety) Regulations 2003, Government Printing, Maseru, 2003.
7. Lesotho Government, National environment Policy, National Environment Secretariat, Maseru, 1996.
8. Lesotho Government, Sanitary Services and Refuse Removal Regulations 1972, Government Printing, Maseru, 1972.
9. Lesotho Government, The Public Health Order 1970, Government Printing, Maseru, 1970.
10. Lesotho Government, The Urban Government Act 1983, Government Printing, Maseru, 1970.
11. Ministry of Health and Social Welfare, Environmental Health Assistants Curriculum Review of 2003, MoLG, Maseru, 2003.
12. Ministry of Health and Social Welfare, Lesotho Health Sector Reforms Plan, MoLG, Maseru, 2000.
13. Ministry of Health and Social Welfare, Health Statistical Tables, MoLG, Maseru, 2003
14. Ministry of Health and Social Welfare, National Medical Waste Situations, MoLG, Maseru, 2004
15. National Environment Secretariat, Chemical Legislation and Enforcement Capacity, National Environment Secretariat, Maseru, 2004.
16. linked/onlinedocs/HCW_practica/Info1.pdf (3rd December, 2004)
17. Pruss A (Ed.), Safe Management of Waste from Healthcare Activities, WHO, Geneva, 1999.
18. S.A Incinerator Company, Company Brochure.
ANNEX A
ORGANOGRAM OF THE MINISTRY OF HEALTH AND SOCIAL WELFARE
ANNEX B
GUIDELINES FOR PRELIMINARY CHOICE OF A LANDFILL
|site No: |
|site name: |
|No. |Selection criteria |Remark at site visit |Preliminary evaluation of suitability of criterion |
| | | |(high/medium/low) |
|1 |Size of area C | | |
|2 |Distance to populated areas | | |
|3 |Distance to sensitive water resources | | |
|4 |Hydrology and hydrogeology | | |
|5 |Geology (topsoil, rocks etc) | | |
|6 |Topography | | |
|7 |Distance from waste arising | | |
|8 |Construction material availability (quarry | | |
| |or clay pit at site) | | |
|9 |Current land use | | |
|10 |Local ecological conditions | | |
|11 |Flooding occurrence | | |
|12 |Transportation links (main road, access | | |
| |road, traffic impacts) | | |
|13 |Public opinion, acceptance | | |
Criteria, level of significance and suitability and score for a selected site
|site No: |
|site name: |
|No. |Criteria |Significance of |Suitability of site, |Score for site |Remarks |
| | |criterion, 1.0 (low) and|High (2) Medium (1) Low|(Significance x | |
| | |2.0 (high) |(0) |Suitability) | |
|1 |Available land area | | | | |
|2 |Distance to populated areas | | | | |
|3 |Proximity to sensitive water | | | | |
| |resources | | | | |
|4 |Hydrology and hydrogeology | | | | |
|5 |Soil/land conditions | | | | |
| |(permeability, stability etc) | | | | |
|6 |Topography | | | | |
|7 |Distance from waste arising | | | | |
|8 |Construction material | | | | |
| |availability | | | | |
|9 |Current land use | | | | |
|10 |Local ecological conditions | | | | |
|11 |Flooding occurrence | | | | |
|12 |Transportation links (main road, | | | | |
| |access road, traffic impacts) | | | | |
|13 |Availability of infrastructure | | | | |
| |(water and power supply etc) | | | | |
|TOTAL SCORE | | |
ANNEX C:
Case Study on Evaluation of Waste Incineration and Composting
Emission Factors from UNEP Tool kit
|Waste incineration Category 1 |
| |Emission Factors -µg TEQ/t of Material |
| |Air |Water |Land |Product/Fly |Residue/Bottom |
| | | | |ash |Ash |
|1.Low Technology combustion, no APC system |3,500 |N/A |N/A |N/A |75 |
|2. Controlled combustion, minimal APC |350 |N/A |N/A |500 |15 |
|3. Controlled combustion, good APC |30 |N/A |N/A |200 |7 |
|4. High technology combustion, sophisticated APC system |0.5 |N/A |N/A |15 |1.5 |
| | | | | | |
|Waste Disposal-landfill category |
|1. Hazardous waste |0 |200 |N/A |N/A |50 |
|2. Non-hazardous waste |0 |30 |N/A |N/A |5 |
| | | | | | |
|Open Burning of Waste Category 6b |
|1. Landfill fires |1,000 |ND |N/A |N/A |600 |
|2. Accidental fires in houses, factories etc |400 |ND |residue |N/A |400 |
|3. Uncontrolled Domestic waste burning |300 |ND |residue |N/A |600 |
|4. Accidental fires in vehicles |94/vehicle |ND |residue |N/A |18/vehicle |
|5. Open burning of wood |60 |ND |ND |N/A |10 |
| | | | | | |
Scenario 1: Country Situation in 2005
• Population of 2.10 million;
• 20% (420,000) of the population lives in the urban centers;
• Waste generation rate of 0. 43 kg per person and day;
• 30 % is collected and disposed in 10 dumpsites;
• Of the dispersed waste, 10 % is burned in barrels, roadside, in gardens, etc.;
• All dumpsites also burn;
• There is no composting of waste;
• There is no municipal solid waste incinerator.
Generation of waste – per year, nation-wide:
|Calculation: |2,100,000 * 0.43 kg / 1000 * 365 |329,595 t/a |
Scenario I: Actual practices → Releases in g TEQ/a
|Disposal in waste dumps |30 % |98,878.5 t/a |
|EF in residues |5 µg TEQ/t |0.494 g TEQ/a |
|Burning waste dumps |90 % |0.9 * 329,595 |
| | |=296,635.5 t/a |
|EF to air |1,000 µg TEQ/t |296,635.5 * 1,000 / 1000,000 |
| | |= 296.64 g TEQ/a |
|EF in residues |600 µg TEQ/t | |
| | |177.98 g TEQ/a |
|Wastes left at home: |70 % |0.7 * 329,505 |
| | |= 230,653.5 t/a |
|EF in (untreated) waste: |5 µg TEQ/t | |
| | |1.15 g TEQ/a |
|Burning of these wastes |10 % |23,065.4 t/a |
|EF to air |300 µg TEQ/t | |
| | |6.92 g TEQ/a |
|EF in residues |600 µg TEQ/t | 13.84 g TEQ/a |
|Releases | | |
| |To air: | 303.56 g TEQ/a |296.64+6.92 |
| |In residues: | 193.46 g TEQ/a |0.494+177.98+1.15+13.84 |
| |Total: | 497.02 g TEQ/a | |
Legend: EF: Emission factor t: ton
TEQ Toxic equivalent a: year
Scenario 2: Country Situation in 2010
• Country population and in the urban centers have not changed;
• Waste generation has not changed;
• The country has established a waste collection system to serve 1 municipal waste incinerator and 10 landfills (all new);
• Half of the total waste is disposed of in new landfills.
• The municipal solid waste incinerator is state-of-the-art burning all domestic waste generated in the urban centers.
• The new landfill does not burn and is not ignited;
• 10 % of the domestic waste generated is not collected;
• Of the dispersed waste, 10 % is burned in barrels, roadside, in gardens, etc.;
• The districts encourage composting in rural areas and have set up 3 central compos-ting facilities and encourage private composting of garden and kitchen wastes. The overall composting rate is 20 % of the total waste generated in the country
Scenario II: Disposal practices in the year 2010
|Generation of municipal solid waste: |329,595 t/a |
|Wastes for incineration in plant: |20% |420,000 * 0.43 * 365 / 1000 |
| | |= 65,919 t/a |
|EF to air |0.5 µg TEQ/t | 0.033 g TEQ/a |
|EF in residues (bottom ash) |1.5 µg TEQ/t |0.099 g TEQ/a |
|EF in residues (fly ash) |15 µg TEQ/t |0.990 g TEQ/a |
|Total in residues: | |1.089 g TEQ/a |
|Composting: |20 % |65,919 t/a |
|EF in product |5 µg TEQ/t |0.33 g TEQ/a |
|Disposal in waste dumps |30 % |98,878.5 t/a |
|Disposal in sanitary landfills | 50 % of total waste |164,797.5 t/a |
|Total in waste dumps and sanitary landfills |80 % |263,676.0 t/a |
|EF in residues | 5 µg TEQ/t |1.32 g TEQ/a |
|Burning of waste dumps: |20 % s |65,919 t/a |
|EF to air | 300 µg TEQ/t |19.78 g TEQ/a |
|EF in residues |600 µg TEQ/t |39.55 g TEQ/a |
|Waste left at home: |10 % | |
| | |32,595.5 t/a |
|EF in waste (untreated) |5 µg TEQ/t |0.165 g TEQ/a |
|Burning of these wastes |10 % |3,259.6 t/a |
|EF to air |300 µg TEQ/t |0.978 g TEQ/a |
|EF in residues |600 µg TEQ/t |1.956 g TEQ/a |
|Releases | | |
| |To air: | 107.79 g TEQ/a |0.033+19.78+0.978 |
| |In residues and products |44.407 g TEQ/a |1.089+0.33+1.32+39.55+0.165+1.956 |
| |Total: |152.197 g TEQ/a | |
2005 (air) vs. 2010 (air) = 303.56 vs. 107.79
2005 (total) vs. 2010 (total) = 497.02 vs. 152.197
An introduction of well managed land fills that are not ignited, the introduction of controlled combustion incinerators with good APC system, together with adequate composting processes do lower air pollution. dioxins and Furans emissions are drastically lowered. Hence, incineration is still the choice of technology BUT only when managed properly.
Table 5 Indicates that the estimated total Health Care Waste in the country may be in excess of 1076 tons a year. On the basis of the current disposal and treatment practices the contribution of this sector to Dioxins and Furans emissions , calculated on the basis of uncontrolled combustion, would be 3.77 g-TEQ/a. Comparing this with a case where a controlled combustion incineration process with good APC system is introduced, it is found that it would lower these emissions down to 0.032 g-TEQ/a, a hundred fold lower.
ANNEX D
WATER QUALITY STANDARDS FOR INDUSTTRIAL EFFLUENT THAT IS TO BE TREATED AT WASA TREATMENT FACILITIES
EFFLUENT QUALTIY STANDARDS FOR DISCHARGE TO PUBLIC SEWER
|Parameters |Concentration |
|pH |Not 10 |
|Temperature |Not > 350c |
|Biochemical Oxygen Demand (BOD5) |400mg/l |
|Chemical Oxygen Demand |600mg/l |
|Suspended solids |1000 mg/l |
|Cyanocompounds (expressed as HCN) |20 mg/l |
|Sulphides, hydrosulphides and polysulphides (expressed as S) |50mg/l |
|A-oils, greases or waxes of mineral origin |20mg/l |
|B-vegetables oils, fats, greases or waxes |250 mg/l |
|Tar and tar products, bitumen, asphalt and distillates |60mg/l |
|Sugars (total sugars and starch expressed as glucose) |1 500mg/l |
|SO4 |600mg/l |
|Chlorides (expressed as Cl) |No limit |
|Copper (expressed as Cu) |2mg/l |
|Nickel (expressed as Ni) |3mg/l |
|Zinc (expressed as Zn) |5mg/l |
|Cadmium (expressed as Cd) |0.5 mg/l |
|Total Chromium (expressed as Cr2O5) |3mg/l |
|Total Lead (expressed as Pb) |2mg/l |
|Mercury (expressed as Hg) |0.1 mg/l |
The effluent shall not contain any substances which, either alone or in combination with any matter in any sewer or pumping station or sewage stabilization pond or sewage treatment works, would give rise to poisonous, inflammable or obnoxious gases in such sewer or pumping stations or would be deleterious either to the fabric or working of the sewage treatment works.
ANNEX E
Economic analysis base for Investment in Health Care Waste Management
1. Handling and Storage
|System element | |Quantity |Unit cost |Total cost |
|Protective clothing | | | | |
| |Long tough plastic gloves |1932 |100.00 |193,200.00 |
| |Overalls | |1932 |250.00 |
| |Shoes | |1932 |350.00 |
| | | | | |
| | | | | |
| | |25l |58926 |70.00 |
| | | | | |
|Totals | | | | |
|Collection trucks |2 | |700,000.00 |1,400,000.00 |
| | | | | |0.00 |
|Collection Tractors |10 | |300,000.00 |3,000,000.00 |
| | | | | |0.00 |
|Containers(skips) |22 | |45,000.00 |990,000.00 |
| | | | | |0.00 |
|Sanitary Landfill |10 | |500/ton/year |151,250,000.00 |
| Capacity tons/year |
| |Maseru | |40000 |20,000,000.00 |2,000,000.00 |
| |Maputsoe-Hlotse |40000 |20,000,000.00 |2,000,000.00 |
| |Butha Buthe |30000 |15,000,000.00 |1,500,000.00 |
| |Teyateyaneng |30000 |15,000,000.00 |1,500,000.00 |
| |Mafeteng | |30000 |15,000,000.00 |1,500,000.00 |
| |M/Hoek | |30000 |15,000,000.00 |1,500,000.00 |
| |Quthing | |30000 |15,000,000.00 |1,500,000.00 |
| |Qacha's nek | |15000 |7,500,000.00 |750,000.00 |
| |Thaba tseka |15000 |7,500,000.00 |750,000.00 |
| |Mokhotlong |15000 |7,500,000.00 |750,000.00 |
|Total landfill investment | |137,500,000.00 |13,750,000.00 |
|Total collection and disposal | | |155, 640,000.00 |
|Notes : This is an external investments as far as the Health Facilities are concerned |
|However, in terms of operatibility of HCWM, the overall national Waste Management has to be at an acceptable level. This investment should be looked at as a national issue that has |
|to be highly coordinated between Health, Local Government and Environment |
4. Training and Awareness raising
Training Programme by Health Service Area
|HAS |Type of Training |Number of |Duration |Projected cost x M 1000 |
| | |Trainees | | |
|Butha Buthe and Seboche |Workshops/In service |33 |6 days |108.504 |
| |Short course |6 |12 days |39.456 |
|Berea |Workshops/In service |33 |6 days |108.504 |
| |Short course |6 |12 days |39.456 |
|Leribe |Workshops/In service |76 |6 days |249.888 |
| |Short course |6 |12 days |39.456 |
|Mafeteng |Workshops/In service |34 |6 days |111.792 |
| |Short course |6 |12 days |39.456 |
|Maluti |Workshops/In service |30 |6 days |98.640 |
| |Short course |6 |12 days |39.456 |
|Mamohau and Paray |Workshops/In service |54 |6 days |177.552 |
| |Short course |6 |12 days |39.456 |
|Mohale’s Hoek |Workshops/In service |36 |6 days |118.368 |
| |Short course |6 |12 days |39.456 |
|Mokhotlong and St James |Workshops/In service |46 |6 days |151.248 |
| |Short course |6 |12 days |39.456 |
|Queen II |Workshops/In service |98 |6 days |322.224 |
| |Short course |6 |12 days |39.456 |
|Qacha’s neck and Tebellong |Workshops/In service |48 |6 days |157.824 |
| |Short course |6 |12 days |39.456 |
|Quthing |Workshops/In service |32 |6 days |105.216 |
| |Short course |6 |12 days |39.456 |
|Scott, Semonkong and St Joseph |Workshops/In service |78 |6 days |256.464 |
| |Short course |6 |12 days |39.456 |
|All HAS - |Short course | | | |
| |-Incinerator operators |2 x 24 |2 days |52.608 |
| | |incinerators | | |
| |-Maintenance technicians |4 x central based|2 days | 4.384 |
| |-Administrators Accountants & Environment Health |3 x 19 HSA |2 days |62.472 |
| |Officer | | | |
|TOTAL | |779 Trainees |222 person days |2,559,160.00 |
Notes:
The costs include transport from home base for trainees, Daily Subsistence and Training provider fees and Materials.(Average M548/person/day)
Two trainees per Health center and
Two trainees per unit in a Hospital (wards, pharmacy, dental, and radiology)
Six members from other external institutions and agencies (Environment, Local Government, labour, Natural resources, Development planning and NGOs)
5. Public Education and Awareness Building
SIGN BOARDS
24 hospitals x M 7,520.00/bill board M 180,480.00
10 disposal sites x M 7,520.00/bill board M 75,200.00
M 255,680.00
RADIO ADVERTS
PC FM
First Batch 3 adverts x 31 days x 2 months x M180.00 M 33,480.00
Second Batch 2 adverts x 31 days x 3 months x M180.00 M 33,480.00
Third Batch 1 advert x 31 days x 1 month x M180.00 M 5,580.00
M 72540.00
Radio Lesotho 10 adverts x 236 M 2,690.00
NEWSPAPER ADVERTS
Public Eye 24 adverts x M 2,334.00 M 56,016.00
The Mirror 24 adverts x M 1,250.00 M 30,000.00
Mopheme 24 adverts x M 650.00 M 15,600.00
WRITTEN MATERIALS
Poster 50,000 x M 3.50 = M 175,000.00
Pamphlets 50,000 x M 1.00 = M 50,000.00
FREE METHODS OF AWARENESS RAISING
- Writing articles in newspapers
- Visiting RadioTalkShows
- Using Soul City Dramas through Phela
- Holding Public Gatherings
- Disseminating Information through Community Health Workers
Summary of Projected National HCWM Plan Implementation Costs for the first Three Years
|Investment Item |Investments and Incremental Costs per year |
| |Year 1 |Year 2 |Year 3 |Total Investment |
|1 Handling and Storage |15,805,658.00 |9,180,506.00 |8,504,308.00 |33,490,472.00 |
|2 Treatment |2,054,950.00 |205,495.00 |205,495.00 |2,465,940.00 |
|3 Collection and Disposal |61,306,667.00 |54,916,667.00 |54,166,667.00 |170,390,001.00 |
|4 Training and Awareness raising |853,053.33 |853,053.33 |853,053.00 |2,559,159.99 |
|5 Public Education and Awareness Building |477,508.67 |477,508.67 |477,508.67 |1,432,526.00 |
|Annual Total |79,644,784.00 |64,780,177.00 |64,207,032.00 |208,627,993.00 |
Annex F
Stakeholders consulted
List of Stakeholders consulted
Stakeholder Institutions
Health Planning & Statistics Director Mrs. M. Makhakhe
NES Senior Environment Officer Mr. T. Tsasanyane
Maseru City Council Principal Health Inspector Mrs R. M. Khooe
Ministry of Local Government Town Clerk (Thaba-Tseka) Mrs Tsepang Koele
Ministry of Local Government Town Clerk (Mokhotlong) Mr.
Ministry of Local Government Economic Planner Mr. Koto Noto
Health Education Chief Health Educator Mr. Ndwampe
PHELA Programme Manager Limpho Mokhochane
Health Facilities
Queen Elizabeth II Senior Nursing Officer Mrs. M. Mafike
Health Division Clinic Nursing Assistant Mrs Malenka Motlejoa
District Psychiatric Nurse Mrs R. Qhobosheane
Khohlo Nt’so Clinic Nurse Clinician Mrs Mamotebang Ramoholi
Paray Hospital Administrator Mr. Thamae
Maluti Hospital Medical Superintendent Dr. N. E. Hurlow
Mokhotlong Hospital Administrator Mrs. A.M. Tsufu
Acting Matron Mrs. Sophie Sekonyela
Health Assistant Alina Makoa
Motebang Hospital Senior Nursing Officer Mrs. Mpoetsi Makau
Ntsekhe Hospital Administrator Mr. Molise Lepota
Ntsekhe Hospital Environmental Officer Mr. Bulara Moja-khomo
Maluti Health Center Nurse Clinician Mrs B. Rampou Seoli
Immaculate Health Center Registered Nurse Sr. Theresia Mozie
Upper Thamae Clinic Public Health Nurse Mrs Mat’sepo Moletsane
Khubetsoana Clinic Nursing Sister Mrs Mat’seliso Mothopeng
Qoaling Filter Clinic Cleaner Mrs Ntina Sekonyela
Immaculate Health Centre Registered Nurse Sr. Theresa Mozie
Tsepo Health Centre Nurse Assistant Ms. Mookho Ntakatsane
St. James Health Centre Nurse Clinician Sr. Alina Mokhachane
Maryland Health Centre Nurse Assistant Sr. Claudia Montsi
General Public
Ha Koeneho Village Small Scale Farmer Mr. Leteka Motloli
Ha Duma Village House Wife Mrs. ‘Malimpho Moeletsi
Leribe (Maryland) House Wife Mrs. ‘Mathato Hlapisi
Ha Tsepo Student Lebohang
Student Rethabile
Student ‘Malefa
Tsosane Dump Site Scavengers (They would not disclose their names)
Mohale’Hoek (Ntsekhe Hospital) Street Vendors Mrs. ‘Malimakatso Mohale
Mr. Kolieile Moiloa
-----------------------
Box 2 : Step-by-step Approach for Medical Departments
Step 1: Establish a three-bin system
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ìâØ;¯¾œ¾ØŽ¾…€wsjs€\s€s€s€s€s€shm'ïCJ OJ[?]QJ[?]^J[?]aJ hm'ï5?mH
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hm'ï5?hm'ï;?OJ[?]QJ[?]jhm'ïU[pic]mHnHu[pic]%j2Èhm'ï5?CJOJ[?]QJ[?]U[pic]\?^J[?]hð 5?CJOJ[?]QJ[?]\?^J[?]Step 2: Use Distinctly different colours for general and infectious waste
Step 3Cover all waste bins; avoid using open containers and waste baskets
Step 4: Observe the different locations for black and yellow waste bags
Step 5: Fix the collection Schedule
Step 6: No bag or Sharps container should be more than three quarters full
Step 7: All bags leaving medical area should be sealed and labeled
Step 8: Use Rigid containers with wheels and lids for temporary storage
Step 9: Sharps containers should be labeled “SHARPS”
Step 10: Reinforce colour coding in all bag holders, pedal bins and waste transporting trolleys
Step 11: Use Separate trolleys for General and Potentially Infectious waste
Step 12: Designate a suitable open, ventilated area for central storage or collection
Step 13: Autoclave Waste from Highly contagious areas before placing in yellow bags
Step 14: Get all checklists for handling and collecting all categories of infectious waste
Step 15:Train – Waste Management Plan should be known to everybody in the health facility
Appoint responsible personnel for Waste management in every department
Train every member of staff in her responsibilities regarding good waste management
E2093
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