Draft Environmental Management Framework - World Bank€¦ · Second Health Sector Development Program Page. 6. Chapter 1: Overview of the Second Health Sector Development Program

Environmental Management Framework 2013

Second Health Sector Development Program Page 1

THE GOVERNMENT OF SRI LANKA

Environmental Management Framework for

Health Care Waste &

Infrastructure Development Second Health Sector Development Program

Ministry of Health

January 8, 2013

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Abbreviations

CEA : Central Environmental Authority

CFE : Caring for the Environment

DLI : Disbursement Linked Indicator

DEOH: Directorate of Environmental and Occupational Health

EIA : Environmental Impact Assessment

EPL : Environmental Protection License

E&OH : Environment and Occupational Health Unit

GCA : Greater Colombo Area

GOSL : Government of Sri Lanka

HCF : Health Care Facility

HCW : Health Care Waste

HCWM: Health Care Waste Management

HSDP : Health Sector Development Project

IDA : International Development Association

MoH : Ministry of Health

MOH : Medical Officer of Health

NAP : National Action Plan

NCCWM : National Committee for Clinical Waste Management

NCD : Non-Communicable Disease

NEA : National Environmental Act

NHDP : National Health Development Plan

PAD : Project Appraisal Document

PHS : Provincial Health Services

PMS : Project Management Secretariat

PSC : Project Steering Committee

PU : Peripheral Unit

RE : Regional Epidemiologist

SA : Situation Analysis



Table of Contents

Chapter 1: Overview of the Second Health Sector Development Program

1.1: Program objectives and proposed activities ... .. .. .. .. .. 6

1.2 Development Objectives of the 2nd

HSDP ... .. .. .. .. .. 6

1.3 Project Description ... .. .. .. .. .. .. .. .. 6

1.4: Objectives of the framework and the intended audience ... .. .. .. .. 12

1.5 Structure of the report ... .. .. .. .. .. .. .. .. 13

1.6 Sources of information .. .. .. .. .. .. .. .. .. 14

Chapter 2: Existing policy/regulatory framework for HCWM in Sri Lanka

2.1: Overview of the organization of the Health sector in the country … .. .. .. 15

2.2: Health care waste management in Sri Lanka .. .. .. .. .. .. 18

2.2.1: General Background .. .. .. .. .. .. .. .. .. 18

2.3 Existing health care waste management framework in the country .. .. .. 19

2.3.1: National Policy .. .. .. .. .. .. .. .. .. 19

2.3.2: National Guidelines .. .. .. .. .. .. .. .. 20

2.3.3: Code of Hygiene .. .. .. .. .. .. .. .. .. 21

2.3.4: National Color code .. .. .. .. .. .. .. .. 21

2.3.5: Legislation and regulation .. .. .. .. .. .. .. .. 22

2.3.6: Other sectoral strategies addressing HCW .. .. .. .. .. 23

2.3.7: Recommended institutional and monitoring framework .. .. .. .. 24

Chapter 3: Review of the present scenario of HCWM in Sri Lanka

3.1: Types of HCW generated .. .. .. .. .. .. .. .. 25

3.2: Baseline information on HCW production in different HCFs .. .. .. .. 26

3.3: Characterization of HCWM in the country .. .. .. .. .. .. 34

3.4: Summary of treatment technologies and infrastructure employed in the country for .. 36

3.5 Achievements and gaps in the implementation of the policy/national action

plan and lessons learnt .. .. .. .. .. .. .. .. .. 37

3.6 Financial resources available for HCWM in the country .. .. .. .. .. .. .. .. .. 39

Chapter 4: Strategy for scaling up HCWM under HSDP II

4.1: Summary of HCWM strategies addressed in the National Health Development Plan .. 40

4.2: Priority areas selected for implementation under HSDP II .. .. .. .. 42

4.3 Description of result indicators to be monitored under 2nd

HSDP .. .. .. .. .. 47



Chapter 5: Implementation and monitoring arrangements for HCWM under the

Second HSDP

5.1 : Project Institutional and Implementation Arrangements .. .. .. .. 49

5.2 Implementation of HCWM under 2nd

HSDP .. .. .. .. .. .. 50

Chapter 6: Technologies available for HCWM and comparison of alternatives

6.1 Treatment Technologies .. .. .. .. .. .. .. .. .. 52

6.2: Incineration .. .. .. .. .. .. .. .. .. .. .. .. 53

6.3: Autoclaving .. .. .. .. .. .. .. .. .. .. .. 55

6.4: Microwave irradiation .. .. .. .. .. .. .. .. .. 55

6.5: Chemical Disinfection .. .. .. .. .. .. .. .. .. 56

6.6: Land disposal .. .. .. .. .. .. .. .. .. .. 57

Chapter 7: Safeguard requirements for infrastructure development under 2nd

HSDP ..

7.1 Environmental Clearance under national laws .. .. .. .. .. .. .. 59

7.2 Incorporation of safeguards into plan, design and contract .. .. .. .. 59

Annexes

Healthcare Waste Management –Rapid Assessment Tool .. .. .. .. 63

Assessment of Healthcare Waste Management in Major Health Institutions .. .. 70



List of Tables

Table 1: Health Institutions and bed strength by District .. .. .. .. 16

Table 2: Overview of the administration of Health Services and classification of

medical institutes .. .. .. .. .. .. .. .. 17

Table 3: National Colour Code for segregation of HCW .. .. .. .. 22

Table 4: Production of non-risk and hazardous HCW per district .. .. .. 26

Table 5: Average production of HCW in different categories of HCFs .. .. 27

Table 6: The daily generation of healthcare waste in government-owned hospitals

in Sri Lanka, calculated using bed capacities in year 2000 .. .. 28

Table 7: Estimates of hazardous waste generation in government hospitals of Sri Lanka

in 2000 .. .. .. .. .. .. .. .. .. 28

Table 8: Quantities of HCW generation in selected HCFs in the Galle District .. 29

Table 9: Quantities of hazardous HCW generated in selected hospitals in the

country (results of the rapid assessment done in 2011) .. .. .. 32

Table 10: Current practices in handling HCW in 33 major hospitals evaluated .. .. 34

Table 11: Description of current practices in handling HCW in 33 major

hospitals evaluated .. .. .. .. .. .. .. .. 35

Table 12: Treatment technologies and infrastructure employed in the country for

HCWM treatment .. .. .. .. .. .. .. .. 36

Table 13: Suitable treatment and disposal technologies according to the different

categories of HCW .. .. .. .. .. .. .. .. 53



Chapter 1: Overview of the Second Health Sector Development Program

1.1: Program objectives and proposed activities

For the country’s vision as reflected in the Mahinda Chintana to be realized, investing in the

modernization of the health system would be a critical pre-requisite. A more modern health

system of international standards, commensurate with the aspirations of a middle-income country

population would not only help achieve the objective of improving living standards and social

inclusion; rather it would contribute to all the objectives set out in the vision document, including

sustained economic growth, and shifting toward a knowledge-based and competitive economy.

Without a healthier population and a system that is geared to handle the health challenges thrown

up by the rapid demographic and epidemiological transitions facing Sri Lanka, the quantum leaps

needed in the availability of highly skilled and more productive labor force would remain an

unrealized dream. The Bank’s Country Partnership Strategy seeks to deepen the World Bank

Group’s support to Sri Lanka in addressing its emerging middle-income country agenda. The

Second Health Sector Development Program (2nd HSDP) would be an important contributor to

all three sub-areas under the area 3 (Improving Living Standards and Social Inclusion) of the

Country Partnership Strategy. Thus, its higher level objective would be to enable the health

system to play its critical part in helping Sri Lanka actualize its aspirations of economic growth,

overall development and improved quality of life of all Sri Lankans.

1.2: Development Objectives of the 2nd

HSDP

The project development objective is to improve the public sector health system so as to respond

to the challenges facing it, especially regarding nutrition and NCDs.

The Project disbursement will be linked to Disbursement Linked Indicators (DLIs) identified

from the focus areas of the National Health Development Plan (NHDP); in close collaboration

with the MoH and the 9 Provincial Health Ministries.

1.3: Project Description

The IDA financing will consist of three components: (i) support to priority areas under the

national health development plan; (ii) results-based financing (RBF) pilot interventions on MCH

- related to millennium development goals 1c, 4 and 5. This component will be co-financed with

a matching grant from the Health Results Innovations Trust Fund (HRITF) and (iii) an

innovation and capacity-building fund which will support implementation of the NHDP with

funds earmarked for technical assistance, training, workshops, testing innovative ideas,

operational research, the proposed demographic and health survey, baseline and end line surveys

and other evaluative studies.

Component I: Support to Priority areas under the National Health Development Plan

(GOSL US$ 5,165 million, of which IDA contribution would be US$ 190 million for 5 years)

Component 1 of IDA financing will contribute to the GOSL’s NHDP. The IDA funds will be

comingled with GOSL funds, while the Bank’s technical engagement and monitoring would

focus on specific thematic areas – (i) addressing nutrition; (ii) improving prevention and control



of non-communicable diseases; (iii) addressing maternal and child health and communicable

diseases (iv) health system improvement measures - which are described below.

Thematic area one: Addressing Malnutrition

Under this thematic area, implementation of “1000 days” interventions with a focus on the

under-served areas will be further strengthened. The nutrition interventions will be specifically

targeted at (i) pregnant women (monitoring and promotion of adequate weight gain during

pregnancy; appropriate micro-nutrient (iron/folate and calcium) and food supplementation, better

monitoring of anemia during pregnancy in the third trimester (at 32 weeks) and deworming; (ii)

strengthening monitoring of low BMI mothers; and (iii) children up to 2 years of life focusing

on behavior change and communication related to breastfeeding, timely introduction of safe and

nutritionally adequate complementary foods, appropriate nutritional care for sick children and

hygiene practices; zinc supplementation during treatment/management of diarrhea; integrated

management of severe acute malnutrition through facility- and community-based interventions

and deworming. The NHDP also ensures improved targeting of these interventions to

underserved areas, estate communities and the urban poor. The use of community

groups/mobilizers will be piloted and encouraged for the implementation community-based

nutrition activities.

The GOSL/IDA resources will be utilized to improve the capacity of the human resource pool

engaged in nutrition interventions across all age groups of the community will be improved. This

would entail various forms of training, mentoring and supervision – to deliver effective and

appropriate nutrition interventions at facility and community levels. Enhancing the capacity of,

as well as empowering community organizations to plan, implement and monitor relevant

nutrition interventions will also be supported where necessary.

The GOSL/IDA resources will be utilized to establish an island-wide monitoring and evaluation

system and a nutrition surveillance (NS) system. The system will monitor the (i) implementation

of the key nutrition (1000 day) interventions; (ii) strengthen the utilization of NS reports for

decision making at national and divisional levels; (iii) link the surveillance data to the national

nutrition information system and to existing tools and systems of the government of Sri Lanka.

IDA credit funds release will be linked to the achievement of the following disbursement linked

indicator for the thematic area – addressing nutrition.

% of MCH clinics with an agreed package of equipment and supplies for monitoring

pregnant women (DLI)

In addition to the DLI for nutrition the following indicator/s relevant to nutrition will also be

monitored during the project period.

% of MOH areas with at least 5 health and nutrition community support groups

Nutrition related PDO indicator - needs to be added based on discussions during

Appraisal



Thematic area two: Improving prevention and control of Non-Communicable Diseases

The GOSL/IDA resources will be utilized to further improve the implementation of framework

convention for tobacco control (FCTC, the tobacco control act and support the introduction of

legislation for the control of indoor air pollution, pesticides and excessive alcohol, salt, sugar

and trans fat usage. Furthermore, using GOSL/IDA resources, mechanisms for increasing safety

awareness and supporting the establishment of safe communities will be encouraged. These

activities will be supported with the development of appropriate and targeted communication

strategies for prevention and control of chronic and acute NCDs.

Acute NCDs will be managed more effectively with the availability of fully functioning 24-hour

emergency treatment units (ETUs) at all levels of hospitals. The GOSL/IDA resources will be

utilized to have in place fully functional 24 hour ETUs at each of the identified hospitals at each

of the levels of care, according to accident and emergency policy, standards and guidelines that

would be finalized in the first year of the project’s implementation. It is expected that the ETUs

will manage acute and chronic NCDs and any other emergency medical / surgical situations

which would improve the quality of services provided to the patients and will also improve the

efficiency of hospital performance. In addition, under this component the GOSL will explore

options for providing pre-hospital services to the population which is essential to improve

outcomes of acute health situations.

The GOSL/IDA resources will also be utilized to establish at least one healthy life style center –

in each of the 325 MOH areas in Sri Lanka. These centers will be established at the primary care

hospital level and are expected to prevent/ delay the onset and promote healthy living to reduce

the burden of chronic NCDs (especially heart diseases, Diabetes Mellitus and early detection of

selected cancers (breast, cervix and oral cavity). Early screening of higher risk individuals,

referral of positive patients for care and health promotion for adopting healthy lifestyles and

regular follow up will be promoted in these centers. These activities are based on the national

guidelines for the screening, diagnosis and management of chronic NCDs in Sri Lanka.

In addition, GOSL/IDA resources will be utilized to expand the screening services and

strengthen the services available in hospitals to improve the quality of care provided for NCD

case management. The use of mobile health screening system for screening at workplaces

(informal and formal) and by further strengthening screening of out-patients attending all

primary and secondary care level hospitals. In addition, quality improvement (includes

infrastructure improvements) of the services provided at hospital clinics (long term) for the

management of the increasing number of diagnosed NCD patients will be strengthened. Within

hospitals, following a needs assessment, expansion of services including strengthening the

laboratory and other investigative services, ICU services, clinic facilities, and other ancillary

services will be supported with the development of master plans for larger facilities along with

the development of networks of health facilities. As appropriate NCD drugs are required for

improving prevention and control of NCDs at all levels of care, GOSL/IDA resources will be

utilized to improve drug quality assurance, drug logistics and distribution system related to NCD

drugs.



The GOSL / IDA resources will be utilized to establish at least one comprehensive rehabilitation

unit in the most advanced health facility in every province to strengthen the tertiary care services

in Sri Lanka. These units would be linked with a two-way referral arrangement for follow up

care along with appropriate facility strengthening of the lower level facility for providing long

term care. Furthermore, appropriate human resource development for these centers will be

supported.

The IDA credit funds release will be linked to the achievement of the following disbursement

linked indicators for the thematic area – addressing NCDs.

% of MOH areas with at least one healthy lifestyle center

% of centrally managed health facilities with ETUs for that level of facility based on

standard guidelines

% of provincially managed health facilities with ETUs for that level of facility based on

standard guidelines

In addition to the DLI for addressing non communicable diseases, the following indicator/s

relevant to NCDs will also be monitored during the project period.

% of persons (over 35 years) screened for selected NCDs at healthy lifestyle centers

% of provinces with at least one health facility providing rehabilitation services

% of regional drug stores and health facilities having one month’s buffer stock for 16

selected NCD drugs

Thematic area three: Addressing maternal and child health and communicable diseases

The NHDP plans to further improve the services provided for MCH and communicable disease

achievements of Sri Lanka. GOSL/IDA resources can be utilized to further improve the hospital

based services for mother and child care and also strengthen the priority communicable diseases

affecting the population. Some of these interventions include improving the prevention and

control of TB, Dengue, Rabies, Leptospirosis, HIV/AIDS.

The above mentioned activities will be planned and implemented utilizing the GOSL/ IDA

resources under the NHDP. IDA funds will not be linked to a DLI under this thematic area but

the following indicators will be monitored under the thematic area – addressing MCH and

Communicable diseases.

% of facilities providing Comprehensive Emergency Obstetric Care (CoEmOC) (will

need to be defined during Appraisal)

Case detection rate for Tuberculosis

Thematic area four: Health systems improvement

NHDP plans to modernize the HMIS, in line with the country’s overall vision of promoting e-

governance, information and communication technologies and turning Sri Lanka into a

“knowledge economy”. GOSL / IDA resources will be utilized to scale up relevant and useful on

going pilot e-initiatives based on the draft e-health policy and strategic plan for e-health in Sri

Lanka. In addition, resources will be utilized in converting the Indoor Morbidity and Mortality

Return (IMMR) which reports all in-patient information using a modified ICD 10 coding system



to an e-IMMR using the complete ICD 10 coding in secondary and tertiary hospitals managed by

central and provincial health teams.

The World Bank financed HSDP, during the period 2005 to 2010, had supported several

interventions aimed at improving health services quality in Sri Lanka. Additional GOSL/IDA

resources will be utilized to establish a national standard on laboratory accreditation for Sri

Lanka and other relevant accreditation standards, guidelines and policies where necessary. The

GOSL/IDA resources will help establish Quality Management Units (QMUs) in each of the

hospitals both centrally and provincially managed. The role of the QMU is to help

institutionalize use of clinical care guidelines and standards required to improve quality of

services. Some of these activities include establishing mechanisms for sample death audits,

morbidity and mortality analysis, premature death analysis, within 48 hour death analysis,

improving the service and clinical quality in laboratories, labor rooms, family planning services,

health care waste practices, and in piloting a responsive grievance mechanism for users of the

health system.

HCWM practices with regard to the following will be addressed using GOSL/IDA resources: (i)

development of annual HCWM plans of larger hospitals and consolidated district HCWM plans;

(ii) prioritizing a few of the larger hospitals in the country for further improving their health care

waste management practices; (iii) capacity building of the Environment and Occupational Health

unit (EOH) at the CMOH to take forward the overall planning and management of HCWM in the

country; and (iv) formalization of the draft national HCWM policy, by obtaining the required

approvals of it.

In addition to QMUs, the GOSL /IDA resources will be utilized to further strengthen the drug

quality assurance laboratory to expand its testing facilities for assessing quality of drugs prior to

distribution. Resources will also be utilized to strengthen the drug logistics and storage system to

plan for adequate buffer stocks of selected drugs and supplies at all levels of services.

The NHDP will support strengthening basic, in service and continuing medical education

programs to all levels of staff. The GOSL/IDA resources will be utilized to strengthen

expenditure management and internal controls in the sector by institutionalizing Financial

Management (FM) and procurement. Comprehensive capacity building program for health sector

staff at the central, provincial and sub-provincial levels will be developed and implemented.

Furthermore, the GOSL/IDA resources under the project will support strengthening the regional

and central training centers providing basic and in service training of all required human resource

categories.

The IDA credit funds release will be linked to the achievement of the following disbursement

linked indicators for the thematic area - system improvement.

% of fully functioning quality management Units (QMUs) in central MOH managed

secondary and tertiary level hospitals Base hospital and upwards)

% of fully functioning quality management Units (QMUs) in provincially managed

secondary and tertiary level hospitals Base hospital and upwards)

% of central MOH managed health facilities sending indoor morbidity data through e-

IMMR



% of provincially managed health facilities sending indoor morbidity data through e-

IMMR

% of the 6 monthly cash forecast (for non-salary recurring and capital expenditures)

released

In addition to the DLI indicator for health system improvement the following indicator/s relevant

to health systems improvement will also be monitored during the project period.

No of laboratories in health facilities that have been accredited using a national standard

% of training institutes managed by the Ministry of Health meeting national standards

No trained on relevant areas (training areas to be discussed)

% of NCB contracts awarded within the first nine months of the previous calendar year

Component II: Innovation and Capacity-Building Fund

This component is meant to support the implementation of innovations within the NHDP and

provide opportunities for capacity building. Funds would be earmarked for technical assistance

(includes the salaries and maintenance of a core team for project implementation and

monitoring), training, workshops, testing innovative ideas, operational research, the demographic

and health survey, baseline and end line surveys and other evaluative studies.

The fund would be accessible to all implementing teams which include the CMOH, PMOH,

MLGPC, MOFP and FC. The proposals / activities financed under this component will be

reviewed and approved by a committee established to monitor this fund. The committee would

be appointed by the Secretary Health in consultation with the World Bank. Criteria for selection

and approval will be defined and cleared by the World Bank before approving proposals

/activities under this component. An operations manual would be prepared prior to

implementation of this component. Approximately US $ 10 million will be allocated from the

IDA credit for the fund.

(Reference: Draft Project Appraisal Document, January 11, 2013)



1.4 Objectives of the framework and the intended audience

Projects and Programs financed with IDA resources need to comply with World Bank

Operational Policies. Therefore, components eligible for funding under the 2nd

HSDP will be

required to satisfy the World Bank‘s safeguard policies, in addition to conforming with

Environmental legislation of the Government of Sri Lanka (GOSL). The 2nd

HSDP is categorized

as Environment Category B and will trigger the safeguard policy on Environmental

Assessment (OP/BP 4.01).

When OP 4.01 is triggered the borrower is required to carry out an assessment of potential issues

triggered by the project/program and to prepare necessary mitigation plans. The 2nd

HSDP being

a sector support will supplement the national health budget and monitor performance in selected

strategic areas. As such, the exact activities funded by IDA resources may not be earmarked and

hence what is possible is to look at the key environmental issues in the health sector and come up

with a framework of actions to be supported during program implementation.

In the health sector, environmental issues creating adverse impacts vary widely in nature. Of

them Health Care Waste Management (HCWM) is considered to be one of the significant issues,

although some other important issues like food safety, occupational health and safety,

management of industrial carcinogens, indoor air pollution, etc. deserve due attention. Over the

program period, support will be provided to expand/improve the services of health care facilities

throughout the country. This is likely to generate more HCW, which in the absence of safe

management and disposal practices can greatly increase the risks to people and the environment

through exposure of infectious and hazardous substances contained in it. Secondly, the

environmental and health impacts related to unsafe disposal of waste water and sewage from

Health Care Facilities (HCFs) are considered to be significant warranting safe disposal options.

Apart from impacts of HCW, waste water and sewage, other environmental impacts directly

caused by program implementation are likely to be triggered by the construction of HCFs.

However, these are likely to be relatively small scale, spread in different locations of the country

and most likely confined to existing premises of the medical institutions and with localized

impacts.

The objective of this report is to present a framework for improving HCWM including waste

water and sewerage management in HCFs in the country. The policy and legislative framework

for HCWM in the country and related technical guidelines, evaluate HCWM practices, treatment

and disposal technologies in use, provide an update of the achievements and gaps in the

implementation of HCW systems (especially in view of the policy and national action plan

prepared in 2001), present level of compliance with legal requirements and the presentation of an

action plan for improving HCWM based on identified gaps. In addition, the report also provides

safeguard requirements for managing impacts from civil works construction under the 2nd

HSDP.



1.5: Structure of the report

The structure of the report is as follows.

Chapter

Focus

Chapter 1

Introduction to 2

nd HSDP

Objectives of the report

Chapter 2

Overview of the organization of the health

sector in the country

Policy and regulatory framework, related

guidelines and institutional set up for

standardizing HCWM

Chapter 3

HCW generation in the country

Overview of present HCW handling and

management practices

Treatment technologies and infrastructure

employed by various HCFs

Implementation progress of the policy and

national action plan prepared in 2001

Achievements, gaps and lessons learnt

Financial resources available for HCWM

Chapter 4

National Health Development Plan and HCWM

activities

Strategies and action plan for improving

HCWM in the next 5 years

Indicators to monitor performance and progress

in the identified priority areas

Time bound implementation plan and resource

requirements

Chapter 5

Institutional arrangements for implementing and

monitoring HCWM activities

Chapter 6

Technologies available for HCWM and

comparison of alternatives

Chapter 7

Safeguard requirements for civil works

Occupational health and safety guidelines

Environmental provisions for inclusion in the

contractor agreements



1.6 Sources of information

Situation Analysis and National Action Plan, 2001, Ministry of Health and Indigenous

Medicine

Draft Health Care Waste Management – National Guidelines, October 2001, Ministry of

Health and Indigenous Medicine

Draft National Policy for HCWM, October 2001, Ministry of Health and Indigenous

Medicine

Situation Analysis and Action Plan for Chest Clinics, STD Clinics and Blood Banks,

2002, Ministry of Health and Indigenous Medicine

Program of Action for Health Care Waste Management, November 2005, Health Sector

Development Project

Draft Report on Situation Analysis of the Waste Generation and Existing HCWM

Systems in Hospitals, October 2006, Health Sector Development Project

Infection Control Handbook, 2008, Ministry of Health

Caring for the Environment 2008-2012, 2008, Ministry of Environment and Natural

Resources

Health Budget 2012, Ministry of Health

National Health Development Plan 2013-2017, Ministry of Health

Draft Project Appraisal Document for the 2nd

Health Sector Development Program, June

2012, World Bank

Annual Health Bulletin, 2007, Ministry of Health

Guidance Manual for the Preparation of National Health Care Waste Management Plans

in Sub-Saharan Countries, World Health Organization and the Secretariat of the Basel

Convention

Health Care Waste Management in Sri Lanka, 2007, CORDAID

Guidelines for the Management of Scheduled Waste in Sri Lanka, 2009, Central

Environmental Authority

Rapid Assessment of HCWM practices in 40 Hospitals in the Country – carried out by

the Ministry of Health in support of the preparation of this report



Chapter 2: Existing policy/regulatory framework for HCWM in Sri Lanka

2.1 Overview of the organization of the Health sector in the country

In Sri Lanka, both public and private sectors provide health care services. The public health care

sector is larger and has a wide coverage that provides accessible care throughout the country. It

is estimated that the public sector provides health care for nearly 60% of the population and 95%

of the total in-patient care. It consists of a hospital based curative care system and a preventive

community health care system which are administered by the Ministry of Health and the

Provincial Health Services1.

Curative services

For curative services, the government has a well established referral system that functions

through an extensive network of HCFs situated across the country. As such, it has been estimated

that a majority of the population has easy access to free western type government health care

services within an average 4.8 km of a patient’s home2.

The network of HCFs comprises of, hierarchically, Peripheral Units (PU) at the village level,

District Hospitals at the district level, Base Hospitals which act as referral units with Medical,

Surgical, Paediatrics and Obstetrics and Gynaecology (OBG) specialties, District General

Hospitals in each district with specialties like ENT/Ophthalmology, Dermatology, Radiology

apart from Medical, Surgical/Paediatrics and OBG, Provincial General Hospitals in each

province and one National Hospital in Colombo which has all the specialties, and super

specialties, and which is the apex referral centre in the health system. In addition, there are

Teaching Hospitals attached to Medical Colleges with all the specialties. Table 1 provides details

of the different HCFs available and the total bed strength by district in 2010.

Preventive services

For preventive services, each Divisional Secretariat has a Medical Officer of Health (MOH) in

charge responsible for an average population of 60,000 people. The Medical Officers of Health

are assisted by Public Health Nursing Sisters (PHNSs), Supervisory Public Health Mid wives

(SPHMs), Supervisory Public Health Inspectors (SPHII), Public Health Inspectors (PHII) and

Public Health Mid Wives (PHMs) who are responsible for the Mother and Child Health

programme and the Environmental and Occupational Health programme including food safety.

In addition, preventive health care services are overseen at the district level by a Deputy

Provincial Director of Health Services (DPDHS) and at the provincial level by a Provincial

Director of Health Services (PDHS). At the national level, all health care services come under

the purview of the Director General of Health Services (DGHS).

1 Annual Health Bulletin, (2003), Ministry of Health




Private health care service sector

The private sector provides mainly curative care, which is estimated to be nearly 50% of the

outpatient care of the population and is largely concentrated in the urban and semi-urban areas3.

It consists of a number of large hospitals, private general practitioners, laboratories, blood banks,

and dental clinics.

4


4 Annual Health Budget, 2012, Ministry of Health

Table 1 – Health Institutions and bed strength by District



Administratively, the national health system which comprises of a network of curative and

preventive health care facilities as described above is divided into three levels – Central,

provincial and district. While the MoH administers the major hospital categories such as the

National Hospital, Teaching Hospitals and the Central Blood Bank at the central level, the

provincial services are administered through the Provincial Directors of Health Services (PDHS)

offices which in turn deliver services through Provincial General Hospitals, General Hospitals,

Base Hospitals, District General Hospitals and Peripheral Units. They generate all sorts of HCW

in significant quantities. Rural Hospitals, Central Dispensaries and Maternity Homes come under

the direct supervision of the MOH units. They do not have surgery units and mostly generate

only general medical wastes and sharps.

Health Administration HCF category Type of Medical

Activity

Type of HCW

generated

Central level

Ministry of Health

Director General of

Health Services

National Hospital

Teaching Hospitals

Central blood Bank

All kinds of medical

care activity, including

specialized treatment

and surgery

All categories of

medical wastes are

generated including

specific medical waste

in some facilities such

as cytotoxic waste

Provincial Level

Provincial Ministry of

Health

Provincial Secretary

Provincial Director

of HS

Provincial General

Hospitals

Provincial Blood

Banks

General Hospitals

Base Hospitals

All kinds of medical

activity including

surgery

Same as above

District Level

Deputy Provincial

Director of HS

Divisional Director

or MOH

District General

Hospitals

Regional Blood

Banks

Peripheral Units

Rural Hospitals

Maternity Homes and

Central Dispensaries

Central Dispensaries

(Primary Care Units)

Curative health care and

only small surgery that

do not require general

anesthesia

Mainly outpatients

Primary health care

including vaccinations.

Same as Base

hospitals but small

quantities

Disposable syringes in

small quantities and

small quantities of

general medical waste

Table 2 - Overview of the administration of Health Services and classification of medical

institutes5

5 Adopted from the Situation Analysis and National Action Plan, 2001, Ministry of Health



2.2: Health care waste management in Sri Lanka

2.2.1: General Background

With HCW gaining greater importance as a significant public health and environmental risk, the

GOSL has over the last decade or so, taken several positive steps to set up better standards of

HCWM in the country and to consider HCWM as an integral part of the delivery of health care

services. The background to this was paved when between 1994 and 1997 the Colombo

Environmental Improvement Project published findings of a study on solid waste management in

the city of Colombo, which indicated that prevailing HCW disposal practices posed a huge threat

to the public and hence needed drastic improvements. Subsequently, when the Colombo

Municipality Council (CMC) defined a 25 year plan to treat municipal waste in a composting

plan with private sector participation, it stipulated that no medical waste should be present in the

waste collected. As a result, an urgent need arose to find a satisfactory alternative solution for the

disposal of HCW generated from the hospitals in the Greater Colombo Area (GCA).

In 2000, the GOSL requested external support to assist the MoH to develop an integrated Health

Care Waste Management system for the country. As a result, within the framework of the

HIV/AIDS Prevention Program initiated by the GOSL and funded by the World Bank, a three

phased program was launched under the direct supervision of the National Steering Committee

for Clinical Waste Management (NCCWM). Initially, an assessment was carried out in analyzing

HCWM practices in HCFs around the country with a specific focus on hospitals located in the

GCA. In the subsequent phase, National Guidelines and the National Policy for HCWM were

drafted and a National Action Plan was prepared aimed at gradually expanding improved

HCWM practices throughout the country in a systematic way over a period of 5 years including a

specific system for the hospitals in the GCA. It was intended that with the implementation

framework in place, the final phase would to be dedicated to implementation of the

recommendations provided in the first two phases. In addition, under the HIV/AIDS Prevention

Project, it was also determined that specific and immediate action needed to be taken to reduce

biological hazards associated with HCW generated from chest clinics, STD clinics and the blood

banks within the country6. As such, a situation analysis and an action plan were prepared

targeting this specific sector of the health services. Equipment was supplied and training

programmes were conducted.

Over the past several years the MoH has successfully implemented a number of programs in

support of the key recommendations made above to improve HCWM in the country. A system to

treat all infectious waste generated from public hospitals within the GCA, which was estimated

to be about 25% of the total generated in 2001, was commissioned and is currently in operation..

6 Situation Analysis and National Action Plan, 2001, Ministry of Health

Situation Analysis and Action Plan for Chest Clinics, STD Clinics and Blood Banks, 2002, Ministry of Health



Several more treatment equipment has been commissioned in various major HCFs across the

country with external as well as government funding support. Despite such achievements (which

are highlighted in greater detail later in this chapter as well as the next), safety from HCW is still

a challenge for Sri Lanka given its total national generation and the resources available for

treatment/disposal. Addressing these challenges in order to have a standardized HCWM system

covering the whole island with sustainable solutions that suit local requirements and conditions

would certainly require current efforts to be stepped up both qualitatively and quantitatively.

The package of enforcement and backstopping documents which were developed by the MOH

between years 2001–2002, referred to above, basically form the implementation framework for

HCWM in the country. Although a decade has passed, these documents still provide a sound

basis on which better HCW planning can be enforced and hence should be strongly considered in

deciding the way forward for future HCWM activities/programs. The sections below provide

greater detail of the policy and legislative framework.

2.3 Existing health care waste management framework in the country

2.3.1: National Policy

Policies, guidelines, procedures and codes of practice are essential to support any health care

waste management system. In 2001, the Government of Sri Lanka drafted a comprehensive

national policy on HCWM. It was divided into three main sections:

General considerations on HCWM and the institutional mechanism for policy

implementation that should be set up at national level.

Provisions for the safe management of HCW in medical Institutions, including

regulations and HCWM plans.

Provisions for the implementation of and the monitoring of HCWM plans at national and

provincial levels including legislation, provision of human and financial resources,

training and awareness and participation of private sector7.

Some salient features of the draft policy are discussed below.

The draft National Policy for Healthcare Waste Management states that all healthcare

waste generated by the medical institutions of the public and private sector must be safely

handled and disposed of. It states that every hospital is legally responsible for the proper

management of waste that it generates until its final disposal and considers HCW as an

integral part of hospital hygiene and infection control. It refers to the legal responsibilities

of HCFs under the National Environment Act (NEA) and other regulatory needs, internal

7 Draft National Policy on Health Care Waste Management, 2001, Ministry of Health



hospital rules etc for creating the legal and regulatory framework for HCWM at the

national, provincial and institutional levels.

Another important feature of the draft policy is that it requires major hospitals to prepare

specific HCWM plans outlining needs, objectives, strategies and procedures for

approved management and disposal of HCW and timeframe for implementation and

submit to Central or Provincial Health Services for validation and support. At the

provincial level, the draft policy requires PHS to set up annual Provincial and District

HCWM plans presenting the strategy for HCM that should be developed at the regional

level. This plan shall compile all the HCWM plans of the HCFs they are responsible and

approved by the Central Health Services before implementation.

The policy recommends specific budget lines to be developed relating to hospital hygiene

and HCW management in the National Accountancy of the Health System in order to

ensure sufficient human and financial resources are allocated to implement the HCWM

plans in medical institutions.

It also states that policy implementation needs to be monitored on the basis of the specific

objectives defined in the National Action Plan (the plan developed to implement the

policy country wide - see section below) and that institutionally, the National Steering

Committee on Clinical Waste Management will be responsible for the overall monitoring

and evaluation and the PHS for the implementation of monitoring procedures in HCFs

within their area of jurisdiction.

Approved HCWM practices, equipment for treatment and disposal, training and

awareness, involvement of civil society, private sector participation are some of the other

key aspects reviewed in the draft policy.

Though the draft policy was submitted to the Cabinet of Ministers and referred to different

agencies for their feedback, official approval was not granted, because before the process could

be completed a cabinet reshuffle took place and the process was interrupted and remains as it is

up to date.

2.3.2: National Guidelines

In 2001, the GOSL drafted national guidelines for HCWM with an aim to providing a better

understanding of the fundamentals of HCWM planning and directing HCFs in setting necessary

procedures and standards to comply with policy and legislative requirements. These were drafted

in a form that attempts to provide fundamental elements that should be integrated into future

legislation specific to HCW. Although guidelines were reviewed by the National Committee for

Clinical Waste Management as well as the MoH, it did not receive formal endorsement by the

government.



The draft national guidelines contained both practical and conceptual information on HCWM

covering four main sections:

Definition and categorization of HCW including potential harmful effects that can result

from its harmful management

Procedures for segregation, packaging, labeling, collection, storage, transportation and

disposal of HCW that should be applied and followed in all HCFs in the country and for

selection of appropriate treatment and disposal technologies and facilities

Instructions for the implementation of HCWM plans including detail description of

duties and responsibilities of health care provider at various levels

Instruction for personnel of Central and Provincial Health Services that should deal with

HCWM to ensure smooth implementation of the guidelines and to set up regular

monitoring mechanisms

In 2007, concise guidelines for HCWM were prepared under the Hospital Efficiency and Quality

component of the Sri Lanka Health Sector Development Project based on the detailed draft

guidelines prepared in 2001. The concise guidelines which mainly contain sections in waste

categorization and HCWM procedures have been formally adopted and incorporated into the

Handbook of Infection Control.

2.3.3: Code of Hygiene

Management of HCW is an integral part of hospital hygiene and infection control that must be

reinforced with internal rules. As such the GOSL developed a Code of Hygiene for STD/TB

clinics in 2008. The national code of hygiene contains HCWM procedures and is seen as part of

an overall set of actions to control the hygiene conditions within the hospital. It sets out duties

and responsibilities of medical and non-medical staff regarding hygiene procedures to be

applied, recommended practices to maintain high level of hygiene and on-going management

and managerial activities to be carried out in the hospital.

The code of practice has to be implemented along with the HCWM guidelines.

2.3.4: National Color code

Separating different waste streams based on the type of treatment and disposal practices is a key

step in the HCW management cycle. To implement a uniform system of segregation throughout

the country, the MoH developed a National colour code for health care waste, dated March 2006

and circulated to all the government health care institutions, which is presently being

implemented. With a view to streamlining the collection of waste, technical specifications for bags



and bins to be used for different waste types were also made available for all hospitals. The national

colour code identifies 7 specific categories.

Colour Category Contents

Yellow Infectious Cultures or stocks from microbiology, tissues

from surgeries/autopsies, material or

equipment in contact with blood or body

fluids soiled linen, dialysis equipments such

as tubing and filters.

Yellow with red stripes Sharp waste Sharps, needles and IV sets contaminated

with body fluids

Black General waste General or municipal waste that is

uncontaminated

Green Biodegradable

waste

Garden, kitchen and food waste

Red Glass waste Uncontaminated bottles, pieces of glass

Blue Paper waste Paper, cardboard and office stationary

Orange Plastic waste Uncontaminated plastic medicine bottles,

saline bottles without IV sets, plastic bags

Table 3 – National Colour Code for segregation of HCW

2.3.5: Legislation and regulation

National legislation is the backbone for planning HCWM in any country and provides the legal

basis for establishing controls and permits. It is vital in making medical and non medical staff in

hospitals for being responsible at their own level and in securing the HCW disposal process.

In Sri Lanka the NEA No 47 of 1980 and its amendments (No 56 1988 and No 53 of 2000) are

the basic legal documents that regulate hazardous waste and consequently HCWM in the

country. Although it’s a comprehensive document and specific regulations on hazardous waste

has been in force since 2002, medical institutions were not included in the list of

institutions/activities for which an Environmental Protection License (EPL) must be requested

from the Central Environmental Authority (CEA) until 2008.

The comprehensive analysis of the situation regarding HCWM in the country conducted in 2001

highlighted that the lack of a legislative framework for HCWM as one of the main shortcomings

and recommended that the government consolidated existing legislation by editing a specific

regulatory document most appropriate for the management and disposal of HCW. In 2008, the

GOSL consolidated the NEA by incorporating medical institutions in the list of

institutions/activities that require an EPL.



Part II of the National Environmental (Protection & Quality) regulation No. 01 of 2008

includes “Health care service centers generating infectious wastes, including medical

laboratories and research centers” as a prescribed activity that requires a license.

Schedule VIII lists Healthcare waste as a scheduled waste from specific sources that no

person shall generate, collect, transport, store, recover, recycle or dispose except under

the licence issued by the Authority and in accordance with standards and other criteria as

may be specified by the Authority.

Source - Guidelines for the management of scheduled waste in Sri Lanka (2009)

Accordingly, every HCF is legally responsible for the proper management of HCW from the

point of generation until its final disposal to ensure minimum environmental and public health

impacts.

However, the regulations on HCWM classify all categories of HCW and emphasize the

importance of safe disposal of all categories of hazardous waste.

2.3.6: Other sectoral strategies addressing HCW

Caring for the Environment (CFE) 2008-2012, which is the second successive sectoral

environmental action plan prepared by the Ministry of Environment and Natural Resources to

implement the National Environmental Policy of 2003, recognizes HCWM as a significant

public health issue in the country that needs intervention, The CFE, which has been focused on 6

key sectors and addresses clinical waste under the waste management sector, has been prepared



with close consultation with the relevant sector agencies including the MoH. With regard to

clinical waste, the CFE broadly identifies the related public health and environmental issues and

refers to the draft national policy and other initiatives that were planned and on-going at the time

with the support of the MoH. Given below in the table are the key strategic actions

recommended in the CFE in order to achieve better institutional and administrative mechanism

for HCWM.

Source – Caring for the Environment 2008-2012

2.3.7: Recommended institutional and monitoring framework

The institutional mechanism for implementing the national policy was broadly envisaged under

three levels of management:

At the central level, co-ordination and development of strategies and mechanisms to

implement policy commitments, in accordance with national requirements, has been

vested with the NCCWM. In addition, development of training and capacity building

packages, training implementation supervision, setting up of HCW monitoring protocols,

overall monitoring and evaluation has been assigned to the NCCWM. The Central Health

Services are responsible for technically backstopping HCFs under its management

purview.

At the provincial level, implementation of the policy has been vested with the Provincial

Councils. In particular the PHS is responsible for setting up provincial HCWM plans,

synthesized from individual hospital HCWM plans coming under its area of jurisdiction,

development of financial resources and for the implementation of HCW

monitoring/auditing procedures.

At the local level, setting up of HCWM plans that outline needs, objectives, strategies,

procedures and timeframes for medical institutions has been vested with the hospital

management.

2.3.7.1 National Committee for Clinical Waste Management (NCCWM). NCCWM is chaired

by the Secretary of MoH with representatives of Sri Lanka Medical Association, CEA, Ministry

of Environment, Ministry of Provincial Councils and Local Governments, MoH relevant staff,



Directors of HCFs. In the past during the first Health Sector Development Project, the committee

met regularly, presently the committee in its full scale is only meeting to resolve specific issues.

However, many of the problems related to clinical waste management are resolved at the DDG

level with the participation of the relevant institution including the regulator. In order to ensure

the national policy is revisited and submitted for final approval and adoption, it would be

necessary for the NCCWM to meet frequently in the near future.

2.3.7.2 Environmental and Occupational Health Unit (E&OH). The Unit’s responsibilities

broadly are as follows: development of policies, guidelines, strategies, Action Plans etc., training

(including TOT) health staff on Environmental and occupational Health issues, provide

Technical Guidance on the same, Inter Sectoral Collaboration at National level in improving

Environmental and Occupational Health Conditions of the Country, co-ordination and conduct

national events in relation to environmental and occupational health and co-ordinate / Supervise

Environmental and occupational Health projects at National, Provincial and District Level. The

unit is headed by a Director and currently has a Deputy Director, Technical experts including

Medical Consultants and other supporting staff who work in areas such as occupational health,

environmental health and food safety. In the absence of the HCWM cell proposed as part the

policy, it has been proposed that E&OH unit will be mandated and capacity built to develop

standards, guidelines, facilitate HCWM activities in health institutions and monitor their

implementation.



Chapter 3: Review of the present scenario of HCWM in Sri Lanka

3.1: Types of HCW generated

The WHO classifies hazardous waste into the following categories. The major hospitals, in

which all the ranges of medical activities are performed, produce the following HCW categories

Infectious waste, suspected to contain pathogens (bacteria, viruses, parasites, or fungi) in

sufficient concentration or quantity to cause disease in susceptible hosts.

Pathological waste, consisting of tissues, organs, body parts, human fetuses and animal

carcasses, blood, and body fluids.

Sharps, items that could cause cuts or puncture wounds, including needles, hypodermic

needles, scalpel and other blades, knives, infusion sets, saws, broken glass, and nails.

Whether or not they are infected, such items are usually considered as hazardous health

care waste.

Pharmaceutical waste, includes expired, unused, spilt, and contaminated pharmaceutical

products, drugs, vaccines, and sera that are no longer required and need to be disposed off

appropriately. It also includes discarded items used in the handling of pharmaceuticals,

such as bottles or boxes with residues, gloves, masks, connecting tubing, and drug vials.

Genotoxic waste, includes certain cytotoxic drugs, vomit, urine, or faeces from patients

treated with cytotoxic drugs, chemicals, and radioactive material. Cytotoxic or

antineoplastic drugs are the principal substance in this category. These drugs are used in

highly specialized units.

Chemical waste, consists of discarded solid, liquid, and gaseous chemicals, used for

diagnostic and experimental work and for cleaning, housekeeping, and disinfecting

procedures. These are considered hazardous if at least one of following properties is

present; toxic, corrosive (pH<2 or pH>12), flammable, reactive (explosive, water-

reactive, shock sensitive) or genotoxic.

Waste with high content of heavy metals.

Pressurized containers. Many types of gases used in health care are often stored in

pressurized cylinders, cartridges, and aerosol cans. Many of these, once empty or of no

further use (although they may still contain residues), must be disposed off.

Radioactive waste.

In addition to the above, waste generated in hospitals include non-risk HCW or domestic waste

that include waste that are not contaminated with infectious or pathogenic agents and includes

food residues, paper, cardboard, plastic wrappings.,



3.2: Baseline information on HCW production and management in different HCFs

A comprehensive national survey to measure types and related quantities of HCW generated in

different HCFs across the country has never been undertaken in Sri Lanka due to practical

reasons. However, various research papers and situation analysis have attempted to estimate the

national generation using different calculations and methodologies. Of these, the most

comprehensive baseline values estimated on HCW quantities generated in Sri Lanka so far is the

situation analysis undertaken by the MoH in 2001 with funding support from the World Bank.

The following section attempts to furnish and discuss findings on HCW generation quoted in

various surveys and investigations reported in the last decade or so including the rapid survey

conducted in a sample of major HCFs in support of the preparation of this framework. In general

a wide variation in the reported rates of HCW generation is observed in the various sources

reviewed. This is primarily due to the fact that different methodologies, calculations and

observations have been used in different investigations. Therefore, it is difficult to carry out a

proper comparative analysis or to establish patterns of HCW production associated with different

levels of HCFs over time.

1. Draft Report on Situation Analysis and National Action Plan, 2001

The following table has been extracted from the draft SA and NAP, and presents the results of an

initial assessment undertaken in the various medical institutes in support of the preparation of the

NAP in 2001. As stated earlier, this was not a national survey but a comprehensive calculation

using direct measurement methods in a sample of different levels of HCFs. The methodology

used for the estimation of HCW quantities has been based on the number of containers used for

medical waste collection during a defined period of time, subjected to volume adjustments based

on a filling rate used for each category of container and finally adjusted applying a volumetric

mass ratio according to the type of waste thrown into the container and their humidity rates.

District TH PH BH DH PU RH Total ton/day HCW %

No of Beds Non-risk Hazardous

Colombo 9436 571 226 302 22 11.84 3.28 26.8%

Gampaha 2259 1212 777 137 139 4.15 1.28 10.5%

Kandy 2293 586 842 364 755 2.98 0.91 7.5%

Kurunegala 1123 528 1421 578 212 2.28 0.76 6.2%

Galle 1592 911 340 95 2.45 0.74 6.0%

Anuradhapura 1052 524 392 611 2.31 0.63 5.2%

Ratnapura 957 465 779 278 161 1.73 0.53 4.4%

Badulla 859 346 848 35 326 1.89 0.53 4.3%

Kalutara 666 716 605 189 159 1.50 0.48 3.9%

Jaffna 927 241 413 265 59 1.36 0.41 3.4%

Matara 897 580 250 222 1.24 0.34 2.8%

Kegalle 613 921 57 207 0.69 0.29 2.4%

Matale 670 229 207 133 0.63 0.28 2.3%



District TH PH BH DH PU RH Total ton/day HCW %

No of Beds Non-risk Hazardous

Puttalam 668 434 183 127 0.55 0.24 2.0%

Batticaloa 618 394 60 36 0.91 0.26 2.1%

Ampara 765 485 135 54 0.48 0.21 1.7%

Polonnaruwa 405 256 232 186 0.35 0.16 1.3%

Nuwara Eliya 237 1050 81 138 0.38 0.16 1.3%

Hambantota 303 586 219 219 0.34 0.16 1.3%

Moneragala 256 693 20 161 0.37 0.16 1.3%

Trincomalee 337 247 140 110 0.34 0.15 1.2%

Vavuniya 193 48 0.25 0.11 0.9%

Mullaitivu 110 135 0.14 0.07 0.6%

Mannar 180 90 31 0.09 0.04 0.3%

Killinochchi 125 67 0.06 0.04 0.3%

Safe Margin (15%) 5.9 1.8

National Daily Production (tons/day) 45.22 14.06

Table 4 - Production of non-risk and hazardous HCW per district in the year 2001.

The Situation Analysis estimated overall production of hazardous HCW at the national level to

be about 15 tons/day. As can be noted in the table above, important disparities in waste

generation were highlighted between districts with Colombo responsible approximately for 25%

of the generation. In Colombo, it was found that HCW generation is concentrated within the

Greater Colombo Area with an estimated 4.2 tons/day (including private hospitals) justifying the

fact that a specific solution had to be found for the district. In addition, 30%of the national

estimate of HCW generation came from Gampaha, Kandy, Kurunegala, Galle and Anuradhapura

and were recommended as priority districts for the application of the NAP.

Institution Average Production Kg per bed per day

Non-risk HCW Hazardous HCW Sharps

Teaching Hospitals 1.38 0.37 0.02

Provincial Hospitals 1.52 0.36 0.01

Base Hospitals 0.75 0.32 <0.01

District Hospitals 0.5 0.20

Peripheral Units 0.5 0.20

Rural Hospitals <0.15 <0.10

Private institutions

(Colombo)

1.5 0.28 0.01

Table 5 - Average production of HCW in different categories of HCFs. (2001) The figures do

not include production of blood and anatomical waste due to their specific disposal.

2. Caring for the Environment 2008-2012

The national strategy and action plan for the implementation of the Environmental Policy, Caring

for the Environment 2008-2012, reports that a study conducted jointly by the MENR, CEA and

the BOI in 2003 on Hazardous Waste Management estimated clinical waste generated to be

5,643.8 tons per year which is in line with the daily generation estimated by the SA in 2001.



It also presents the following estimates relating to daily generation of HCW in different

categories of hospitals as indicated in the table below. The data has been sourced from an article

published in the Ceylon Medical Journal in September 2004 which uses international daily waste

generation rates from high income countries as a comparative scale to estimate HCW generated

in Sri Lanka. The study does not include the private sector hospitals and assumes that its

exclusion will compensate for the over-estimation that would result in using data from high-

income countries.

According to the study, estimates from global arena suggests that the University hospitals

generate higher quantities of healthcare waste at 4.1-8.7 kg/bed/day and that General hospitals,

district hospitals and primary healthcare units generate much lower quantities viz. 2.1-4.2

kg/bed/day, 0.5-1.8 kg/bed/day, and 0.05-0.2 kg/bed/day, respectively. Using these rates and the

bed capacities in year 2000, the daily HCW generation in the government sector hospitals of Sri

Lanka has been given as below.

Hospital category No. of

hospitals

Total number of

beds

Estimated daily waste generation

(kg/day)

Lower estimate Upper

estimate

University /Teaching

hospitals

15 14,659 60,102 127,533

General/Provincial

hospitals

6 4,966 10,429 20,857

Base hospitals 36 9,865 4,933 17.757

Primary healthcare units*

(DH, PU, RH, MH and CD)

868 23,212 1,161 4,624

Total 925 52,702 76,624 170,790

Table 6 -The daily generation of healthcare waste in government-owned hospitals in Sri Lanka,

calculated using bed capacities in year 2000.

According to this analysis the total HCW produced by listed government sector hospitals is

between 76,624 and 170,790 Kg daily. Out of the total healthcare waste generated, the WHO

estimates that only 10-25% falls into the hazardous category. In line with this, the estimated

daily hazardous waste generation in Sri Lanka has been estimated as given in the table below.

Total Health Care

Waste (kg/day)

Hazardous waste (Kg/day)

At 10% of total HCW At 25% of total HCW

Lower estimate 76,623 7,662 19,155

Upper estimate 170,789 17,078 42,697

Table 7 - Estimates of hazardous waste generation in government hospitals of Sri Lanka in 2000



Even at the lower estimate of 10% of total healthcare waste being hazardous, the figure is

significantly higher than what has been reported in the study conducted by the MENR on

hazardous waste generation (2003) but significantly lower than the figure reported in the

Situation Analysis undertaken by the MoH (2001).

3. Situation analysis in a selected district of the Southern Province

In 2006, the University of Ruhuna carried out a situation analysis in the Galle District of the

Southern Province, with funding from the World Bank supported Health Sector Development

Project (HSDP), in order to complete a needs assessment and subsequently a prioritized action

plan for HCWM for the district. This activity was started as a pilot project under HSDP in order

to implement HCWM island wide. During the study 29 hospitals of different categories in the

district were investigated using a survey questionnaire and site visits supported by discussions

with hospital staff and quantities of HCW generated were calculated. The table below present the

results of a sample of hospitals investigated for which detailed results were presented in the

report.

Name of Hospital Bed

Strength

Total waste

generation

(Kg/day)

Non-risk

Waste

(Kg/day)

Hazardous

Waste 8

(Kg/day)

Total Waste

Generation

(Kg/bed/day)

Hazardous

Waste

Generation

(Kg/bed/day)

Peripheral Units

Induruwa 33 14.95 11.96 2.99 0.45 0.09

District Hospitals

Udugama 148 177.5 166.85 10.65 1.19 0.07

Unawatuna 68 40.4 39.18 1.21 0.59 0.02

Baddegama 98 30.2 21.14 9.06 0.31 0.09

Base Hospitals

Balapitiya 275 681.7 613.53 68.17 2.4 0.25

Elpitiya 171 134.6 122.48 12.11 0.79 0.07

Hiniduma 102 140.5 139.09 1.4 1.38 0.01

Teaching Hospitals

Karapitya 1410 1559 1057.5 352.5 1.11 0.25

Mahamodara 406 442.9 252.45 190.44 1.09 0.47

Table 8 – Quantities of HCW generation in selected HCFs in the Galle District in 2006

According to the analysis above, the two teaching hospitals in the district produce hazardous

waste in the range of 0.25-0.47 kg/bed/day which is close to the average production rate of 0.37

kg/bed/day reported in the situation analysis report of 2001. However, the rates reported for Base

Hospitals, District Hospitals and Peripheral Units show a significant variation from the average

figures reported in the situation analysis report in 2001.

8 Mainly sharps and infectious waste



4. Rapid assessment of HCW management in a sample of HCFs across the country

conducted by the MoH in 2011.

In November 2011 the MoH conducted a rapid assessment of a selected sample of medical

institutions belonging to major HCFs in order to briefly assess the current levels of waste

generation and HCWM practices employed using a survey questionnaire. The questionnaire is

attached as Annex 1. Out of 40 hospitals targeted, 35 responded. Feedback on estimated waste

quantities in different waste categories reported by the hospital authorities has been summarized

in the table below.



Name Bed

Strength

Bed

Occupancy

rate

Quantity of hazardous solid waste generated

Infectious

(Kg)

Sharps

(Kg)

Anatomical

(Kg)

Chemical

(l)

Radioactive

(l)

Cytotoxic

(Kg)

Pharmaceutical

(Kg)

Teaching Hospitals

1. 1

1

1

National Hospital of

Sri Lanka

3300 82% 500 100 25 2

2 Castle Street

Hospital for Women

485 89% 160

9 7.5

3 Lady Ridgeway 901 78% 140 15

4 Colombo South 1093 83% 200

100 50

5 Peradeniya 954 72% 125

50 0.6

6 De Soyza Maternity

Hospital

343 87% 100

5

7 National Cancer

Institute

876 113% 177 74 1000

8 Karapitiya 1606 85% 450

30

9 Chest Hospital 671 80% 80 6 5

10 Sirimavo

Bandarnaike CH

115 89% 10

5

11 Jaffna 1228 90% 1000

150 1800

12 Kurunegala 1650 87% 2000

79

13 National Institute of

Mental Health

1514 63% 13

2

14 Sri Jayawardenapura

G H

1046 66% 100

15

15 Kandy 2286 81% 470

71 60 600

16 Mahamodara –

Galle

252 95% 55

4



Table 9 – Quantities of hazardous HCW generated in selected hospitals in the country (results of the rapid assessment done in 2011)

17 Colombo North 1405 90% 120 24

18 Kegalle

746 83% 327 76

19 Infectious Diseases

Hospital

200 56% 10

1

District General Hospitals

20 Gampaha 708 74% 90

10

21 Rehabilitation

Hospital _ Ragama

259 72% 20

4

22 Kalutara 300 83% 300

10

23 Ratnapura 1010 78% 1000

50 30

24 Badualla 1375 78% 1500

75 10

25 Ampara 530 80% 200

50

26 Negambo 676 75% 400

300

27 Nuwara eliya

427 90% 50 5

28 Nawalapitiya 526 69% 30

12

29 Trincomalee

435 70% 62

7

30 Polonnaruwa

747 72% 130

13

31 Matale 737 60% 250 10

Base Hospitals

32 Gampola 352 83% 25

10

33 Teldeniya 87 50% 05 0.5

34 Kantale 231 43% 20 10

35 Dehiattakandiya 135 100% 50 1



It is difficult to calculate the daily average production of hazardous HCW per medical institution

from the results above as the information is not complete. Most hospitals have provided only

estimated quantities for infectious waste and sharps generated while other types of wastes are not

properly accounted for. With regard to infectious and sharp wastes, the daily average production

indicates a wide variation even within the same category of hospital. For example, for infectious

waste the values range from 0.05 – 0.8 kg per bed for Teaching Hospitals, 0.05 to 1 kg/bed for

District General Hospitals and 0.02 to 0.37 kg/bed for Base Hospitals. The lowest generation of

infectious waste for Teaching Hospitals is recorded from the Infectious Diseases Hospital.

Similarly, the daily average production of sharp waste range from 0.008 to 0.1 kg/bed for

Teaching Hospitals (as opposed to 0.02 calculated in the SA, 2001), 0.03 to .0.4 kg/bed for

District General Hospitals and 0.005 to 0.04 kg/bed for Base Hospitals.

A proper estimation of the quantities of HCW produced should be made over a period of time to

arrive at average figures while taking into account potential slack periods or other unusual

circumstances that may cause significant variations in the waste quantities. While this type of

rapid surveys have number of limitations, it is doubtful if hospitals possess accurate data with

regard to HCW generation.

Observations

Reasonably accurate data and information on waste production and waste management practices

are essential for planning an effective waste management programme. As such, it is important for

medical institutions to properly record current levels of waste production and document waste

management practices as it forms the basis for formulating a suitable HCWM strategy for the

institution and consequently at the regional and national levels. As mentioned earlier, although

there have been various attempts to estimate the national HCW generation in the last decade or

so, as outlined above, of which the situation analysis conducted in 2001 could be considered as

the best estimate, no comprehensive national survey has been undertaken.

As can be seen from the above, even the various attempts made so far to estimate baseline HCW

generation levels over time show wide variations which makes it difficult to carry out a

comparative analysis over time or to project future levels based on established historical patterns.

According to yet another study conducted by the AIT on HCWM in South Asia in 2008, medical

waste generation in Sri Lanka was presented as 0.36Kg/bed/day9. This figure is in line with the

average production of medical waste reported for the major HCF under the Situation Analysis

(2001). Using this rate, assuming there has been no change in the demand for health services and

given the total bed strength of 69,501, the current level of hazardous HCW production in the

state sector hospitals would be around 25 tons per day. However, this is a very rough estimate

(on the upper side) which does not take into account the various factors that would influence the

total quantity of hazardous waste generated such as the size and functions of different HCFs

9 Visvanathan, C., 2008, Medical Waste Management in Asia, Asian Institute of Technology



(smaller facilities generate small quantities of hazardous wastes), occupancy rates, the increased

quality of segregation in the larger facilities and the consequent reduction of infectious waste etc.

3.3: Characterization of HCWM in the country

The handling of health-care waste is critical in minimizing health risks to workers who handle

HCW, general population and the deleterious impacts to the environment. As such,

implementation of safe HCWM procedures aimed at minimizing potential risks should be

practiced at every stage of the waste management cycle starting from segregation and

identification of hazardous and non-risk HCW, packaging, storage, treatment and disposal. The

rapid assessment conducted by the MoH in 2011 investigated some activities relating to the

handling of HCW in the selected HCFs surveyed. Presented here below is a general picture

obtained from the survey outcome as well as information available with the MoH.

Description Responses

Yes No No Response

Segregation of waste according to national

colour code

35 None None

Waste collection and on-site transportation 35 None None

Waste storage 35 None None

Waste Storage Space 30

(2 not

satisfactory)

4 1

Off-site transportation 1

Waste treatment 24

8

Open

burning

1

Waste disposal No clear response

Table 10: Current practices in handling HCW in 33 major hospitals evaluated in 2012.

The table below provides a narrative to the figures presented above.

Description Remarks

Segregation The survey responses show that there is a good attempt in

medical institutions at all levels to segregate waste at the

source according to the national colour code. This is a very

positive aspect of the current HCWM practices which should

be maintained and reinforced as this is the starting point in an

effective waste management system and helps to reduce the

cost of final disposal that must be borne by the HCFs.

Waste Collection Generally, the handling of infectious waste at source by

doctors, nurses and para-medical staff is relatively acceptable,

partly because generators are trained personnel who

understand potential risks involved. It is the collection beyond

ward level that has a relatively higher possibility of causing

injury or infection. Only one hospital has shredders that can



destroy the used syringes at the treatment site. Shredding is

generally undertaken after collection and before final disposal.

On-site transportation is mainly done by hand carts and

trolleys.

On-site storage Most of the hospitals evaluated have dedicated space for on-

site storage of HCW excepting 4. However, standards of

hygiene of these storage rooms may considerably vary.

However, it’s not clear from the feedback whether these sites

are adequate (excepting two which have highlighted

inadequate storage space) in respect of access and protection

from the effects of weather, scavenging by animals etc.

Waste Transportation In most situations final disposal sites are situated quite a

distance from the point of generation and with low technology

used during transportation, spills can easily take place which

can be a potential source of infection transfer. In most of the

hospitals waste is transported to the on-site storage facility by

sanitary laborers using carts and trolleys or by hand. These

laborers do not wear adequate protective gear. Off-site

transportation to treatment facilities is carried out by a few

hospitals which are part of the integrated HCWM system

implemented in the GCA. Final Disposal of treated waste is a

challenge both by public system and outsourced to private

sector.

Waste treatment and disposal

Of the 33 hospitals evaluated, 3 hospitals use steam sterilizers,

13 use incinerators (type and capacity not mentioned), 5

outsourced to a private sector service provider, 8 carrying out

open burning. The hospital in Nuwera Eliya is making use of

the semi-engineered landfill operated by the Municipal

Council to dispose hazardous waste. In addition, a few

hospitals operate sharp pits and placenta pits to dispose sharps

and placentas in a safe way.

Current treatment and disposal practices employed by HCFs

managing their own waste can be seen to vary. It can be seen

that the variations depend on the type and quantity of the HCF

produced and the resources available.

The stream-sterilizers, which are considered the most

acceptable in terms of environmental compliance that have

been put in place, have been in operation only for a short

period. While the running cost is effective, the capital cost of

setting up the system is continues to be a challenge (please

refer to sub-section 3.5 for further details).



In Sri Lanka, finding sustainable solutions for the treatment

and disposal of HCW is one of the main challenges

encountered, given the high technological and capital input

requirements. While some of the major hospitals either own

and operate modern treatment facilities or outsource to a

private service provider, many other facilities lack sustainable

options to dispose of the HCW generated within their

institutions.

Table 11 – Description of current practices in handling HCW in 33 major hospitals evaluated in

2012

3.4: Summary of treatment technologies and infrastructure employed in the country for

HCWM

1. Burial – Infectious and general waste are being buried in some of the health institutions

where land space is available.

2. Open burning - Mixed waste or infectious waste separated are being burnt

3. Barrel incinerators – Infectious waste are being put to a barrel placed on bricks and a

mesh and then burnt

4. Sharp pits- Deposit sharps in a pit layer wise covering with lime

5. Needle burners - burning of infected part (metal) of the syringes.

6. Incineration – Some institutions use low temperature (below 1000’c) single chamber

incinerators and some use dual chamber high temperature (above 1000’c) incinerators for

incinerating infectious waste and sharps.

7. Steam Sterilization

Autoclaving; laboratory cultures and some infectious waste are autoclaved before

disposal

Indirect Steam Sterilization – Few hospitals (04) use indirect steam sterilizers for waste

treatment.

8. Chemical disinfection - Some infectious waste are chemically disinfected. (Sodium

hyperchloride)

9. Placenta pits – Placenta are put in to a series of pits alternatively for natural digestion.

Name of Hospital Treatment Technology Funding Assistance

NHSL Steam sterilization WB

LRH Do WB

CSHW Do WB

GH Ampara Incineration UNOPs

Bu Kalmunai north Do UNOPS

BH – Kalnumai South Do UNOPS

BH Pottuwil Do UNOPS



BH Akkaraipaattu Do UNOPS

BH samanthurai Do UNOPS

TH- Mahamodara Steam sterilization Swedish government

TH- Batticaloa Incineration USAID

GH – Nuwara eliya Sharp pit JAICA

Table 12 – Treatment technologies and infrastructure available in some of the health institutions

funded under different agencies.

3.5 Other achievements and challenges in HCWM in Sri Lanka

Three stream sterilizers in Colombo National Hospital and Castle Hospital and replication of

the technology: Currently, the systems are running using hospital staff and with maintenance

contract with Premium International Pvt.Ltd, the supplier of the systems. The current challenge

of the sterilized waste is the disposal, as the CMC does not have adequate dumping sites. While

the MoH has explored on the possibility of replication this technology with further

improvements such as inclusive of internal shredders, the capital cost needed for such units

(currently approximately LKR 70 million per unit) is beyond the ability of the government to

provide investment. Therefore, the GOSL is still relying on external support to set up appropriate

technologies for HCW treatment and disposal.

Procurement of HCWM consumables: All consumables required based on the HCWM

guidelines are procured by the respective HCF for their needs from the budget allocated to them.

The management of such consumables also lies within the HCF.

Public Private Partnerships (PPP): The GOSL has an agreement with the private company

Finleys to manage waste generated by around 10 numbers of HCFs in Colombo and 01 from

Kandy. They have been treating and disposing around 2.5 tons of medical waste out of the 4

tones currently generated. The concentration has been on sharps (paid at LKR 75 per kg) and

infectious waste (paid at LKR 57.50 per kg). Finleys provides infectious bins to the HCFs and

has been collecting waste in a timely manner. Dumping has been taking place in partially in

Karadiyana and 1.5 tones of treated waste was burned in Lanka Refectories in Meepe. However,

in recent time, Finleys have been facing the challenge of dumping both in Karadiyana and

burning in Meepe due to public complaints. Finleys also face the issue of receiving payments

from the government sector on time.

Wastewater and sewage management: Through time, most of the hospitals have expanded their

capacities for health care provision, wastewater and sewage system have not been expanded.

Currently, the wastewater is connected to the existing sewerage system. An agreement and

payments have been made with the GOSL’s Department of Buildings’ (DoB) Sanitary Engineer

to manage the issues-related to wastewater and sewage. However, the support from the DoB has



not been adequate to resolve issues arising due to inadequate management facilities. MoH’s

Engineering Department is in the process of hiring a consultant to conduct an assessment of the

issues. In addition, Asian Development Bank supported sewage project for Colombo

metropolitan area is developing a waste water management system classified according to the

level of hazard ranging from minimal hazard (green), intermediate (amber) and high hazard (red)

for Colombo metropolitan area. Discussions were held and on principal, Central Environmental

Authority and CMC agreed to this. But implementation will need time to identify methodologies

of treating waste water included under intermediate and high hazard categories ( such as

radioactive waste, cytotoxic waste, vaccines, certain pharmaceuticals, mercury waste etc.),

Biodegradable waste: Biodegradable waste is also a problem in HCFs. For example,

Maharagama Cancer Hospital produces 1 ton of biodegradable waste per day and Kandy

Teaching Hospital 4 tonnes per day. Each HCF uses their own methods of deposing this waste

including giving them to animal farms, composting, etc. MoH has managed to provide biogas

plants to 10 major HCFs (Teaching Hospital Jaffna, Teaching Hospital Ragama, Cancer Institute

Maharagama, General Hospital Polonnaruwa, General Hospital Kuliyapitiya, Teaching hospital

Kandy, General Hospital Gampaha, General Hospital Trincomalee, General Hospital Nagoda,

DGH-

Moneragala) last year in collaboration with the project (“Piliasaru”) carried out by CEA.

Construction of the plants have been completed in majority of the sites and has initiated the

process. CEA has got a 05-year warranty with the supplier. Hospitals have to

maintain and feed the waste properly. Requests have been made for the

second batch this year.

Managing Mercury, electronic and cytotoxic waste: While Sri Lanka is hoping to phase out the

use of Mercury particularly thermometers, pressure gauge machines and dental amalgams the

change is still slow. The alternatives options are also slow to take place due to electronic/digital

accuracy and calibration needs linked to quality issues. Currently, MoH is in discussion with

Orange Bulb Company who has a Mercury recycling facility on the possibility of assisting the

recycling process.

Initiatives also have been taken to manage electronic waste in hospitals.

Maharagama Cancer Hospital currently produces 100kg of cytotoxic waste per day , which is

taken to Holcims cement plant in Puttlam. Industrial technology Institute has developed

guidelines for packaging and transportation of such waste. The waste is transported once in two

months by Holicms. Eight more HCFs based in Kandy, Ratnapura, Kurunegala, Badulla,

Anuradhapura, Karapitiya, Batticaloa and Jaffna produces cytotoxic waste with inadequate

facilities to manage them.



Monitoring and training of HCWM and other health-related environmental issues due to

HCW: Quality Secretariat that has been set up at the MoH and their regional units have

commenced the monitoring of quality of HCFs based on the 5s system. Generally, larger

hospitals do have a Consultant Microbiologist responsible to ensure monitoring. CEA also

monitors the environmental compliance, but mostly based on public complaints. Training on

HCWM is conducted in many forms both with resources from GOSL budget and from the

support from donors. For example, this calendar year the following programs have been

conducted:

Community Medicine Department, Colombo Medical Faculty, University of Colombo –

60 staff (including Hospital Directors, Infection Control Nursing Officers, PHIs/health

Education staff of 20 hospitals)

Annual environmental health training in all districts to public health staff through WHO

financing by the E&OH unit of the MoH

MoH also conducts training when specific issues arise both related to technical and

legislative compliance conducted in collaboration with CEA

UNOPS financed Occupational Health and safety training to waste handlers in Ampara

district by the E&OH unit of the MoH – 250 trained

Occupational Health training for waste handlers held at CSHW by the E&OH Unit of the

MoH. – 60 trained

3.6 Achievements and gaps in the implementation of the policy/national action plan and

lessons learnt

In 2001, a National Action Plan (NAP) was prepared by the MoH , under a consultancy

assignment, to translate the national policy and guidelines into action as part of the government’s

long-term goal to upgrade and standardize HCWM procedures throughout the country, and there

by ensure the safe, environmentally friendly and cost effective management of HCW. The NAP

was broadly made up of seven packages of actions that were grouped thematically and was

complete with defined institutional responsibilities and potential indicators for each action, a

rough cost estimate for implementation and a timeframe which recapitulates each specific action

recommended for implementation within each package. The overall duration of the NAP was

intended to be 5 years.

Implementation of the NAP has been selective. While some important specific actions have been

implemented, the overall implementation success of the NAP has been limited and as a result the

desired outcomes in standardizing HCWM in the country have not been fully realized. The

section below elaborates on the gaps, achievements and lessons learnt from the last 10 years of

implementation experience.



Key Achievements

Consolidation of the National Environmental Act by gazetting disposal of HCW as a

prescribed activity that needs to be carried out under an environmental protection license.

Development and the implementation of the national colour code

Development of national guidelines on HCWM and code of hygiene and instructions

booklet for STD/TB clinics

Creation of a budget line for HCWM in the national budget for the health services.

Establishment of a HCWM system for the public hospitals within the Greater Colombo

Area with two semi-centralized autoclaves and related administrative/management

arrangements for continued operation.

Provision of infrastructure and equipment to improve HCW disposal practices in a

number of major hospitals in the provinces with government and donor funding (see table

above).

Provision of training on HCWM for healthcare workers and other personnel in several

state hospitals under the HIV/AIDS Prevention Project, Health Sector Development

Project and WHO sponsored programs. A HCWM cell was established in the Department

of Community Medicine (Colombo Medical Faculty) which conducts training programs

on HCWM on an annual basis to about 60 hospital staff in collaboration with the MoH .

Inclusion of HCWM in the academic curricular for several post graduate courses

conducted by the Medical Faculty of the University of Colombo.(M.Sc in Medical

Administration/ Community Medicine)

Development of guidelines for transportation of cytotoxic waste for treatment & disposal

Post graduate research has been carried out on HCWM

Key Gaps

Formal adoption of the draft national policy and detailed guidelines on HCWM (note:

HCWM guidelines included in the National Guidelines on Infection Control are very

concise and do not carry details on institutional responsibilities, detail procedures etc for

waste handling). Cabinet approval for these documents has been long overdue.

Lack of validation and formal adoption of the NAP, setting up of working groups and

evaluation criteria to monitor progress

An officially recognized and dedicated institutional arrangement to co-ordinate, assist

and monitor implementation of the NAP. The NAP proposed the official designation of a

national project coordinator, officers within the PHS and HCWM officers at the major

hospital categories to oversee implementation of the recommended actions.

Subsequently, the establishment of a HCWM unit at the MoH was proposed and

initiated. Neither of these materialized.

Specific technical guidelines and format for the preparation of hospital HCWM plans

A protocol for the monitoring and auditing of HCWM plans



Although a specific budget line for HCWM is identified for each medical institution, it

may not relate to the actual costs associated with implementation of a proper HCWM

plan

Lack of research on HCWM or number and type of accidents associated with the

mishandling of HCW.

Key Lessons learnt

It is important that proper HCWM plans are established at the hospital/provinces as it will

provide a realistic indication to the MoH /PHS as to waste quantities generated,

characterization, need for management, appropriate equipment/technology and associated

costs. Without such a basis progress in HCWM will be difficult to assess or monitor.

Selection of the most appropriate equipment and technology for waste treatment is the

most critical aspect in the management of HCW. The technology suitable for each HCF

or cluster of HCFs should be selected based on careful consideration of local conditions

including sitting of such facilities. After nearly 1.5 years of operation, it has been

proposed and canvassed that the steam sterilizer installed at the NHSL under the HCWM

program for hospitals in the CMC area, has to be shifted to a location in the outskirts of

Colombo. This is mainly because of the limited space and ad hoc expansion of the

hospitals. The financial implications of such subsequent changes to the hospital

authorities could potentially be making the HCWM program cost ineffective.

Experience has shown that even when hazardous HCW is treated, disposal could still be a

problem in Sri Lanka. The CMC’s refusal to collect treated HCW owing to certain local

government regulations has been a stumbling block in the smooth functioning of the

HCWM system implemented within the GCA.

Hospitals may not be maintaining a proper information system on waste generation which

is amply shown in the rapid questionnaire survey conducted by the MoH in 2011 in

support of this framework. Information on waste generation is the basis on which the

management system should be decided upon; as such this is an important area the

hospital authorities should pay attention to.

3.7 Financial resources available for HCWM in the country

The MoH allocates around Rs 50 million (0.067 % of the health budget) to the HCFs under the

central government for HCWM. Provincial Authorities also allocate some funds to HCWM,

however, data not readily available on this due to various reasons. Some of the deficiencies

found in the rapid appraisal 2011 can be directly linked to the inadequate funding. GOSL and

MoH find it difficult to increase the allocation due to budgetary constraints.

Hospital HCWM plans or provincial HCWM plans should be the basis on which financial

allocations should be decided upon for inclusion in the health budget. However, having said that,

given the multiple demands placed on health services and the limited resources available,



government funding for the health sector may not be able to provide the needed injection of

capital finance for installing sustainable technology for the management and disposal of HCW.

Thus, it is important for designated officers of the MoH and the PHS to work closely with other

sectoral government agencies, donor agencies, etc to source necessary support for the

implementation of HCWM plans. So far, external funding in the management of HCW has been

a huge impetus in Sri Lanka and should be further collaborated with to continue taking HCWM

forward to better levels.



Chapter 4: Strategy for scaling up HCWM under HSDP II

4.1: Summary of HCWM strategies addressed in the National Health Development Plan

1. Establish healthcare waste treatment facilities island wide

2. Develop required guidelines and standards for healthcare waste management

3. Obtain Environmental Protection License and Hazardous Waste License for healthcare

institutions

Environmental & Occupational Health Unit has identified the following objectives and strategies

under HCWM.

Objectives

1. To develop a national policy on healthcare waste management ( HCWM)

2. To develop a national plan on HCWM .

3. To implement HCWM plan in hospitals

4. To harmonize the HCWM plan in all institutions

5. To build capacity among health staff on HCWM at all levels

Strategies

1. To review and update institutional capacities

2. To improve the infrastructure facilities

3. To improve the competencies of staff

4. To transfer the ownership of HCWM to respective institutions

5. To build inter-sectoral coordination securing the intra sectoral coordination

6. To promote the usage of appropriate technology for HCW treatment.

Based on the above objectives and strategies the following national action plan has been

constructed for implementation.



National Action Plan on HCWM (2013 – 2017)

Activities 2013 2014 2015 2016 2017

1. Update the draft policy on HCWM

and obtain cabinet approval

2. Strengthen Environmental &

Occupational Health Unit to develop

standards, guidelines, and facilitate

Healthcare waste management

activities in health institutions

3. Carryout situational analysis and

needs assessment of HCF

4. Develop Action Plans for HCWM in

the Healthcare Institutions.

5. Training of Health staff at all levels

on HCWM

6. Establish HCWM teams in hospitals

7. Supply of HCWM equipment to

Health Institutions

8. Develop HCWM infrastructure

facilities

9. Establish HCWM treatment options

at HCF

10. Develop waste water guideline

11. Develop Waste water and sewerage

treatment plant at HCF

12. Develop solid waste management

options as resource recovery

processes

13. Develop HCWM monitoring formats

and systems

14. Facilitate obtaining EPL and SWL

for health institutions

15. Inter-sectoral Collaboration on

HCWM

16. Monitor/audit the implementation of

HCWM plans and compliance

towards regulatory requirements



4.2: Priority areas selected for implementation under HSDP II

Although HCWM has increasingly gained recognition as an area of critical importance over the

last decade and many steps have taken towards establishing better management, it still remains a

significant environmental and public health issue in the health sector. Reaching complete safety

from the risks of HCW produced in the country requires current efforts to be extended both

quantitatively and qualitatively in a progressive manner.

With support from the Second Health Sector Development Project funded by the World Bank,

the following key actions are recommended for implementation during the lifetime of the project.

Actions Indicators of

Achievement

Lead Responsibility (please also refer

page 50)

1. Strengthening the national implementation framework for HCWM in the country

1. Establishing policy commitment and

responsibility for HCWM

Draft National Policy on

HCWM updated and

formally endorsed and

approved.

NCCWM & MoH

It is important that a formal commitment to a national policy is made before any action plan for

improving HCWM can be undertaken. While a comprehensive national policy was developed in

2001, the objectives and underlying principals of which are detailed on page 19, it was not

formally endorsed by the government. Therefore it remains to be a draft policy to this date

pending approval.

As more than a decade has passed since the policy was drafted, it is recommended that the

National Committee on Clinical Waste Management review the policy and update it as

necessary to suit current challenges and demands in HCWM. Following the review and

agreement to its content by the MoH, the draft policy should be re-submitted for cabinet

approval subsequent to which a stakeholder consultation should be conducted and finally

approved with parliamentary endorsement.




Achievement


page 50)

2 Strengthen Environmental and

Occupational Health Unit within the

MoH to facilitate HCWM activities.

Strengthen E&OH Unit

with necessary staffing and

budgetary allocations

established.

MoH

Strengthening the Directorate of Environment and Occupational Health of the MoH is essential

in managing a HCWM program at the national level and ensuring continued efforts in

implementing a national HCWM program and its long-term sustainability. HCWM is a

specialized service requiring technical skill and know-how. As such, a strengthening the unit

staffed with suitable expertise can play a vital role in strategically directing the sector,

technically backstopping HCFs to improve the management of HCW within their institutions

and providing monitoring oversight at the national level.

Although the creation of a specialized unit for HCWM was initiated under HSDP long delays

were experienced in getting the necessary management clearances and as a result administrative

formalities could not be completed prior to project closure. The Management Services

Department, which is responsible for creating cadre had several discussions with the MoH but

could not get the approval for cadre during the project period. Therefore it is recommended that

the Environmental & Occupational Health Unit be strengthened to providing technical oversight

and co-ordinating and guiding hospital authorities on HCWM issues.

A formal institutional arrangement that links the E&OH unit to the health institutions be agreed

upon.

2. Operationalizing Health Care Waste Management in HCFs

1 Simultaneous situational and needs

analysis of HCFs focused on setting

up the baseline and identifying gaps

related HCWM systems and their

level of operations

Situational and needs

analysis of HCFs report

that will feed to updating

of initial HCWM plans

Directorate of

Environment and

Occupational

Health/MoH in

collaboration with

NCCWM

The rapid assessment conducted by the MoH has demonstrated the need for detailed analysis of

the following key areas based on past and current experiences in order to ensure action plans

that will be put in place are well grounded based on the actual situation and needs of the HCFs.

Analysis of institutional, planning and implementation challenges for effective HCWM

Strengths and weaknesses of different technologies in use including proposed

technologies for waste treatment

Analysis of issues related to wastewater and sewerage systems (issues, types of systems

in place, legislative requirement, etc.)

Analysis of wastewater constituents and the disposal practices

Analysis of cluster (regional) approach to HCWM and possible Public Private




Achievement


page 50)

Partnership (PPP) arrangements (including reasons for PPP models have not been widely

used and barriers that needs to be addressed)

This analysis should be provide the capital cost of existing systems and systems proposed and

recurrent cost for operationalizing systems and cost-benefit analysis. It will provide guidance on

the feasibility of setting up individual HCWM systems for each HCFs vs. regional facilities.

2 Develop a standard template/form for

HCWM plans for medical institutions

and for PHS. If necessary, prepare

additional technical guidelines

consisting of basic steps in the

preparation of HCWM plans to

supplement the draft National

Guidelines.

Template for institutional

and provincial HCWM

plans.

Technical guidelines for

preparing HCWM plan.

Directorate of

Environment and

Occupational

Health/MoH in

collaboration with

NCCWM

While draft national policy/guidelines may provide the framework for standardizing HCWM

procedures across the country, translating recommended practices at the HCF level by either

improving or initiating HCWM systems is unlikely to be sustainable unless a process of

planning is introduced and established.

It is important that the major HCFs introduce a process of planning for HCWM that culminates

in the preparation of HCWM plan specific to each institution, which can be updated on a yearly

basis or periodically as necessary. The HCWM plan is the basic document which will

summarize the (i) generation of hazardous HCW (type and quantity), (ii) designation of

responsibilities of the hospital waste management team, (iii) waste management procedures to

be set up/improved, (iv) choice of treatment and disposal technology, (v) financial resources

required, (vi) monitoring/evaluation protocol of plan implementation etc.

The draft national guidelines prepared in 2001 include guidance on some of the key steps

involved in preparing a HCWM plan. However, if required, the MoH could supplement this

with a practical guide for developing a hospital HCWM plan. Several useful sources 10

are

available on the internet from which a supplementary guide could be developed for the use by

hospital management.

3 All Teaching Hospitals to prepare

HCWM plans and to obtain

Environmental Protection License

within 3 years

EPL status obtained by 22

Teaching Hospitals

Hospital

Management and

MoH

10

WHO, 2002, Basic Steps in the Preparation of Health Care Waste Management Plans for Health Care Establishments (Health Care Waste Practical Information Series No 2)




Achievement


page 50)

Teaching hospitals are the largest type of HCF in the country and generate all sorts of hazardous

health care wastes in significant quantities. Given that the overall capital and operational costs

for implementing and standardizing HCWM measures remains high, it makes sense to first start

improvement in HCWM in the larger hospitals and then extends to smaller health-care

establishments.

Of the 22 Teaching Hospitals in the country, only 06 are in possession of an Environmental

Protection License where around 08 more institutions are pending the licenses. Others are in the

process upgrading the HCWM system and obtaining the EPL and SWL.

It is recommended that the MoH review current HCWM practices employed in all THs and

assist them in setting up specific HCWM plans, which can be updated periodically, and which

will progressively lead the institutions to comply or improve compliance with legislative

requirements. The establishment of HCWM plans and monitoring its implementation will

oblige medical institutions and administrative authorities to consider HCWM as an integral

issue of health care services and progressively reinforce organizational capacities to achieve

better standards.

4 Other selected major hospitals to

develop comprehensive HCWM

plans.

Hospital specific HCWM

plans developed and

financed

Hospital

Management

Apart from Teaching Hospitals, Provincial General Hospitals, District General Hospitals and

Base Hospitals are the other major HCFs that offer a range of specialized health care services

and consequently produce significant quantities of hazardous HCW. According to the National

Health Budget of 2012 there are 87 major HCFs spreaded across the country.

As it may not be possible to cover all of the 87 major hospitals under the 2nd

HSDP, it will focus

on the major facilities in those provinces that rank high in terms of the quantity of HCW

produced.

5 Selected provinces to prepare

provincial HCWM plans

Provincial/regional

HCWM plans established

PHS

Based on HCWM plans of medical institutions under its purview, it is recommended that the

PHS set up annual provincial HCWM for the selected provinces which will present the strategy

for HCWM at the regional level. It will provide the PHS a clear analysis of the prevailing

situation in the province/region and help set up short, medium and long term objectives and

associated expenditure.

An officially nominated focal point in the PHS (recommended – RE) should be in charge of

developing the provincial HCWM plan with technical backstopping from the proposed HCWM




Achievement


page 50)

unit of the E&OH unit of the MoH.

3.Training and awareness

1 Prepare and implement a national

training programme

Training program

developed.

MoH

Under the HIV/AIDS Prevention and Health Sector Development Projects, the MoH carried out

numerous training programs to train health care workers in the proper management of HCW.

Currently, the MoH in collaboration with the University of Colombo conducts a HCWM

training program annually for a small selected group. In order to achieve acceptable practices in

health-care waste management and compliance with regulations, it is essential to continue

training specifically targeting managers and other personnel primarily involved in the waste

stream management in different HCFs across the country. Also, it may be important for hospital

waste management teams and focal points in the PHS to receive technical training on the

development of HCWM plans.

It is recommended that the Directorate of Environment and Occupational Health/MoH

develops and implements a national HCWM training program, based on current needs and

emerging challenges, identified training gaps and capacity constraints etc to build the

skill/knowledge base that will facilitate an optimal outcome from HCWM investments made.

4. Monitoring of HCWM activities

1 Establishment of a monitoring

framework to review and audit

HCWM plans implemented at all

levels.

National HCWM

monitoring framework

developed and

implemented

NCCWM & MoH

A national programme for the management of health-care waste should be viewed as a

continuous process which requires periodic monitoring and assessment by the responsible

government agency. Such periodic reviews are important in ensuring sustainability of the

process. A monitoring framework is, thus, needed to be set up which will establish monitoring

protocols, institutional mechanisms, data storage and reporting procedures etc to follow up on

the implementation of HCWM plans at the institutional and provincial levels.

It is essential that the monitoring framework provide the necessary tools to measure if the

objectives of a HCWM program have been achieved. They would broadly include;




Achievement


page 50)

The set-up of adequate indicators of achievement or performance. Qualitative should

always be coupled with quantitative indicators in order to monitor and evaluate the

outcome of the HCWM plan.

A simple, regular reporting system to keep the appropriate authorities constantly

informed with sufficiently accurate and relevant information that can be easily verified,

enabling decision makers to change the implementation strategy if necessary based on

the practices encountered in the HCFs;

Annual environmental audits to assess the compliance with regulatory requirements

4.3 Description of result indicators to be monitored under 2nd

HSDP

Result Outcome Indicators Baseline Time

Frame

1 Review and formally

endorse the draft national

policy on HCWM

i. Draft policy reviewed by the NCCWM Draft policy 2013

ii. Draft policy re-submit for cabinet

approval

2013

iii. Stakeholder views sought on cabinet

approved policy

2014

iv. Policy approved by the Parliament 2014

v. National policy on HCWM approved and

formally adopted

2015

2 Strengthen EOH Unit i. Formal mandate for the unit with detailed

job descriptions for recommended cadre

positions developed.

General

mandate of

the E&OH

unit in place

with

relevant

staff

2015

ii. Separate budget line for HCWM under

Environmental & Occupational Health

Unit

No separate

budget line

2014

iii. Infrastructure developed for

Environmental & Occupational Health

Unit

Below

minimum

facilities in

place, which

are

inadequate

for the

effectiveness

and

efficiency of

the Unit and

its proposed

2016




Frame

expanded

mandate

3 Develop a standard

template/form for HCWM

plans for medical institutes

and for PHS. If

necessary, prepare

additional guidelines

consisting of basic steps

for the preparation of

HCWM plans.

i. Standard template for hospital specific

HCWM plan developed.

Only

national

HCWM plan

available

2014

ii. Standard template for Provincial HCWM

plan developed

iii. Technical guidelines developed and

adopted

Generic

technical

guidelines

are

available.

More

specific

guidelines

needed

4 All Teaching & Provincial

Hospitals to prepare

HCWM plans and to

obtain Environmental

Protection License within

3 years

i. EPL status obtained – 8 Teaching

Hospitals

3 2013

ii. EPL status obtained – 8 Teaching

Hospitals

2014

iii. EPL status obtained – 6 Teaching

Hospitals

2015

5 District General Hospitals

and Base Hospitals A& B

to prepare comprehensive

HCWM plans

i. HCWM plans developed for – 04

hospitals

0 2013

ii. HCWM plans developed for - 20

Hospitals

2014

iii. HCWM plans developed for - 20

Hospitals

2015

iv. HCWM plans developed for - 20

Hospitals

2016

v. HCWM plans developed for- 20

Hospitals

2017

6 Selected provinces to

prepare provincial HCWM

plans

i. Provincial HCWM plan developed for –

04 provinces

0 2015

ii. Provincial HCWM plan developed for -

05

provinces

2015

7 Prepare and implement a

national training

programme

i. Training program developed 0 2014

ii. No of training programs conducted – 3 2015

iii. No of training programs conducted – 5 2016

iv. No of training programs conducted - 5 2017

8 Establishment of a

monitoring framework to

review and audit HCWM

plans implemented at all

levels.

i. Monitoring framework developed and

endorsed by the MOH

No

framework

currently,

although ad

hoc

monitoring

2015




Frame

taking place

ii. Monitoring actions implemented

including the annual audits

- 2015-2017



Chapter 5: Implementation and monitoring arrangements for HCWM under the Second

HSDP

5.1 Project Institutional and Implementation Arrangements

As a sector assistance program, the implementation of the 2nd

HSDP will be the responsibility of

regular implementing divisions/units in charge of the subject matter under the leadership of the

MOH and the PHS. The actual project implementation will involve central and district level

administrative and technical staff, health workers and technicians.

Directorate of Environmental Health and Occupational Health (E&OH) of the ministry of health

will oversee and coordinate the implementation of the HCWM project. In order to achieve this

objective a strengthening of the present EOHD will be done as discussed in the National action

plan.

The project Management team of the E&OH unit will be responsible for the following key tasks:

i. Operating the Project Account;

ii. Reviewing the DHPs and the plans and budgets for approval by the PCT;

iii. coordinating the elaboration of operational documents, including:

iv. Preparing TORs and contracts for technical assistance (e.g. capacity building of

PMUs, Health Forum organization, annual audits);

v. Consolidating reports necessary for documenting use of IDA funds and

implementation progress and results;

vi. Reporting on procurement documents for large items;

vii. Managing capacity building activities. In particular, with the support of

consultancy firms, it will develop training programs in the areas of

planning/monitoring and procurement/financial reporting for the districts;

viii. Coordinating monitoring and evaluation activities;

ix. Communicating to key stakeholders the nature, progress and outcome of the

Program;

x. Liaise with international agencies such as IDA, JICA, WHO, and other partners to

ensure that all sector activities are well coordinated.

The project management team will also be supported by a Project Steering Committee (PSC)

appointed by the MoH MOH who will oversee implementation of program activities. More

specifically, the role of the PSC will be to (i) monitor the achievements of project objectives, (ii)

provide policy direction, general project oversight and take necessary decisions to address

implementation issues which may arise during the life of the project. The relevant division of the



MoH and the will ensure that the PSC recommendations to resolve project implementation

issues are satisfactorily implemented.

With technical assistance, the project management team will set up a management information

system, for all project activities (provincially and centrally managed components), that links

financial and procurement management information to the physical progress of the project. With

this tool, the project management team will supervise, monitor, and report on project activities to

the PCT and to the Bank, and will ensure that implementation of the various project components

are implemented in accordance with the rules set out in the Operations Manual, and that annual

audits are carried out as stipulated in the Grant Agreement.

At the Provincial level, under the technical and policy guidance of the MoH, the Local

Government and the Provincial Councils will serve as the coordinating and monitoring agencies

responsible for overseeing the implementation of the district programs. Actual implementation of

project activities will be the responsibility of the District health authorities (2 to 3 Districts in

each Province) and their divisional staff responsible for planning, executing and monitoring their

District Health Plan. Districts will continue to receive considerable technical assistance and on-

the-job training to strengthen Program Management Centers (PMCs) capacity to implement the

project, the core operational body to implement the Program under a Performance Based

approach.

5.2 Implementation of HCWM under 2nd

HSDP

The Second Health Sector Development Project will basically support the implementation of the

National Health Development Plan through the programs of the MoH and the 9 provincial

MoHs. As the program is designed to be implemented through the regular health institutional

structure, responsibility of implementing and monitoring results related to HCWM will lie with

the relevant divisions/units of the MoH, PHS and the medical institutions.

Institutional

Level

Division/Unit Responsibility in implementing the action plan for HCWM

Central

Level

Directorate of

Environment

and

Occupational

Health

(DEOH) of the

MoH

The mandate of implementing environmental and occupational

health programs including HCWM within the Central MoH lies

with the Directorate of Environmental and Occupational Health

(DEOH) which comes under the purview of DDG – Public Health

Services 1

Therefore, under the 2nd

HSDP it will take the lead in co-ordinating

with higher levels of the Ministry and the NCCWM to re-establish

the process to formalize a policy framework for HCWM and

technical guidelines that support the implementation of the

approved national policy.

Develop incentives and mechanism to help facilitate HCFs to

comply with the legal requirements. In particular, the DEOH will



Institutional

Level

Division/Unit Responsibility in implementing the action plan for HCWM

be responsible for providing technical assistance for the

implementation of the HCWM policy, particularly developing

necessary guidelines and templates for the development of HCWM

plans.

Identify capacity constraints for HCWM and developing a national

training program targeting areas lagging in proper HCWM and to

train major HCFs and PHS to develop comprehensive HCWM

plans.

MoH Lead responsibility in establishing a dedicated institutional unit

under the purview of the DEOH for HCWM. The structure, cadre,

detail mandate, dedicated budget etc for the unit will need to be

discussed and finalized during program implementation.

NSCCWM Review and update the draft policy on HCWM

Develop a national monitoring framework to monitor and audit

HCWM plans; the introduction of a protocol will lead the HCFs to

regularly follow up on HCWM plan implementation.

Overall monitoring and evaluation of HCWM activities under the

2nd

HSDP

Provincial

Level

PHS

Ensure establishment of Provincial HCWM plans presenting the

strategy for the region and update periodically. This plan should be

compiled from all the individual HCWM plans of the HCFs they

are responsible for, provide a clear picture of the status of HCWM

in the region, and set up short and long term objectives.

Hospital

Level

Major HCFs

MoH /PHS

Every hospital is legally responsible for the proper management of

the waste that it generates until final disposal. Directors of every

HCF will take the responsibility to implement safe HCW

procedures in their institutions. Therefore, all major hospitals will

take the responsibility of establishing HCWM plans for the

institution and implement accordingly.

The DEOH of MoH and the PHS should (i) co-ordinate efforts to

ensure that HCWM plans are annually set up in the entire major

hospitals, (ii) provide technical services and (iii) supply adequate

resources.

5.3 Use of IDA resources

No limits are defined on the use of IDA resources for implementing this framework. If IDA

financing is utilized to procurement of works, goods and services, prior clearance from the

World Bank of proposed activities, related TORs and draft and final outputs will be necessary. If

final negotiation indicate that IDA resources are only utilized for non-procurable items, prior

clearances will not be necessary, except the sharing of key outputs (monitoring indicators) and

annual progress report based on the Action Plan covering the project period.



Chapter 6: Technologies available for HCWM and comparison of alternatives

Several alternative technologies have been developed and are in use to treat and dispose of

hazardous HCW. Broadly, they include incineration in rotary kilns or double chamber

incinerators, incineration in single chamber incinerators, autoclaving, hydroclaving which is an

improved derivative technology of the traditional autoclaving, chemical disinfection, microwave

irradiation and sanitary landfilling. In Sri Lanka, the two most popularly used technologies are

autoclaving and incineration The final choice of treatment technology for a HCF will depend on

various factors, many of which are specific to local conditions, but should be fundamentally

driven by the objective of minimizing negative impacts on human health and the environment.

Certain treatment options while effectively reducing infection hazards and preventing scavenging

may contribute to other health and environmental concerns, such as emission of toxic material

into the atmosphere of waste containing high contents of heavy metals or chlorine compounds

when incinerated below recommended temperatures. Therefore, the selection of treatment

technology has to be a carefully evaluated one in light of local circumstances and the overall

waste management strategy of the country.

As there is ample literature produced by various organizations11

including the WHO on guiding

medical institutions in selecting the most appropriate treatment and disposal technology,

depending on the types and quantities of waste produced and other specific local conditions, this

chapter will be limited to providing a broad technical overview of the options only. The table

below presents suitable treatment and disposal technologies according to the different categories

of HCW and has been sourced from the Guidance Manual for Preparing a National Health Care

Waste Management published by the WHO12

.

Waste

Category

Rotary

Kiln

Two

Chamber

Incinerators

Single

Chamber

Incinerator

Auto/Hydroclave Chemical

Disinfection

Microwave

Irradiation

Sanitary

Landfill

Non-rsik HCW In all HCFs, the non-risk HCW which constitute of food residues, plastic/polythene containers,

waste paper etc should always be segregated from hazardous waste and disposed of with general

municipal waste and/or removed to a recycling facility, as appropriate.

Human

Anatomical

waste

Yes Yes No No No No

Waste sharps Yes Yes Yes Yes Yes For small

11

The “Technical Guidelines on Environmentally Sound Management of Biomedical and Healthcare waste” (2002) adopted by

the Conference of the Parties to the Basel Convention;

• Safe management of wastes from health-care activities, WHO (1999);

• Teacher’s Guide: Safe management of wastes from health-care activities, WHO (1998);

• (Draft) Guidance for the development of National Action Plans, WHO (2002);“Basic Steps in the Preparation of Health Care

Waste Management Plans for Health Care Establishments”, WHORegional Office for the Eastern Mediterranean (CEHA) (2002). 12

Guidance Manual for the Preparation of National Health Care Waste Management Plans in Sub-Saharan Countries, World

Health Organization and the Secretariat of the Basel Convention



quantities

with

encapsulation

Pharmaceutical

waste

Yes Small

amounts

No No No No No

Cytotoxic

waste

Yes No

Yes for

modern

ones

No

No No No Small

quantities

with

inertization

Infectious

waste

Yes Yes Yes Yes Yes Yes

Highly

Infectious

waste

Yes Yes Yes Yes Yes Yes but only

after pre-

treatment

Radioactive

waste

No No No No No No Yes but need

to be

specially

designed

Other

hazardous

waste

Yes No No No No No No

Yes if

specially

designed

Table 13 - suitable treatment and disposal technologies according to the different categories of

HCW

The section below is a comparison of the alternative technologies available to treat hazardous

HCW and has been adopted from the Situation Analysis report of 2001 (MoH ) and relevant

Who guidelines13

.

6.1 Incineration

Incineration is the only technology that can effectively treat most types of health care waste. It

involves a high-temperature dry oxidation process that reduces organic combustible waste to

inorganic incombustible matter with a resultant significant reduction in the waste volume and

weight. Incinerators can range from extremely sophisticated high-temperature operating plants to

very basic combustion units that operate at much lower temperatures. Broadly, they can be

categorized as (i) Double chamber pyrolotic incinerators (ii) single chamber incinerators and (iii)

rotary kilns. One of the main drawbacks of this technology is the gaseous emissions the process

yields, particularly toxic substances if the waste material contains cytotoxic drugs, chemicals,

halogenated material or waste with high contents of heavy metals (such as batteries and broken

mercury thermometers etc). Higher operating temperatures and treatment of flue gases limit

potential for atmospheric pollution and odors caused by the incineration process.

Therefore, selection of the incineration equipment is important and should be carefully evaluated

on the basis of available resources, local conditions and of public health benefits against the

potential risks of air and groundwater pollution caused by inadequate destruction of certain toxic

13



wastes. It is recommended that incinerators designed especially to treat HCW should operate at

temperatures between 900°C – 1200°C. To achieve optimal results from incineration, the waste

should meet certain criteria such as having a low heating value, high content of combustible

matter, very low content of incombustible matter , low moisture content etc.

Description Pyrolotic double chamber incinerators (incineration at 900°C – 1900°C)

Rotary kiln (incineration at 1200 °C)

Single chamber incinerators (incineration at low temperatures 300°C –

400°C)

Advantages Pyrolotic incinerators and rotary kilns

Complete destruction and sterilization of waste/sharps and hence

elimination of health risks

Significant reduction in waste volume and weight

Very high disinfection efficiency

Destroys all types of liquid, pharmaceutical and other organic waste

Large quantities of waste can be treated

Single chamber incinerators

Good disinfection efficiency

Reduces waste volume and weight significantly

No need for highly trained operators

Disadvantages Pyrolotic incinerators and rotary kilns

High investment costs

Emits toxic flue gases and hence need extensive flue gas emission control

systems

Depending on the treatment of flue gases, discharge of wastewater

containing toxic metals can occur

Well trained staff is required for operation

Expensive to operate and maintain

Generates ash residues that needs safe disposal (about 1% of unburnt

material)

Single chamber incinerators

Needs frequent de-ashing and removal of soot and slag

Contributes to significant atmospheric pollution due to low operating

temperatures and lack of emission control systems

Inefficient in destroying thermally resistant chemicals and drugs

No destruction of sharps

Capacity (per hour) 50Kg to several metric tons or 200Kg – 10 tons per day

High-temperature incineration of chemical and pharmaceutical waste in industrial cement or

steel kilns is commonly practiced by many countries as in Sri Lanka. Currently, waste from

hospitals is sent to the only licensed industrial kiln operated by Holcim Lanka in Puttalam.

Currently, around 10 mobile incinerators have been set up on around 10 HCFs at a cost of LKR



6.5 million plus taxes for each unit. These units can be run at 1,000ºC. Each unit can incinerate

200kg per day at 40kg per cycle. The biggest challenge in managing incinerators in Sri Lanka is

to ensure they run within the required temperature. Therefore, the usage is being discouraged by

WHO and South Asia region of the World Bank.

6.3: Autoclaving

Autoclaving is the process of exposing infectious waste to high temperature, high pressure steam

in an enclosed container, similar to the autoclave sterilization of medical equipment. It

inactivates most types of micro-organisms, if properly operated with sufficient temperatures and

contact time, and once disinfected the output can be considered non-hazardous which can be

land-filled with general municipal waste. Autoclaving requires shredding of wastes and sharps

prior to loading to the equipment in order to increase disinfection efficiency. This method is most

appropriate for infectious and sharp wastes and not for certain types of wastes such as

anatomical, pharmaceutical, chemical wastes. The equipment requires to be operated and

maintained by adequately trained technicians and the effectiveness of the disinfection process

has to be routinely checked using a bacteriological test.

Description Minimum contact times and temperatures will depend on several factors such

as the moisture content of the waste and ease of penetration of the steam.

Research has shown that effective inactivation of all vegetative

microorganisms and most bacterial spores in a small amount of waste (about

5– 8kg) requires a 60-minute cycle at 121°C (minimum) and 1 bar (100kPa);

this allows for full steam penetration of the waste material.

Advantages

Relatively simple to operate

Low environmental impact

Disadvantages

Relatively expensive to install and operate

Large autoclaves may need boiler with stack emission control systems

Shredder is liable to mechanical failures and breakdown requiring regular

maintenance

Efficiency of disinfection is very sensitive to the operational conditions.

Generates wastewater

Large quantities of disinfected waste needs final disposal to a landfill

Capacity (per hour) From 10 to 1500 Kg

Autoclaving is the commonly used technology in the country for sterilizing medical equipment

as well as infectious HCW. The HCWM system implemented for the public hospitals in the GCA

comprises of two semi-centralized steam sterilizers located in two strategic locations which

disinfects waste generated in 3 major HCFs in the said area. The 3 systems cost LKR 86 million

as capital cost. As indicated earlier, while more efficient systems are available in the market, the

cost of procurement is very high.



6.4: Microwave irradiation

In this type of treatment, HCW is exposed to a high energy electromagnetic field in an enclosed

chamber which rapidly heats up the liquids contained in the waste and consequently destroys the

infectious components. Prior to being irradiated the HCW has to pass through a preparative

process which includes segregation to remove undesirable material, shredding and

humidification and once disinfected the waste is compacted before being disposed of. Similar to

the autoclaving technique, the output from a microwave facility is considered non-hazardous and

is suitable to be land-filled with municipal waste. The efficiency of microwave disinfection will

depend on the operating conditions and should be checked routinely through bacteriological

tests. As the process is powered by electricity and does not involve the application of steam,

generation of gaseous emissions and wastewater are minimal compared to incineration and even

autoclaving, which can require combustion of fuel for the generation of steam.

Description It is reported that most microorganisms are destroyed by the action of

microwaves with a frequency of about 2450 MHz and a wavelength of

12.24cm.

Advantages

Good reduction in waste volume due to shredding and compacting

involved

Good infection efficiency under optimal operating conditions

Environmentally sound

Disadvantages

High investment and operation cost

Sophisticated and complex technology, hence require highly skilled

operators

Cannot treat certain categories of waste such as pharmaceutical waste,

cytotoxic waste etc

Only solids can be treated and that too only once shredded

No reduction in the weight of waste treated

Potential high maintenance as shredders are subjected to frequent

breakdowns and poor functioning

Capacity (per hour) 22 – 1100 Kg

The microwave process is widely used in many developed countries. However, it’s not very

popular in developing countries due to the high initial cost and maintenance involve. At the

moment the technology is not popular in Sri Lanka as a suitable solution for treating HCW.

6.5: Chemical Disinfection

In this method, chemical disinfection that is used routinely to kill microorganisms on medical

equipment and on floors has been extended to treat HCW. Chemicals are added to HCW to kill

or inactivate pathogens it contains and is most suitable for treating liquid waste such as blood,

urine,. However, solid HCW such as sharps and microbial cultures may also be treated but



requires to be shredded to ensure that a maximum surface area comes into contact with the

disinfectant. Once treated, HCW is considered non-risk HCW and can be disposed with

municipal waste but the chemical disinfectant may create significant environmental problems if

not disposed securely. Hence, in planning the use of chemical disinfection it is important to

carefully consider the requirements for the eventual disposal of the chemical residues. It is

recommended that thermal sterilization be considered with preference over this method of

treatment for reasons of efficiency and environmental pollution. Chemical disinfection is usually

carried out on hospital premises, however, commercial, self-contained, and fully automatic

systems have been developed for health-care waste treatment and are being used mostly in

developed countries.

Description Chemicals that are used are mostly strong oxidants such as chlorine

compounds, ammonium slats, aldehydes, phenolic compounds etc)

Advantages

Shredding, when carried out, reduces the volume of waste

High disinfection efficiency

Effective for highly infectious liquid wastes

Disadvantages

Use of hazardous chemicals has the potential to cause environmental

contamination

Polluted wastewater produced in the process (as water is usually

added during shredding to prevent excessive warming and to

facilitate better contact with the disinfectant)

Require highly trained technicians to operate and maintain

automated systems

Inadequate for pharmaceutical, chemical and some types of

infectious waste

Capacity (per hour) 22 to 1100 Kg

6.6: Land disposal

Disposal of HCW in municipal landfills is not advisable if it is untreated, however, it could be

regarded as an acceptable disposal route if the medical authority genuinely lacks the means to

treat waste prior to disposal. Allowing HCW to accumulate in hospital premises or elsewhere

constitute a far greater risk of infection transmission than disposal in a sanitary landfill. When

this solution has to be used, it is important that HCW be disposed of in a sanitary landfill and

rapidly covered. As sanitary landfills are designed to geologically isolate waste from the

environment and are managed with controlled operation, contamination of soil and water, air

pollution, smell ad direct contact with people can be significantly prevented. However, HCW

should not be deposited on or around open dumps which could lead not only to acute pollution

problems but a great risk of subsequent disease transmission.



In the absence of sanitary landfills, a controlled dump site which fulfills minimum requirements,

such having certain engineering work completed to effectively retain waste and an established

system for rational and organized deposit of waste, could be used. It is further recommended that

HCW be deposited using one of the following techniques; (i) bury in a shallow hollow excavated

in mature municipal waste at the base of the working face and cover with a fresh layer of

municipal waste (ii) bury in a excavate deep pit in mature municipal waste and backfill with the

removed municipal waste or (iii) design and dedicate a special cell in the landfill where only

HCW will be received.

In smaller HCFs with means for minimal HCW management programs, especially in remote

areas or areas with severe hardships, safe burial in a specially constructed burial pit may be the

only viable option. As a minimum, the hospital should follow certain basic rules in managing the

burial pit such as lining the pit with a material of low permeability, restricting access to the site

to authorized personnel only, covering HCW with a layer of soil after each load and with lime if

ordour has to be suppressed, bringing only hazardous waste to the site to optimize the space

available in the pit etc,. Once filled, the pit should be sealed off.

Advantages Simple and inexpensive to operate

No specific construction cost is involved if operated within available

landfill systems

Protected from scavengers gaining access to HCW

Disadvantages HCW is not treated and remains hazardous

Strong co-ordination between waste collector and landfill operator

required

Reduces awareness among health care workers of the need to

segregate waste categories

Potentially high transport cost that may be involved

Disposal in special HCW cells need conscientious operation

according to specific guidelines

Sri Lanka does not operate fully engineered sanitary landfills. However, the Nuwera Eliya

Municipal Council operates a semi-engineered small landfill which is used by the Nuwera Eliya

General Hospital to dispose of its hazardous HCW. Ampara has land fill sites developed by

UNOPS. All other landfills used by local authorities are unsafe dump sites and hence is not safe

for the disposal of infectious HCW.



Chapter 7: Safeguard requirements for infrastructure development work under 2nd

HSDP

The second HSDP may invest in the development of health infrastructure, mainly buildings to

improve/expand health care services. Environmental impacts of such construction, which would

in most cases take place within the existing premises, are likely to be localized, relatively small

scale, spread in different locations of the country and confined to the construction site. However,

the hospital management and health authorities should take precautions to minimize any

potential adverse impacts caused by civil works and also to ensure that environmental friendly

practices are employed when planning and designing the sub-project.

7.1 Environmental Clearance under national laws

Under EIA regulations of the NEA, development of hospital infrastructure that may involve the

following will need to obtain environmental clearance from the Central Environmental

Authority.

Clearing of land area exceeding 50 hectares

Reclamation of land, wetland area exceeding 4 hectares

Construction of waste treatment plants treating toxic or hazardous wastes

Construction of buildings/structures within any of the sensitive areas defined in Part III of

the EIA regulations

It is very unlikely that infrastructure development undertakings of the project would belong to

any of the prescribed categories mentioned above, however, in the unlikely event it does an

application need to be submitted to the CEA using the Basic Information Questionnaire available

on its website. Based on the application the CEA will make a determination on the level of

assessment required and instruct the relevant authorities of the requirements that need to be met

in obtaining EIA clearance.

7.2 Incorporation of safeguards into plan, design and contract

Irrespective of the outcome of environmental screening under the NEA, construction of HCFs

under the 2nd

HSDP will adopt the following broad guidelines in planning, designing and

construction of the facilities.

Planning and Siting

Good area planning should precede any construction design work in existing or new

premises. If the proposed new health premises are part of a long-term plan for developing

the area, the project should support the preparation of a vision plan for the premises in

order to provide a future development perspective and enable the optimal utilization of

space and energy.



When new sites are developed, the project should give strong consideration to proper site

selection criteria such as (i) accessibility (ii) availability of services such as water supply

and other infrastructure essential for development of a health care service (iii) availability

of space for waste management activities (iv) proximity to ecologically sensitive areas (v)

minimum interference with local hydrology (vi) minimum potential impact on the

surroundings of the health premises (vii) areas known to be vulnerable to natural disasters

etc

Spatial planning within the health premises should also give priority to potential for

creating green areas and other facilities for visitor/resident comfort.

Designing

The design of health facilities should give due consideration to the comfort of users and

needs of patients, children, disabled and the old.

The design of the buildings should also ensure adequate ventilation and lights and should

give priority to making the most of the potential of natural systems and renewable energy

sources.

The health facility should have adequate safe water supply and sewage/wastewater

disposal systems.

The building design also should make ample spaces and provisions for collection,

storage, transfer, treatment and disposal of HCW generated by the facility during the

operational phase. If the type of treatment facility (such as incineration) is determined the

design should incorporate the infrastructure needed to support its functioning.

Construction Protection of Ground Cover and Vegetation

Removal of existing green cover including trees should be limited to the bare minimum.

Disposal of solid waste and debris

All construction debris and residual spoil material including any left earth should be

disposed by the contractor at a location approved by the Local Authority for such a

purpose.

The debris and spoil should be disposed in such a manner that (i) waterways and drainage

paths are not blocked; (ii) the disposed material should not be washed away by floods and

(iii) should not be a nuisance to the public.

Soil Erosion

The contractor should be instructed to take all steps necessary to ensure the stability of

slopes including those related to temporary works.

Work that will lead to heavy erosion shall be avoided during the raining season. If such

activities need to be continued during rainy season prior approval must be obtained from



the hospital authority by submitting a proposal on actions that will be undertaken by the

contractor to prevent erosion.

The work, permanent or temporary shall consist of measures as per design or as directed

by the Engineer to control soil erosion, sedimentation and water pollution to the

satisfaction of the Engineer. Typical measures would include grass cover, slope drains,

retaining walls etc.

Noise

All noise generating machinery used during construction should be fitted with noise

control devises and comply with the standards stipulated by the CEA for sensitive

environments. The use of noise generating machinery should be limited to day time hours

and cause minimum disturbance to patients if in-patient care facilities already exist within

the premises and to local communities in the area.

Labour Camps

If labour camps are established, they should be provided with adequate and appropriate

facilities for disposal of sewerage and solid waste. The sewage systems shall be properly

designed, built and operated so that no pollution to ground or adjacent water

bodies/watercourses takes place. Garbage bins should be provided in the camps,

regularly emptied and disposed off in a hygienic manner, to a designated site by the Local

Authority.

The labour camps should be monitored for cleanliness and hygiene and necessary

measures should be taken to prevent any breeding of vectors.

The labour camps must be removed from the site after its need is over along with septic

tanks, garbage and other construction debris and clean. The area should be restored back

to its former condition before handing the site over.

Dust Management

To prevent dust pollution during the construction period, regular watering of the

construction site must be carried out and all material stocks onsite must be covered to

prevent dust and other particles getting airborne.

All vehicles delivering materials shall be covered to avoid spillage and dust emission.

Health and Safety

Prevention of breeding of mosquitoes at places of work, labour camps, material stores etc

should be given top priority. Stagnation of water in all areas including gutters, used and

empty cans, containers, tyres, etc must be monitored.

Contractor’s places of work, labour camps, plus office and store buildings must be kept

clean and devoid of garbage to prevent breeding of rats and other vectors such as flies.

Construction vehicles, machinery and equipment must be stationed only in designated

areas of the work site and should not pose any danger to the public or hospital users.



Material stockpiles should be located sufficiently away from the areas frequently used by

hospital workers and visitors.

If possible, construction sites should be fenced out temporarily in order to avoid any risk

posed to hospital workers and users.

Vehicle speed limits must be enforced for construction vehicles in areas near and inside

hospital premises.

Ongoing safety training and the use of safety equipment including personal protection

equipment to workers (correct type, issuance of equipment, inspection and maintenance

of equipment, replacement of worn out equipment); signs, signals, barricades and lighting

and process to follow during serious accidents

Sourcing of Raw Material

The contractor must ensure that all raw materials such as sand, rubble, metal, timber etc

required for the construction of the building are sources from licensed sources. If the

contractor himself pans to operate his own quarry/sand pit, all necessary approvals from

the relevant authorities must be obtained. Copies of such approvals should be submitted

to the hospital authority.



Annexes

Healthcare Waste Management –Rapid Assessment Tool

1. Hospital Information

2. Does the hospital have a approved Health Care Waste Management Plan? Yes

No

…………………………………………………………………………………………………

………………

3. Amount of Healthcare Waste Generated per day:

Waste type Quantity

Infectious waste

Chemical waste

Pharmaceutical waste

Sharps

Radio-active waste

Bio degradable Waste

Plastic/ polythene

Paper

a) Name of the Hospital :………………………………………

b) Bed Strength:………………………………………………...

c) Bed Occupancy Rate:……………………………………….

d) Number of wards:……………………………………………

e) Number of Staff:…………………………………………….

f) Doctors/ Nurses/ / Paramedics/ Minor Staff ………………..



Electronic waste / mercury

waste

Other

4. Details on waste handling and disposal (solid waste)

4.1 Details on waste segregation – into which categories are HCW separated?

No Segregation Non-risk HCW Hazardous HCW

Sharps Radioactive HCW Other

4.2 What type of containers are used to segregate waste (bags, cardboard boxes,

plastic/metal containers)

………………………………………………………………………………………………

………………………

………………………………………………………………………………………………

………………………

4.3 What type of labeling and color coding is used for marking segregated waste?

………………………………………………………………………………………………

………………………

………………………………………………………………………………………………

……………………

4.4 What is the method of waste collection and on-site transportation

Manual Cart/Trolley Other



4.5 Do sanitary laborers use protective clothing like masks, boots, gloves and aprons?

Yes No

4.6 What types of containers are used for collection and internal transport of waste?

(Bins, bags, boxes, trolleys, wheelbarrows etc)

………………………………………………………………………………………………

………………………

………………………………………………………………………………………………

………………………

4.7 Where is segregated waste stored while awaiting removal from the hospital or

disposal? Is this area secure?

………………………………………………………………………………………………

………………………

………………………………………………………………………………………………

………………………

4.8 Is there off-site transportation of HCW involved prior to disposal? If yes, please

provide details of the following:

Does the hospital have an approved off-site transportation plan?

………………………………………………………………………………………………

………………………

Who does the transportation?

………………………………………………………………………………………………

………………………

How often is waste removed?

………………………………………………………………………………………………

………………………

What are the control methods practiced?



………………………………………………………………………………………………

………………………

………………………………………………………………………………………………

………………………

4.9 How is HCW treated prior to disposal?

………………………………………………………………………………………………

………………………

………………………………………………………………………………………………

………………………

………………………………………………………………………………………………

………………………

………………………………………………………………………………………………

………………………

4.10 Is there a waste treatment facility available within the hospital? (incinerator/steam

sterilizer)

…………………………………………………………………………………………………

……………………

…………………………………………………………………………………………………

……………………

or

4.11 Has the hospital outsourced HCW treatment to third party? If so, does the

organization offer satisfactory services?

…………………………………………………………………………………………………

………………

…………………………………………………………………………………………………

…………………



4.12 Where is the treated waste finally disposed to?

…………………………………………………………………………………………………

……………………

…………………………………………………………………………………………………

……………………

5. Waste water generation, treatment and disposal

5.1 What is the quantity of

(i) Waste water generated per

day……………………………………………………………………

(ii) Water usage per

day…………………………………………………………………………

……

5.2 Methodology of waste water treatment and disposal

…………………………………………………………………………………………………

……………………

…………………………………………………………………………………………………

……………………

6. Staff responsible for HCW management

6.1 Is there a waste management team in the hospital with designated responsibilities?

Please provide a brief overview of how duties and responsibilities for HCWM is

organized.



…………………………………………………………………………………………………

……………………

…………………………………………………………………………………………………

…………………

…………………………………………………………………………………………………

……………………

…………………………………………………………………………………………………

……………………

6.2 Who is the focal point for HCWM in your hospital?

…………………………………………………………………………………………………

……………………

7 Has the hospital obtained the services of a cleaning service

Yes No

8 Status of obtaining Environmental Protection License and Scheduled Waste License from

the Central Environmental Authority

…………………………………………………………………………………………………

……………………

…………………………………………………………………………………………………

……………………



9 Do you think the current practices of waste handling, storage and disposal offer sufficient

security and protection against risks posed by hazardous HCW

…………………………………………………………………………………………………

………………

…………………………………………………………………………………………………

…………………

10 Issues / comments related to Healthcare Waste Management in your institution

…………………………………………………………………………………………………

……………………

…………………………………………………………………………………………………

……………………

…………………………………………………………………………………………………

……………………

…………………………………………………………………………………………………

……………………



Assessment of Healthcare Waste Management in Major Health Institutions

Name Bed

Streng

th

Bed

Occupanc

y rate

No of

Staff

Quantity of solid

waste generated

( Category wise)

Quantity

of Waste

Water

generated

Method

of

Waste

segrega

-tion

Method of

Waste

Transportati

on and

Storage

Method of

Waste

Treatment

& Disposal

Method

of

Waste

water

treatme

nt

Method of

Sewerage

Treatment

Traini

ng on

HCW

M

EPL/H

WL

obtained

1.

NHSL

3300 82% 6750 Infectious 500

Kg

Sharps 100 Kg

Chemical 25liters

Pharmaceutical

waste 10Kg

Radio active – 2

Kg

E waste 100Kg

per year

Mercury – 5Kg

per year

Used –

3750 units

NCC Storage

available

Steam

Sterilization

Disposal by

CMC

Connect

ed to

main

sewer

- Trainin

g

conduc

ted

Pending

licenses

2.TH-

CSHW

485 89.66% 1042 Infectious –

160Kg

Sharps – 9Kg

Chemical – 7.5l

50m3 –

100m3

As per

the

Nationa

l Colour

Code

Carts, storage

available

Steam

sterilization

& shredding

CMC –

recycling

paper, plastic

general

waste

Chemic

al –(

TCL)

No

treatment

Trainin

g

conduc

ted

Yes

3..Lady

Ridgeway

Hospital

901 78.4 2220 Infectious waste –

125Kg

Sharps – 15 Kg

08 Kg per 2

weeks

10 tube light

bulbs

Water

usage

675.6 m3

NCC Waste

transportation

–by Carts

Storage

available

Steam

sterilization

and

shredding at

CSHW

No No yes Applicati

ons

submitted

4TH-

Colombo

South

1093 83% 1990 Infectious- 200kg

Sharps – 100Kg

Placenta body

791.40

litres

NCC Storage

available

Treatment –

outsourced

Bio

No - yes Applicati

ons

submitted



Name Bed

Streng

th

Bed

Occupanc

y rate

No of

Staff

Quantity of solid

waste generated

( Category wise)

Quantity

of Waste

Water

generated

Method

of

Waste

segrega

-tion

Method of

Waste

Transportati

on and

Storage

Method of

Waste

Treatment

& Disposal

Method

of

Waste

water

treatme

nt

Method of

Sewerage

Treatment

Traini

ng on

HCW

M

EPL/H

WL

obtained

parts( 350kg per

week)

degradable-

local

authority

Other

recycled.

5.TH-

Peradeniy

a

954 72% 1789 Infectious –

125Kg

Sharps – 50%

Chemical – 65

litres

Radio active

600ml

180000 l NCC Storage room Out sourced Connect

ed to

sewer

Sewerage

treatment

plant

Chlorination

yes

6.De

Soyza

Maternity

Hospital

343 86.67% 850 Infectious – 100

Kg

Sharps – 5Kg

100 m3 NCC Storage Room Out sourced no No yes Applicati

ons

prepared

7.

National

Cancer

Institute

876 1199 Infectious –

177Kg

Sharps – 74Kg

Plastic Cytotoxic

75Kg

Glass Cytotoxic –

25Kg

- NCC No Out sourced No Sewerage

treatment

plant

yes Applicati

on

Submitte

d

8.T H -

Karapitiya

1606 85.7% 2571 Infectious –

175Kg

Sharps 30Kg

25 liters NCC Storage

Rooms

Incinerator

available –

not adequate

yes Applicati

ons to be

submitted

.

9.TH –

Chest

Hospital

671

- 423 Infectious – 80

Kg

Sharps – 6kg

Chemical – 5Kg

275 m3 NCC Storage – not

satisfactory

Incineration

– not

adequate

Waste

water

treatme

nt plant

yes NO

10.TH- 115 89.15% 355 Infectious -08 Kg - NCC No - storage Open Waste yes Not No



Name Bed

Streng

th

Bed

Occupanc

y rate

No of

Staff

Quantity of solid

waste generated

( Category wise)

Quantity

of Waste

Water

generated

Method

of

Waste

segrega

-tion

Method of

Waste

Transportati

on and

Storage

Method of

Waste

Treatment

& Disposal

Method

of

Waste

water

treatme

nt

Method of

Sewerage

Treatment

Traini

ng on

HCW

M

EPL/H

WL

obtained

Sirimavo

Bandarnai

ke CH

Sharps – 5Kg burning water

connect

ed to

sewer

adequa

te

11.TH _

Jaffna

1228 90& 1104 Infectious

1000Kg

Sharps 150Kg

Cytotoxic 1800Lg

per year

165,000

gallons

NO

Disposed by

Local

authority

Waste

water

connect

ed to

sewer

yes Not

adequa

te

Preparati

on for

Submissi

on

12.TH –

Kurunegal

a

1650 87% 2725 Infectious –

2000Kg ????

Sharps – 79.5%

250m3 NCC Under

construction

Incineration

Not adequate

No No yes No

13.Nation

al Institute

of Mental

Health

1514 62.81% 1052 Infectious – 13

Kg

Sharps – 1.5 Kg

- NCC Storage area

available

Out sourced No Available

not

functioning

yes Applicati

ons

submitted

14. Sri

Jayawarde

napura G

H

1046 66% 1608 Infectious –

100Kg

Sharps – 15Kg

Chemical –

100Kg

- NCC Storage

Available

Incineration yes yes yes Licenses

obtained

15.TH -

Kandy

2286 81% 4672 Infectious –

470Kg

Sharps – 71Kg

Placenta – 60Kg

Cytotoxic Waste –

600Kg

NCC Storage

Available

Out Sourced No Yes Yes Licenses

Obtained

16.TH –

Mahamod

ara - Galle

252 95.54% 758 Infectious – 55Kg

Sharps – 4-5

boxes

20m3 NCC Demarcated

storage area

Steam

Sterilizer

No No No Applicati

ons

submitted

17.TH-

Colombo

North


120Kg

Sharps -24Kg

- NCC Demarcated

Area

Incinerator

+

Out Sourced

No No yes



Name Bed

Streng

th

Bed

Occupanc

y rate

No of

Staff

Quantity of solid

waste generated

( Category wise)

Quantity

of Waste

Water

generated

Method

of

Waste

segrega

-tion

Method of

Waste

Transportati

on and

Storage

Method of

Waste

Treatment

& Disposal

Method

of

Waste

water

treatme

nt

Method of

Sewerage

Treatment

Traini

ng on

HCW

M

EPL/H

WL

obtained

18.TH -

Kegalle


327Kg

Sharps – 76.5Kg

Chemical Waste -

54 liters

- NCC yes Burning and

buring

Connect

ed to

sewer

yes yes No

19.IDH 200 220 Infectious – 8 –

10 Kg

Sharps - 01Kg

Chemical 1-2Kg

NCC Secure Area

20. DGH-

Gampaha

708 73.83% 979 Infectious – 90Kg

Sharps – 10Kg

03m3 NCC Separate Huts

Available

Incineration Drafted

a

project

prposal

NO

21

Rehabilitat

ion

Hospital _

Ragama

259 72.5% 322 Infectious – 20Kg

Sharps – 4Kg

240m3 NCC No Clinical

Waste –

transported

to NCTH -

Ragama

Collecte

d in a

closed

pit

No Applicati

ons

Submitte

d

22. DGH -

Kalutara


300Kg

Sharps -10Kg

30 000

liters

NCC Storage room

available not

adequate

Open

burning of

infectious

waste

Sharps – out

sourced

Connect

ed to

Sewera

ge

System

Yes Applicati

ons

submitted

23.PGH

Ratnapura

1010 78% 1847 Infectious –

1000Kg

Sharps – 50Kg

Pharmaceutical

waste – 20Kg

Cytotoxic waste –

30Kg per year

500000L

Water

usage-

1200000L

NCC Storage and

demarcated

area

available.

Incinerator. No

method

Sewerage

system

available.

yes No



Name Bed

Streng

th

Bed

Occupanc

y rate

No of

Staff

Quantity of solid

waste generated

( Category wise)

Quantity

of Waste

Water

generated

Method

of

Waste

segrega

-tion

Method of

Waste

Transportati

on and

Storage

Method of

Waste

Treatment

& Disposal

Method

of

Waste

water

treatme

nt

Method of

Sewerage

Treatment

Traini

ng on

HCW

M

EPL/H

WL

obtained

Mercury waste –

50 l x12 per year.

24..PGH

Badulla

1375 78% 1807 Infectious –

1500Kg

Sharps -75Kg

Chemical 90 100 l

Cytotoxic 10Kg

per year

1,10,000l NCC Storage

available

incineration Adding

TCLfilt

eration

Connect

ed to

sewerag

e

Sewerage

system

available.

yes Applicati

ons

submitted

25. DGH

– Ampara

530 80% 930 Infectious -175 -

200Kg

Sharps – 50 -70

Kg

- NCC Demarcated

area available

Incineratorav

ailable – not

adequate

Waste

water

treatme

nt

system

availabl

e

- yes Applicati

ons

Submitte

d

26. DGH

_

Negambo

676 - 873 Infectious –

400Kg

Sharps – 300Kg

- NCC Yes Open

burning/

burring

Connect

ed to

Sewera

ge

System

yes No No

27. DGH

– Nuwara

eliya

427 90% 617 Infectious – 50

Kg

Sharps- 05Kg

10 liters NCC Storage

Available

Disposed at

the land fill

Sharps –

Sharp pit at

the land fill

Connect

ed to

sewerag

e

System

yes yes No

28.DGH –

Nawalapiti

ya

526 69.3% 567 Infectious – 25-

30Kg

Sharps – 12-15Kg

4000-

6000 liters

NCC yes Buring

burning

Connect

ed to

sewerag

e

Yes – needs

repairs

yes Applicati

ons

submitted

29.DGH -

Matale

737 60.62% 22 Infectious 250 Kg

Sharps 10Kg

Pharmaceutical

2500 liters NCC yes Incineration Connect

ed to

Sewera

Sewerage

system

available

conduc

ted

Applicati

ons

submitted



Name Bed

Streng

th

Bed

Occupanc

y rate

No of

Staff

Quantity of solid

waste generated

( Category wise)

Quantity

of Waste

Water

generated

Method

of

Waste

segrega

-tion

Method of

Waste

Transportati

on and

Storage

Method of

Waste

Treatment

& Disposal

Method

of

Waste

water

treatme

nt

Method of

Sewerage

Treatment

Traini

ng on

HCW

M

EPL/H

WL

obtained

waste -650 mg

Chemical – 10

liters

Mercury – 120 g

per year

ge pit .

30. GH –

Trincomal

ee

435 0.61% Infectious – 62Kg

Sharps-07Kg

- No Incineration/

Placenta pits/

burning

Connect

ed to

sewerag

e

system

Sewerage

system

No No

31.GH –

Polonnaru

wa


130kg

Sharps – 130Kg

Chemical – 03

liters

Radio – active 08

liters

400m3 NCC yes Open

burning

Connect

ed to

sewerag

e plant

Yes yes Yes ???

32. BH -

Gampola

352 82.9 488 Infectious – 10

Kg

Sharps – 10 Kg

- NCC yes Incineration - - No No

33. BH =

Teldeniya

87 45-50% 75 Infectious – 05Kg

Sharps – 500g

- NCC yes Incinerator (

Locally

made)

Filterati

on

Method

No No No

34.BH-

Kantale

231 43.36% 388 Infectious – 20Kg

Sharps – 10kg

320 Liters NCC Yes Incineration

& Placenta

Pit

No Request

made

yes No

35. Base

Hospital -

Dehiattaka

ndiya

135 100% 246 Infectious 50 kg

Sharps 1 Kg

Pharmaceutical

waste 1 Kg

Chemical 3 Kg

Radio active

400 liters NCC yes Open

burning/

incineration

Soakage

pit

- No No



Name Bed

Streng

th

Bed

Occupanc

y rate

No of

Staff

Quantity of solid

waste generated

( Category wise)

Quantity

of Waste

Water

generated

Method

of

Waste

segrega

-tion

Method of

Waste

Transportati

on and

Storage

Method of

Waste

Treatment

& Disposal

Method

of

Waste

water

treatme

nt

Method of

Sewerage

Treatment

Traini

ng on

HCW

M

EPL/H

WL

obtained

waste – 3kg

E waste 01 Kg per

year

Cytotoxic waste

0.5l per year

Documents

Draft Environmental Management Framework - World Bank€¦ · Second Health Sector Development Program Page. 6. Chapter 1: Overview of the Second Health Sector Development Program