Health Care Waste Management in India - World Bank€¦ · iv Healthcare Waste Management in India....

Health Care Waste Management in IndiaLessons from Experience

Environment and Social Development DepartmentSouth Asia Region

BEKIR ONURSAL

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Health Care Waste Management in IndiaLessons From Experience

BEKIR ONURSAL

October 2003

THE

WORLD

BANK

Copyright © 2004

This paper has not undergone the review accorded to official World Bank publications. The findings,interpretations, and conclusions expressed herein are those of the author(s) and do not necessarily reflectthe views of the International Bank for Reconstruction and Development / The World Bank and its affiliated organizations, or those of the Executive Directors of The World Bank or the governments theyrepresent. The World Bank does not guarantee the accuracy of the data included in this work.The boundaries, colors, denominations, and other information shown on any map in this work do notimply any judgement on the part of The World Bank concerning the legal status of any territory or theendorsement or acceptance of such boundaries.

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Foreword . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .v

Acknowledgments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vii

Abbreviations and Acronyms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .ix

Executive Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xi

A National Legal Framework for Managing Health Care Wastes . . . . . . . . . . . . . . . . . . . . . . . . .xiState Strategies and Activities Related to Health Care Waste Management . . . . . . . . . . . . . . . . .xiiHealth Care Facilities’ Waste Management Practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xiiThe Private Sector’s Role in Health Care Waste Management . . . . . . . . . . . . . . . . . . . . . . . . .xiiiLessons Learned from India’s Experience . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xiiiRoad to the Future . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xiv

Chapter 1. The Problem of Health Care Wastes . . . . . . . . . . . . . . . . . . 1

Exposure and Risks from Biomedical Wastes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1Health Care Waste Management Efforts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2

Chapter 2. A National Legal Framework for Managing Health Care Wastes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

The Biomedical Waste Rules of 1998 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3National Guidelines for Implementing the Biomedical Waste Rules . . . . . . . . . . . . . . . . . . . . . 5National Training and Coordination with States . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7

Chapter 3. State Strategies and Activities Related to Health Care Waste Management . . . . . . . . . . . . . . . . . . . . . . . . . . 9

State Strategies for Health Care Waste Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9State Guidelines for Health Care Waste Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12

Table of Contents

iii

State Assistance to Government Health Care Facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Training for Health Care Facility Personnel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Supply of Materials for Health Care Facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Procurement of Waste Treatment Equipment and Disposal Facilities . . . . . . . . . . . . . . . . . . . 13

State Regulatory Agencies’ Enforcement of the Biomedical Waste Rules . . . . . . . . . . . . . . . . . 13

Chapter 4. Health Care Facilities’Waste Management Activities . . . . . . 15

Health Care Facilities’ Commitment to Managing Wastes . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15Health Care Facilities’Waste Audits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Planning for Managing Wastes at Health Care Facilities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Chapter 5. The Private Sector’s Role in Providing Waste Management Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

On-Site Waste Management Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Off-Site Waste Management Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Chapter 6. Lessons from India’s Experience . . . . . . . . . . . . . . . . . . . . 27

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Appendix A. India’s Health Care Waste Management Practices and Requirements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33

Appendix B. Results of Health Care Waste Audits for Government Hospitals in Three States . . . . . . . . . . . . . . . . . . . . . 37

Boxes

Box 1. Main Features of India’s Biomedical Waste Rules of 1998 (amended twice in 2000) . . . . . . . . . . . . . . . . . .4Box 2. Biomedical Waste Treatment and Disposal Technologies Specified in India’s Biomedical Waste Rules . . . . . .6Box 3. Incineration of Health Care Wastes in India . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7Box 4. Comparison of Biomedical Waste Management Strategies in Two States:Andhra Pradesh and Kerala . . . . .11Box 5.A Privately Owned CWTF in the Twin Cities Area of Andhra Pradesh . . . . . . . . . . . . . . . . . . . . . . . . . . .23

Tables

Table 1. Overview of the Types of Health Care Wastes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2Table 2. Composition and Amount of Health Care Waste Generated by 25 Government Hospitals

in 3 States before Implementation of the Biomedical Waste Rules . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17Table 3. Biomedical Waste Generation Rates at Selected Hospitals in Madhya Pradesh and Uttar Pradesh . . . . . . .18Table 4. Composition and Amount of Communal Waste Generated by Eight Hospitals in West Bengal . . . . . . . . .19

iv Healthcare Waste Management in India

The World Bank has supported in the health sectorin India for many years. As part of that involve-ment, the Bank has made increasing efforts to

highlight issues related to management of health carewastes.These efforts reflect both a growing internationalawareness and a response to particular events in India.

Improper management of health care wastes is apublic concern because of risks of infection, injury, andother health hazards. Poor health care waste managementis also a reflection of broader management deficiencies inhealth care facilities. Public awareness about the dangersof careless disposal, and the introduction of regulatorymeasures for managing these wastes, are both relativelynew in India.

This report presents an overview of the responsesand concerns in India associated with health care wastemanagement at the central, state, and local levels. Thereport is based on the Bank’s experience in working withclients and draws heavily on an internal review of Bankoperations. We hope that the experience reported herewill stimulate debate among, and support for, thoseengaged in these issues.

Richard AckermannDirector, Environment and Social Development

South Asia RegionThe World Bank

Foreword

v

This report was prepared in the Environment andSocial Development Department of the SouthAsia Region of the World Bank. Many cases pre-

sented in this report are based on a review of the Bank’shealth sector portfolio in the South Asia Region byBekir Onursal and Banu Setlur, in coordination withTawhid Nawaz.

The author of this report, Bekir Onursal, wouldlike to extend special thanks to Richard Ackermann for

his guidance and support; to Ravi Agarwal, DavidHanrahan, Prasad Modak, Allan Rotman, and PanneerSelvam for their review and suggestions on the draftreport; and to K.S. Sai Baba for updated health carewaste management information for Karnataka. Theauthor would also like to thank Ai Chin Wee, NancyCarson, Kaye Henry, Kerry Kemp, Lana Moriarty, andBela Varma for administrative and editorial support dur-ing preparation of this report.

Acknowledgments

vii

BMW Biomedical wasteCPCB Central Pollution Control BoardCWTF Common waste treatment facilityHCW Health care waste

NGO Nongovermental organizationSPCB State Pollution Control BoardWHO World Health Organization

Abbreviations and Acronyms

ix

Health care wastes (HCWs) are all wastes gener-ated by health care and health research facilitiesand associated laboratories. They include both

(a) “communal waste,” such as paper and bottles that canbe dealt with through the local solid waste managementsystem; and (b) potentially dangerous “biomedicalwastes” (BMWs), such as sharps (needles, scalpels, knives,blades, broken glass) and wastes with infectious, haz-ardous, radioactive, and genotoxic properties that endan-ger human health and the environment. ManagingHCWs safely is essential, but not easy.

This report describes India’s steep learning curve inthe management of HCWs in the last decade and drawsa number of lessons from India’s experience. Since 1995,India has made great progress in managing HCWs,notwithstanding delays caused by weaknesses in thecountry’s legal and institutional framework for HCWmanagement.The national government has promulgatedBiomedical Waste Rules, prepared national guidelines,and implemented a national training program. States havedevised their own HCW management strategies andguidelines and provided assistance to government hospi-tals in implementing HCW management initiatives.Nongovernmental organizations (NGOs) have played amajor role in bringing the HCW management agenda tothe attention of government officials, creating publicawareness of HCW issues and training health care facili-ty personnel.The culture at many health care facilities haschanged to recognize the importance of adopting goodHCW management practices, and the private sector hasbecome increasingly involved in providing HCW man-

agement services both on and off the premises of healthcare facilities. India can now build on this initial HCWmanagement experience to improve legislative andpractical approaches. Coupling the current HCW man-agement knowledge base with more effective use ofinformation technology could help health care facilitiesin India internalize good HCW management practicesas an essential component of their operation.

A National Legal Framework forManaging Health Care WastesIn 1995, despite rising concerns about toxic emissionsfrom the incineration of municipal and HCWs, India’sMinistry of Environment and Forests drafted HCWmanagement legislation that identified incineration asthe technology of choice for health care facilities. Soonthereafter, the Supreme Court ordered the installationof approximately 60 incinerators at hospitals in theNew Delhi area that had more than 50 beds. Many ofthe incinerators that were installed are no longer func-tional and therefore represent a wasted investment; ofthe 26 incinerators that remain, all but one are substan-dard by today’s standards.The situation with respect toinvestments in substandard incinerators at health carefacilities in New Delhi has parallels in many otherurban areas of India.

Nongovernmental organizations in India played amajor role in heightening awareness of health and envi-ronmental issues related to the management of HCWsamong government officials and the public. In 1995, theNGO Srishti conducted a survey that revealed unsanitary

Executive Summary

xi

practices and risks in dealing with HCWs. In 1996, Srishtiinitiated public interest litigation against the governmentthat led the Supreme Court to reverse its order for incin-eration at health care facilities.The Supreme Court subse-quently ordered India’s Central Pollution Control Board(CPCB)—the technical arm of the Ministry ofEnvironment and Forests—to consider alternative andsafer technologies in HCW management rules and to setup technology standards. During the following two years,while CPCB was evaluating alternative HCW treatmentand disposal technologies, there were consultations amongthe government, health care sector, scientific community,industry, and NGOs about incineration and other options.The result of this process, in 1998, was the promulgationby the Ministry of Environment and Forests of a new setof rules for handling BMW.

India’s new rules—the Biomedical Waste (Handlingand Management) Rules of 1998—were based on theprinciple of segregation of communal waste from BMW,followed by containment, treatment, and disposal ofBMWs in different categories.The new rules also listedwaste treatment and disposal technology options, alongwith standards.The rules were amended twice in 2000,primarily to address administrative matters.

The Biomedical Waste Rules still have some internalinconsistencies and deviate in some respects from the1999 World Health Organization (WHO) guidelines forthe safe management of HCWs (Prüss, Giroult, andRushbrook 1999). Nonetheless, these rules—and subse-quent national guidelines—established a national frame-work for HCW management and were instrumental inraising awareness in India about the health risks and goodmanagement practices of HCWs among health care facil-ity personnel; government officials at the central, state,and local levels; and the general public.

State Strategies and Activities Related to Health Care Waste ManagementThe responsibility for implementing India’s BiomedicalWaste Rules was delegated to individual states and territories, with State Pollution Control Boards(SPCBs) in states and Pollution Control Committees interritories designated as the authorities. The nationalrules require that each state constitute a committee toadvise the state government and the SPCBs aboutimplementation of the rules. For such an advisory com-mittee to function effectively, there must be close coor-dination and participation among different stake-holders—in particular, state environmental and health

agencies, local authorities, health care facility represen-tatives, academia, and NGOs.

Individual states have had to develop their own specific strategies for HCW management. One of thestrategic decisions that state authorities had to make washow to refine the technology options included in theBiomedical Waste Rules. Another strategic decision forstate authorities was whether to opt for on-site treatmentof BMWs or common treatment of BMWs. Commontreatment of BMWs can offer several advantages in termsof better and more efficient operation of the treatmentequipment by trained personnel, reduction of the poten-tial adverse human health impacts and waste treatmentand disposal costs, and lessening of the enforcement burden on the regulatory agencies involved. For thesereasons, India’s central government views common wastetreatment as the most appropriate approach to the treat-ment of BMWs generated in urban areas.

State health departments have prepared guidelinesto facilitate implementation of the Biomedical WasteRules at government hospitals.A review of these guide-lines reveals a number of shortcomings. An importantcurrent need, therefore, is to improve the quality of theseguidelines and identify good practices for disseminationacross states.

State health departments also have provided assis-tance to government hospitals for HCW management inthe form of personnel training, waste management audit-ing, preparation of hospital-specific plans, procurement ofmaterials and supplies, and construction of on-site dis-posal facilities. Private hospitals in India have had tocomply with the requirements of the Biomedical WasteRules using their own resources.

Health Care Facilities’WasteManagement PracticesOne of India’s major achievements has been to changethe attitudes of the operators of health care facilities toincorporate good HCW management practices in theirdaily operations and to purchase on-site waste manage-ment services from the private sector. The assistance provided to government hospitals by state health depart-ments—in part through World Bank–financed projects—has contributed to this change. National and regionalworkshops, training programs, and other efforts have ledto an increasing recognition that hygiene and HCWmanagement are essential to good hospital managementpractices. Despite the progress that has been made,however, there is room for improvement in bringing

xii Healthcare Waste Management in India

HCW management to the attention of medical officersand doctors, improving hospital-specific plans, and con-ducting refresher training so that health care facility staffcan fully internalize these plans.

A review of HCW management practices at govern-ment hospitals in India reveals wide differences in prac-tices among hospitals in different states. State-level HCWmanagement guidelines are sometimes prepared by localconsultants and NGOs with no or little experience inother states, and such consultants and NGOs may vary intheir interpretations of the Biomedical Waste Rules,which are themselves inconsistent. Hospital-specificHCW management plans are also prepared by local pri-vate consultants or NGOs that vary in their interpreta-tions of state-specific HCW management guidelines.

The Private Sector’s Role in Health Care Waste ManagementSince the implementation of the Biomedical WasteRules, private sector firms have become increasinglyinvolved in providing both on-site and off-site HCWmanagement services for health care facilities. The culture change resulting from implementation of theBiomedical Waste Rules has led some government hospitals to contract with private sector organizationsfor on-site waste management services previously performed by health care facility personnel. Althoughsome facility staff concerned about losing their jobs haveresisted this approach, the experience of using privatecontractors for on-site HCW management has yieldedsignificant improvements in the overall cleanliness andsanitary conditions for health care facility personnel,patients, and their visitors, as well as a positive change inpublic opinion.

Participation by private sector firms in the provisionof off-site HCW management services has been associat-ed with the collection of segregated BMWs from thehealth care facilities, treatment at common waste treat-ment facilities (CWTFs), and disposal of the treatedwastes.These services have become an integral part of astate strategy in some states of India. Major credit goes toofficials in the State of Andhra Pradesh. These officialswere instrumental in convincing health care facility rep-resentatives to pay for off-site treatment and disposal oftheir BMWs; they were also able to bring along the firstinvestor for a CWTF with no government subsidies, justa guarantee from the state government that the CWTFwill receive BMW from a specified number of care facil-ities with a specified number of beds. Successful experi-

ence with the first CWTF in Andhra Pradesh led to theinvestment of a second CWTF based on the build-own-operate model by the private sector there.The approachwas subsequently replicated in Karnataka, Maharashtra,Punjab, Rajasthan, Tamil Nadu, and there are currentplans for CWTFs in Gujarat, Kerala, New Delhi, UttarPradesh, and West Bengal.

Lessons Learned from India’s ExperienceSeveral major lessons can be drawn from India’s experience:• Initiating HCW management legislation and practice

without adequate background work results in delayand costly readjustments. Preparing background stud-ies with a situation analysis, evaluating alternatives,and involving key stakeholders in the process areintegral steps to establishing a sound basis for HCWmanagement legislation. India did not take all thesesteps, and the result was a rather convoluted processwith delays in the preparation and implementation ofIndia’s HCW management legislation.

• HCW guidelines must be timely and informed by fieldexperience. HCW guidelines are an important tool forimplementation of the Biomedical Waste Rules byhealth care facilities, BMW transporters, and BMWtreatment and disposal facility owners and operators.National guidelines for implementing the BiomedicalWaste Rules were published at a rather late date andwere not comprehensive. This situation, along withinternal inconsistencies in the Biomedical Waste Rulesthemselves, resulted in considerable implementationdifficulties.

• Many approaches and tools are necessary to informopinions and change actions. The central and stategovernments, NGOs, the media, and others haveplayed an important role in creating awareness of andsharing knowledge about HCW management issuesamong the general public, policymakers, and otherparties in India.The tools used by these parties rangefrom the promulgation of national rules to trainingsessions for the personnel of health care facilities.

• Hospitals can change their culture and improve HCWmanagement practices. Since implementation of the Biomedical Waste Rules, and with assistance pro-vided to health care facilities by state health depart-ments, the culture at many health care facilities inIndia has changed to recognize hygiene and HCWmanagement as essential to good hospital manage-ment practices.

Executive Summary xiii

• The private sector’s role in on-site HCW managementis becoming increasingly important. With the imple-mentation of the Biomedical Waste Rules andincreased recognition of the need for good HCWmanagement practices at health care facilities, the pri-vate sector’s involvement in providing on-site HCWmanagement services is growing.

• Effective state strategies for CWTFs, with private sector involvement, are emerging. Management ofBMWs at a CWTF has become an integral part ofthe state HCW management strategy in some statesof India. State officials in Andhra Pradesh succeededin convincing health care facility representatives topay for off-site treatment of their BMWs at a privately built, owned, and operated CWTF—andtheir success with this approach has led other statesto emulate it.

• Strong and clear regulatory commitment improvesimplementation of the Biomedical Waste Rules. SPCBsin the states and Pollution Control Committees in theterritories are the regulatory agencies in India respon-sible for enforcing the requirements of the BiomedicalWaste Rules. The capacity of these agencies to act—and their determination to do so—has made a majordifference in the effectiveness of implementing theBiomedical Waste Rules.

• Information technology has a crucial role to play inHCW management. Information technology has greatpotential for creating public awareness of HCW man-agement issues and for sharing knowledge aboutHCW management practices at health care facilities.

Road to the FutureDespite inefficiencies caused by weaknesses in India’s legaland regulatory framework and institutions, the road to thefuture in HCW management in India is now clear. Thediligent efforts by NGOs in India that demonstrated theunsafe conditions of on-site incinerators have resulted inguidelines that allow incineration at CWTFs but prohibituse of on-site incineration without a special permit fromthe CPCB.There is hope that the initial successful experi-ence with privately built, owned, and operated CWTFs inAndhra Pradesh and other states in India will form thefoundation for common practice for urban areas of India.Changes in culture regarding hygiene and HCW manage-ment practices have occurred at many health care facilities,and many facilities now accept the need to pay for off-sitetreatment and disposal of BMWs.The challenge now is topromote broader and better implementation of HCWmanagement practices across India, while taking intoaccount the wide variety of circumstances, facilities, andcapabilities in the country’s health sector.

xiv Healthcare Waste Management in India

Health care wastes (HCWs) are all wastes gener-ated from health care and health research facil-ities and associated laboratories. The different

types of HCWs and examples of each type are presentedin Table 1. Most HCWs are “communal waste”—solidwastes generated from administrative, housekeeping,kitchen-related, and maintenance operations of healthcare facilities. Such waste can usually be dealt withthrough the local solid waste management system. OtherHCWs are sharps and wastes with infectious, hazardous,radioactive, or genotoxic characteristics that are poten-tially hazardous to humans and the environment. Thesemore dangerous HCWs—called “biomedical wastes”(BMWs) in India—constitute only a small fraction of thetotal waste stream, but their presence demands carefulmanagement. Defining, identifying, and separatingBMWs from communal wastes is central to the propermanagement of HCWs.

Exposure and Risks from Biomedical WastesSources of BMWs in health care facilities include wards,delivery rooms, operating theaters, emergency and out-patient services, laboratories, and pharmaceutical andchemical stores. Persons at risk of exposure includehealth care facility employees (doctors, nurses, health careassistants, maintenance personnel, and support personnel

for waste handling, transportation, and laundry), patientsand their visitors, and waste management facilityemployees and scavengers.

Infectious wastes containing potentially harmfulmicro-organisms can infect hospital patients, health careemployees, and patients’ visitors. Used needles, syringes,and other sharps present risks of injury and infection (forexample, hepatitis B and C, and HIV) for health careemployees. Chemical and pharmaceutical wastes maycause intoxication or injuries such as burns. Genotoxicwastes are hazardous and may have mutagenic,1 terato-genic,2 or carcinogenic properties. Radioactive sourcesmay cause severe injuries to humans such as destruction oftissue. Untreated liquid wastes from health care facilitiesand sewerage present risk of surface water contamination,and leachate from untreated or improperly treated HCWsmay contaminate groundwater at disposal sites.

Improper disposal of BMWs in open dumpsincreases the risk of injury from sharps and the spread ofinfectious diseases to waste handlers and scavengers, anduncontrolled burning of BMWs increases the risk ofexposure to hazardous emissions. In addition, poorlydesigned or operated BMW incinerators pose health andenvironmental risks to incinerator operators and nearbycommunities. Such incinerators may emit carcinogenicdioxins and furans,3 formed through incomplete com-bustion at low temperatures of BMWs containing

CHAPTER 1

The Problem of Health Care Wastes

1

1.A mutagen is an agent that can induce or increase the frequency of a mutation in an organism.

2.A teratogen is an agent that causes malfunction of an embryo or a fetus.

3. Dioxins and furans are polychlorinated hydrocarbons.

chlorine-based components (such as polyvinyl chlorideor sodium hypochlorite) and organic materials.4

Emissions of particulate matter containing heavy metals(for example, cadmium, lead, and mercury) increase therisk of neurotoxic and carcinogenic effects. Acid gases(for example, hydrogen chloride and sulfur dioxide) cancause eye and respiratory irritation as well as environ-mental damage (acid rain) and material damage (corro-sion of metals).

Health Care Waste Management EffortsSystematic efforts to mitigate risks associated withHCWs are fairly recent. In the United States, public out-

cry over the discovery of hypodermic needles and otherBMWs littering the New Jersey beaches in the summerof 1988 triggered legislative measures at the federal andstate levels.5 Following the U.S. trend, other industrialand most developing countries initiated a wave of regu-latory actions on HCW management. In South Asia, sys-tematic efforts to mitigate the adverse impacts of BMWswere initiated in 1995 by the Government of India. InBangladesh, although HCW management has beenaddressed through specific projects since 1999, the legalframework is not yet established. In Sri Lanka, despite alate start, a strong basis was created for a legislative frame-work in 2001.

2 Healthcare Waste Management in India

Table 1. Overview of the Types of Health Care Wastes

Types of Health Care Wastes Examples

Communal wastea (solid wastes that are not infectious, chemical, or radioactive) Cardboard boxes, paper, food waste, plastic and glass bottles

Biomedical wastesb

Infectious waste (wastes suspected of Cultures, tissues, dressings, swabs, and other blood-soaked items; waste containing pathogens) from isolation wards

Anatomical waste Recognizable body parts

Sharps Needles, scalpels, knives, blades, broken glass

Pharmaceutical waste Expired or no longer needed medicines or pharmaceuticals

Genotoxic waste Wastes containing genotoxic drugs and chemicals (used in cancer therapy)

Chemical waste Laboratory reagents, film developer, solvents, expired or no longer needed disinfectants, and organic chemical wastes (for example, formaldehyde,phenol-based cleaning solutions)

Heavy metal waste Batteries, broken thermometers, blood pressure gauges

Pressurized containers Aerosol cans, gas cylinders (that is, anesthetic gases such as nitrous oxide,halothane, enflurane, and ethylene oxide; oxygen, compressed air)

Radioactive waste Unused liquids from radiotherapy; waste materials from patients treated or tested with unsealed radionuclides

a.Also known as “general health care wastes.”

b.Also known as “hazardous health care wastes,”“health care risk wastes,” or “special wastes.”

Source: Prüss, Giroult, and Rushbrook 1999.

4.Temperatures between 200˚C and 400˚C are most conductive to forming dioxins and furans.

5.The U.S. Government enacted the Medical Waste Tracking Act in November 1988, and the U.S. Environmental Protection Agency prom-ulgated the Standards for the Tracking and Management of Medical Wastes in 1989; subsequently, states passed their own health care waste manage-ment legislation.

India was the first country in South Asia to establish alegal framework for the management of health carewastes. The development of India’s legal framework

began in 1995.At that time, the scope of the HCW prob-lem was rather large.According to the Central PollutionControl Board (CPCB)—the technical arm of India’sMinistry of Environment and Forests—an estimated 150tons/day of biomedical waste generated from health carefacilities were being mixed in with communal wasteswithout adequate attention to proper waste managementprocedures (CPCB 2000).

In 1995, India’s Ministry of Environment and Forestsdrafted rules for managing BMWs that proposed (a) thateach health care facility with more than 30 beds or serv-ing more than 1,000 patients per month install an incin-erator on its premises; and (b) that smaller health carefacilities set up a common incinerator facility. Shortlythereafter, in March 1996, the Supreme Court directedthe Government of India to install incinerators at all hos-pitals in the New Delhi area that had more than 50 beds.Sixty incinerators were installed in the New Delhi area,and 26 of them are still in service. Only one of theseincinerators meets today’s national norms—an incinera-tor at RML Hospital that was re-engineered by CPCB.

Meanwhile, in 1995, Srishti, a nongovernmentalorganization (NGO), had taken a survey that revealedunsanitary practices and associated risks in dealing withHCWs in India. In 1996, Srishti initiated public interestlitigation against the government that led the SupremeCourt to revise its initial position for incineration athealth care facilities by ordering India's Central Pollution

Control Board (CPCB)—the technical arm of theMinistry of Environment and Forests—to consider alter-native and safer technologies in HCW management rulesand to set up technology standards.

A major drawback of incineration is that it producestoxic air emissions. The principal pollutants in terms ofpublic health are heavy metals (such as cadmium, mercu-ry, and lead), hazardous by-products from combustion(such as dioxins and furans), and particulate matter. Srishtiasked the Supreme Court to require alternative and safertechnologies in the rules and the setting up of standardsfor these alternative technologies.

At Srishti’s urging, India’s Supreme Court revised itsinitial position and ordered CPCB to consider alternativeBMW treatment and disposal technologies. Between1996 and 1998, while CPCB was evaluating alternativetechnologies, there were intensive consultations amonggovernment officials, health care representatives, scientists,members of the industry, and NGOs.The culmination ofall these efforts was the preparation and publication byIndia’s Ministry of Environment and Forests of theBiomedical Waste (Handling and Management) Rules of1998.Those rules are discussed further below.

The Biomedical Waste Rules of 1998India’s Biomedical Waste Rules of 1998, which wereamended twice in 2000, are based on the principle ofsegregation of communal waste from BMWs, followed bycontainment, treatment, and disposal of different cate-gories of BMW (Box 1).The rules classify BMWs into 10categories and require specific containment, treatment,

CHAPTER 2

A National Legal Framework forManaging Health Care Wastes

3


a.There will be no chemical pretreatment before incineration. Chlorinated plastics will not be incinerated.

b. Deep burial is allowed only in cities with population less than 500,000 and in rural areas.

Source: Ministry of Environment and Forests 1998.

In 1998, India’s Ministry of Environment and Forests pre-pared and issued the Biomedical Waste (Handling andManagement) Rules.The main features of the current rulesare summarized here and in the table below:• Definition of biomedical waste. Any waste that is generat-

ed during the diagnosis, treatment, or immunization ofhuman beings or animals, or in research activities pertain-ing to or in the production or testing of biologicals.

• Application of the Biomedical Waste Rules. The rulesapply to all persons who generate, collect, receive, store,transport, treat, dispose, or handle BMWs in any form.

• Duty of occupier (operator). It is the duty of the occupier(operator) of a health care facility—that is, hospital, nurs-ing home, clinic, dispensary, veterinary institution, animalhouse, pathological laboratory, blood bank—to ensurethat BMWs are handled without any adverse effect tohuman health and the environment, and according to theprescribed treatment and disposal requirements in theBiomedical Waste Rules.

• Prescribed authority. State Pollution Control Boards(SPCBs) in states and Pollution Control Committees interritories are responsible for permitting and enforcingthe requirements of the Biomedical Waste Rules.

• Permitting. Each occupier (operator) handling BMWs andproviding services to 1,000 or more patients per month isrequired to obtain a permit from the prescribed authority.

• Recordkeeping. Each occupier (operator) is required tomaintain records on the generation, collection, reception,storage, transportation, treatment, and disposal of BMWs.All records are subject to inspection and verification bythe prescribed authority at any time.

• Accident reporting. Each occupier (operator) is required toreport any accident related to the management of BMWs.

• Annual reporting. Each occupier is required to submit anannual report to the prescribed authority to provideinformation about categories and amounts of wastes gen-erated and treated, and modes of treatment.

• Common disposal/incineration sites. Local public entitiesare required to provide common disposal/incinerationsites, and the occupiers (operators) of such sites arerequired to comply with the Biomedical Waste Rules.

• Segregation, packaging, transportation, and storage.

BMWs are not to be mixed with other waste. Accordingto the Rules, BMWs are to be segregated into labeledbags/containers. Transportation of BMWs is to be con-ducted in authorized vehicles. No untreated waste is to bestored more than 48 hours, unless special permission isobtained from the regulatory authorities.

• Standards. Technology and discharge standards for inciner-ation, autoclaving, microwaving, liquid waste discharges,and deep burial are prescribed in the Biomedical WasteRules.

Box 1. Main Features of India’s Biomedical Waste Rules of 1998 (amended twice in 2000)

No. Biomedical waste category Container color Treatment/disposal option

1 Human anatomical waste Yellow Incinerationa/Deep burialb

2 Animal waste Yellow Incinerationa/Deep burialb

3 Microbiology and biotechnology waste Yellow Incinerationa/Autoclaving/Microwaving(infectious wastes from laboratory) Red

4 Waste sharps (for example, needles, Blue/White translucent Disinfection/Mutilation/Autoclaving/syringes, scalpels) Microwaving

5 Discarded medicines and cytotoxic drugs Black Incineration/Destruction and secure landfilling

6 Soiled waste (items contaminated with Yellow Incinerationa/blood or body fluids such as cotton Red Autoclaving/Microwavingdressings, beddings)

7 Solid waste (for example, tubing, Blue/White Disinfection by chemical treatment/ catheters, intravenous sets) translucent/Red Autoclaving/Microwaving

8 Liquid waste (from laboratory, washing, — Disinfection by chemical treatment and cleaning, housekeeping, disinfecting) discharge into drains

9 Incineration ash Black Municipal landfilling

10 Chemical waste Black Chemical treatment and discharge into drains for liquids, and secured landfills for solids

Chapter 2.A National Legal Framework for Managing Health 5

and disposal methods for each waste category. Anoverview of the BMW treatment and disposal technolo-gies specified in the Biomedical Waste Rules is presentedin Box 2. BMW treatment options include autoclaving,microwaving, incineration, and chemical treatment; inaddition, hydroclaving has been approved by CPCB as analternative treatment technology. BMW disposal optionsinclude deep burial and secure and municipal landfillingfor solid wastes, and discharge into drains (after chemicaltreatment) for liquid wastes.

India’s Biomedical Waste Rules are similar to those ininternational practice, although they have some internalinconsistencies and deviate in some respects from the pro-cedures the World Health Organization (WHO) recom-mends for managing HCWs.Appendix A highlights someof the similarities and differences between India’s rulesand the 1999 WHO guidelines for the safe managementof HCWs (Prüss, Giroult, and Rushbrook 1999).

National Guidelines for Implementing the Biomedical Waste RulesEach state or territory in India is responsible for imple-menting India’s Biomedical Waste Rules, and StatePollution Control Boards in states or Pollution ControlCommittees in the territories are designated as the pre-scribed authorities. Although environmental standardsand guidelines for the management of BMWs weredeveloped by India’s CPCB in 1996 (CPCB 1996), thesewere merely technical standards for technology optionsfor health care facilities.

In 2000, CPCB published a manual on hospitalwaste management that provided technical guidance forcarrying out India’s Biomedical Waste Rules in the areasof HCW segregation, storage, transport, and treatment(CPCB 2000).The CPCB manual gave special emphasisto BMW incineration, covering incinerator emissions,maintenance requirements, operational problems andsolutions, and pollution control systems. Suggestionsregarding common waste treatment facilities (CWTFs)for BMW treatment were also included in the manual.

CPCB’s manual was informative, but it was notcomprehensive enough to cover all aspects of India’sBiomedical Waste Rules, such as sharps management,handling of infectious liquid wastes, minimization ofBMW generation, training of health care facility employ-

ees, and recordkeeping and monitoring procedures. Asdiscussed below, a positive development is that CPCB hasrecently issued two sets of draft guidelines, one set per-taining to the treatment of BMWs at CWTFs (CPCB,n.d.-a) and the other pertaining to the design and con-struction of BMW incinerators (CPCB, n.d.-b).

CPCB’s recent draft guidelines on CWTFs set outrequirements for the location, land size, coverage area (interms of the maximum number of beds served), treatmentequipment, and infrastructure setup of the CWTF; collec-tion and transportation of BMWs, and disposal of treatedBMWs; and other operational issues.The listed technolo-gies in the draft guidelines include those prescribed in theBiomedical Waste Rules, plus hydroclaving. The draftguidelines’ prescriptions are not always well justified. Forexample, the minimum coverage of each CWTF is set at10,000 health care facility beds, without consideration forlocal conditions such as the geographical dispersion of thehealth care facilities; the suggested land area for eachCWTF is 1 acre, but no basis for this suggestion is pre-sented. In addition, the draft guidelines propose a 150-km-radius operational area, which would cover healthcare facilities in rural areas. This proposal becomes moreimportant in the current debates around sharps wastesfrom immunization in India as the new types of autodis-posable plastic syringes are being characterized as saferoptions than glass syringes.Moreover,CPCB’s draft guide-lines appear to be prescriptive on the waste managementcharge scheme6 instead of letting the optimum schemedevelop on the basis of experience gained in India.

CPCB’s recent draft guidelines for BMW incinera-tors include requirements for the incinerator design andits air pollution control device, physical structures (incin-eration and waste storage rooms), operator qualifications,personal protection equipment, and emergency proce-dures (Box 3). These guidelines restrict incineration ofBMWs only at CWTFs, with the exception of on-siteincineration upon special approval by CPCB. The draftguidelines’ strong bias against on-site incineration athealth care facilities is a major deviation from theBiomedical Waste Rules, which are equally applicable tothe on-site and CWTF incinerators. It is clear that thenew emphasis reflects the recent findings about the poordesign and operating conditions of on-site incinerationequipment at health care facilities in India vis-à-vis therequirements of the Biomedical Waste Rules.

6.The proposed scheme is based on a health care facility’s estimate of the daily generation of BMW (which is provided to the SPCB whileobtaining authorization), followed by a one-month tracking period of each health care facility’s waste generation by the CWTF operator.


Incineration. Incineration is a high-temperature oxidationprocess that involves combustion of the organic portion of BMW components, producing gaseous emissions andinorganic solid residues (ash).These emissions include steam,carbon dioxide, nitrogen oxides, particulate matter, and toxicsubstances (for example, metals, halogenic acids). In addition,under suboptimal combustion conditions, carbon monoxideand hazardous pollutants such as dioxins and furans may beemitted. Incineration significantly reduces waste volumes(typically 85 to 95 percent), and eliminates pathogens fromBMWs. Incineration is not suitable for such health carewastes as pressurized gas containers, large amounts of reactivechemical wastes, wastes treated with halogenated chemicals,halogenated plastics such as polyvinyl chloride, wastes withmercury or cadmium (such as broken thermometers, usedlead or mercury batteries), or radiographic wastes.Incinerators that meet the CPCB draft incineration regu-lations must have a sophisticated (for example, double-chamber) design and include a scrubber as the air pollutioncontrol equipment.Ash from these incinerators must be dis-posed of in a secure landfill. Such incinerators are associatedwith high investment and operating costs and require highlyskilled operating personnel.

Autoclaving. Autoclaving uses saturated steam in direct con-tact with the BMW in a pressure vessel at time lengths andtemperatures sufficient to kill the pathogens.The BiomedicalWaste Rules specify the minimum temperature, pressure, andresidence time for autoclaves for safe disinfection.Autoclavingis not suitable for human anatomical, animal, chemical, orpharmaceutical wastes. Before autoclaving, BMWs requireshredding to an acceptable size, an operation that wouldinvolve frequent breakdown. Autoclaving produces a wastethat can be landfilled with municipal waste. A wastewaterstream is generated that needs to be disposed of with appro-priate controls.Autoclave operation requires qualified techni-cians, and medium investment and operating costs.

Hydroclaving is similar to autoclaving except that the BMWis heated indirectly through the outer jacket of the vessel.The BMW is continuously tumbled in the chamber duringthe process.

Microwaving. Application of an electromagnetic field overthe BMW provokes the liquid in the waste to oscillate andheat up, destroying the infectious components by conduc-tion. This technology is effective if the ultraviolet radiationreaches the waste material. Before microwaving, BMWs

require shredding to an acceptable size and humidification.Microwaving is not suitable for human anatomical, animal,chemical, or pharmaceutical wastes, or for large metal parts.Microwaving produces a waste that can be landfilled withmunicipal waste.The advantages of this treatment technolo-gy are its small electrical energy needs and no steam require-ment.The disadvantages include the need for qualified tech-nicians and frequent breakdown of shredders.This technolo-gy requires medium investment and operating costs.

Chemical disinfection. Addition of strong oxidants—likechlorine compounds, ammonium salts, aldehydes, or phenolcompounds—kills or inactivates pathogens in the BMW.Chemical disinfection is most suitable for treating liquidwastes such as blood, urine, stools, or health care facilitysewage. However, microbiological cultures, mutilated sharps,or shredded solids can also be treated by chemical disinfec-tion. Disinfection efficiency depends on such factors as thetype and amount of chemical used, and the extent and dura-tion of contact between the disinfectant and the BMW. Toenhance the contact, shredding of solid BMW would beneeded.As chemical disinfectants have hazardous (in particu-lar, toxic) properties, users should wear protective clothes.Chemical disinfectants should not be discharged to surfacewaters, and no large quantities should be allowed into sewers.

Deep burial. The Biomedical Waste Rules require thathuman anatomical and animal wastes in cities with popula-tion less than 500,000 and in rural areas be disposed of bydeep burial. Accordingly, the deep burial site should be pre-pared by digging a pit or trench of about 2 meters deep inan area that is not prone to flooding or erosion, and wherethe soil is relatively impermeable, there are no inhabitants orshallow wells in the vicinity, and the risk to surface watercontamination is remote. The pit should be half-filled withthe BMW, then covered with lime within 50 cm of the sur-face, before filling the rest of the pit with soil. On each occa-sion when BMW is added to the pit, a layer of 10 cm of soilshould be added to cover the waste.

Secure landfilling. Secure landfilling involves disposal of solidBMWs at a landfill designed and operated to receive haz-ardous wastes.The Biomedical Waste Rules require disposalof discarded medicines, cytotoxic drugs, solid chemicalwastes, and incineration ash in secured landfills.

Municipal landfilling. Municipal landfilling involves disposalof communal HCWs and disinfected solid BMWs at a land-fill designed and operated to receive municipal solid waste.

Box 2. Biomedical Waste Treatment and Disposal Technologies Specified in India’s Biomedical Waste Rules

Chapter 2.A National Legal Framework for Managing Health 7

National Training and Coordination with StatesIndia’s Ministry of Environment and Forests has spon-sored training programs through the Indian Institute ofTechnology for SPCB officials to receive training relatedto BMW recycling, treatment, and disposal. In addition,

an international workshop on HCW management washeld in New Delhi, and national workshops were held inlarge cities like Mumbai, Bangalore, Hyderabad andJaipur.The benefits from such meetings can be seen in therole played by participants in influencing CPCB decisionson drafting the guidelines for CWTFs and incinerators.

In recent years, growing public concern about toxic air emis-sions has led to more stringent incineration technology stan-dards around the world to reduce pollutants of concern topublic health, including heavy metals (such as cadmium,mercury, and lead), hazardous byproducts from combustion(such as dioxins and furans), and particulate matter. Thenewer incineration technology standards have tightened theincinerator design and operating parameters and imposedmonitoring and recording requirements for certain operatingparameters and pollutant discharges. The newer standardsmake incineration a more costly and complex technologythat requires specially trained operating personnel. Thesestandards have led the United States and several Europeancountries (for example, the United Kingdom, Germany,Austria, Belgium, France) to shift away from small-scaleincineration of BMWs at health care facilities and to usealternative technologies such as autoclaving or microwaving,which are more cost-effective and reliable to operate.

Incineration is one of the BMW treatment and dispos-al technologies that is covered by India’s Biomedical WasteRules of 1998 (amended twice in 2000). In 2000, the NGOSrishti conducted a survey of the status of operating inciner-ators in India and presented the results to the Ministry ofEnvironment and Forests and its technical arm—CPCB.Theresults indicated that most of the on-site incinerators athealth care facilities in India were not in compliance withthe Biomedical Waste Rules.

This finding led CPCB to issue draft guidelines allow-ing incineration only at CWTFs unless a special permit foron-site incineration is obtained from CPCB. The draftguidelines for BMW incinerators specify the design criteriafor the incinerator and the associated air pollution controldevice, as well as the minimum requirements (in terms oftraining, personal protection equipment, emergency proce-dures) for the incinerator operator.The main features of theincinerator design criteria include the following:

• A minimum capacity of 50 kg/hour with high-pressureVenturi scrubbing system for air pollution control(rotary kiln design may be used for capacities above 250kg/hour)

• Double-chamber design with “controlled air” incinera-tion principle to minimize particulate emission (with 100percent excess air for the overall design)

• Minimum temperature of 800±50˚C in the primarychamber and 1,050±50˚C in the secondary chamber

• Circular design for primary and secondary chambers (tominimize formation of air pockets observed in rectangu-lar designs)

• A minimum of 1 sec. residence time in the secondarychamber

• A minimum negative draft of 0.05 to 0.1 inch of watercolumn in the primary chamber to avoid leakage ofgaseous emissions from the chamber (safety precaution)

• Charging of BMW into the incinerator through a con-veyor or loading device (instead of manual handling) toensure that there is no direct exposure of the operator tothe furnace atmosphere

• Computerized programmable logic control (PLC) for thecharging system to maintain specified temperatures in theprimary and secondary chambers, to ensure completecombustion of the previous batch, and to avoid unsafeoperating conditions

• Emergency bypass stack• Graphic or computer recording devices to automatically

and continuously monitor and record dates, time of day,load identification number, and operating parameters suchas temperatures in both chambers, and CO and CO2 ingaseous emissions throughout the duration of the inciner-ation cycle

• Refractory lining of the primary and secondary chambersto sustain a minimum temperature of 1,000˚C and1,200˚C, respectively.

Source: CPCB n.d.-b.

Box 3. Incineration of Health Care Wastes in India


India’s central government could play an importantrole in providing leadership to the states, particularly inthe assessment of treatment technologies for implement-ing the national BMW legislation and facilitating infor-mation sharing across the states. A recent review by theWorld Bank of HCW management programs in selectedstates of India found that comparative testing of autoclaveand microwave technologies for the treatment of infec-tious wastes was conducted in the states of AndhraPradesh and Punjab. In both states, the conclusion wasthat autoclave technology was preferred over microwavetechnology for environmental, operational, and cost rea-sons. This finding illustrates the need for states to sharetheir professional experiences in order to learn from eachother and avoid duplication of effort.

Modern tools such as the Internet could be usefulfor public access to HCW management information

to foster public awareness and create public pressure for compliance. The Web sites hosted by the Ministry of Environment and Forests and CPCB could be used more effectively to disseminate information on national programs and to coordinate HCW man-agement activities implemented in different states.These Web sites, in addition to posting currently available regulations and guidelines, could includeannouncements about national or regional training pro-grams on HCW management, as well as informationabout the compliance status, research programs, andhighlights of implementation of the HCW manage-ment activities in the states. Such information wouldenable states to keep abreast of new developmentsthroughout the country and to strengthen their statepolicies and programs on the basis of lessons learnedfrom others.

As noted earlier, the responsibility for implementing theBiomedical Waste Rules in India rests with individualstates and territories, and the prescribed authorities areSPCBs in states and Pollution Control Committees interritories. Each state is required to constitute an adviso-ry committee to advise the state government and theSPCBs about implementing the rules. Constituting sucha committee requires close coordination and participa-tion at the state level among state environmental andhealth agencies, local authorities, health care facility rep-resentatives, academia, and NGOs.

Ideally, implementation of the Biomedical WasteRules at the state level includes (a) the development of astate strategy for HCW management, (b) the preparationof state HCW management guidelines, (c) the provisionof state assistance to government health care facilities, and(d) state enforcement of regulatory requirements.Developments in the states with respect to each of theseareas are discussed below.

State Strategies for Health Care Waste ManagementState authorities in India have made several strategicdecisions pertaining to HCW management. One deci-sion was how to refine the technology options includedin the Biomedical Waste Rules. Although the rules list

incineration as an option for certain categories of BMW,7

concerted efforts by NGOs—including Srishti, ToxicLink, and Jyotsna Chauhan Associates—and the presshave convinced some SPCBs to rule out the use of on-site incineration.

In the State of Andhra Pradesh, for example, wheremost health care facilities are in the heart of cities, theAndhra Pradesh Pollution Control Board prohibitedincineration at health care facilities in the entire stateafter considering the potential adverse impacts of pollu-tant emissions from substandard incinerators.The KeralaPollution Control Board recently opted for autoclavingand deep burial of BMWs instead of incineration. TheTamil Nadu Pollution Control Board has banned incin-eration of BMWs—except for body parts and human tis-sues—in favor of autoclaving and sanitary landfilling.

National and state authorities have made some tech-nology choices for HCW management taking intoaccount human health impacts in urban and rural areas.The Biomedical Waste Rules specify that incineration isthe disposal scheme required for human anatomical andanimal wastes for cities with population greater than500,000, and deep burial is the disposal scheme requiredfor such wastes for smaller cities and rural areas. In theState of Karnataka, however, because of the poor per-formance of incinerators at health care facilities, on-site

CHAPTER 3

State Strategies and Activities Related toHealth Care Waste Management

9

7.The Biomedical Waste Rules list as options incineration of human anatomical waste (BMW Category 1) and incineration of animal waste(BMW Category 2) in population centers of more than 500,000 habitants, and incineration of discarded medicine and cytotoxic drugs (BMWCategory 5).


incineration has been prohibited within the limits of sixcity municipal corporations8 and in all district headquar-ters. Of these locations in Karnataka, where the popula-tion exceeds 500,000, destruction of human anatomicaland animal wastes is to be accomplished by incinerationonly at CWTFs to comply with both the BiomedicalWaste Rules and state requirements. Bangalore, Hubli-Dharwad, and Mysore comply with this requirement,but in Mangalore, human anatomical and animal wastesare currently disposed of by deep burial.9 In AndhraPradesh, state authorities have selected deep burial as thedisposal scheme for biodegradable infectious wastes10 inareas with a population less than 500,000.This approachis not in compliance with the Biomedical Waste Rules,which require local autoclaving, microwaving, or incin-eration instead of deep burial, but it is in accordance withthe 1999 WHO guidelines for the safe management ofwastes from health care activities (Prüss, Giroult, andRushbrook 1999).

Another strategic decision for state authorities inIndia was whether to opt for on-site treatment of BMWsor common treatment of BMWs. Common treatment ofBMWs offers several advantages. First, a CWTF can belocated away from hospital premises and urban areas, sig-nificantly reducing the potential adverse human healthimpacts. Second, a CWTF reduces treatment and dispos-al costs by treating large quantities of wastes collectedfrom many facilities (that is, it offers economies of scale),although the savings must be balanced by the additionaltransportation costs from all the facilities to the CWTF.11

Third, a CWTF can employ specially trained personnelwho could not be easily supported by individual healthcare facilities, resulting in better and more efficient oper-ation. Fourth, the permitting, monitoring, and enforce-ment efforts by regulatory agencies of one CWTF arelikely to be fairly effective.

Nonetheless, there are challenges associated with acommon treatment of BMWs. A CWTF approachimposes a direct financial burden on the operators ofhealth care facilities, who previously paid minimal

amounts for services associated with waste management.It also requires operational and behavioral changes by theoperators of health care facility operators, who mustproperly segregate wastes into the types of BMW accept-ed by the CWTF operator.A more important concern isthe difficulty of ensuring continued involvement of theprivate sector in a CWTF when the market is uncertainbecause of the absence of a culture of compliance and aweak enforcement regime.

India’s central government views common wastetreatment as the most appropriate approach to the treat-ment of BMWs generated in urban areas.Andhra Pradeshwas the first state to devise and implement a CWTFscheme (Box 4). Initially, resistance to the scheme arosefrom doctors who were unwilling to accept a CWTFapproach for the “Twin Cities” area of Hyderabad andSecunderabad and objected to the charges required forBMW treatment and disposal.Workshops were held withdoctors and other facility staff to overcome their resist-ance, and mass awareness campaigns were conducted inAndhra Pradesh about the need for safe BMW treatmentand disposal. Two privately owned CWTFs were set upin the state to treat BMWs from Hyderabad andWarangal Districts, using the same types of technologies(incineration and autoclaving) (Onursal and Setlur 2002).

The successful model for a privately owned andoperated CWTF used in Andhra Pradesh was subse-quently emulated in other states—including Karnataka,Maharashtra, Punjab, Rajasthan,Tamil Nadu—and plansfor similar CWTFs have recently been adopted in theStates of Gujarat, Kerala, New Delhi, Uttar Pradesh, andWest Bengal.• Karnataka. In Karnataka, two CWTFs—one in north

and the other in south Bangalore— have been operat-ing using incineration and microwave technologies toserve about 6,000 beds in the city.12 Another CWTFin Mysore, which uses the incineration and autoclavetechnologies, was commissioned for 67 health carefacilities with 7,000 beds.13 Two additional CWTFs,both based on the incineration technology, were com-

8.These six municipal corporations are in the cities of Bangalore, Belgaum, Gulbarga, Hubli-Dharwad, Mangalore, and Mysore. Of these cities,Bangalore, Hubli-Dharwad, Mangalore, and Mysore have a population exceeding 500,000.

9.A CWTF project is underway for Mangalore.

10. Biodegradable infectious wastes are called “soiled wastes” (BMW Category 6) in the Biomedical Waste Rules.

11. In India, the capital cost of on-site treatment of BMWs for a 100-bed facility is reported to be about Rs. 1.4 million (about US$28,000),or Rs. 14,000/bed (about US$280/bed).The capital cost of a CWTF handling BMWs from 10,000 beds is reported to be about Rs. 15 million(about US$300,000), or Rs. 1,500/bed (about US$30/bed). In a study by the NGO Srishti, the breakeven cost between on-site treatment and off-site CWTF treatment is found to correspond to catering about 1,000–1,500 beds.

12. The CWTF in South Bangalore by Maridi Eco Industries was commissioned in August 2001, and the CWTF in North Bangalore byMedicare Incin. Pvt. Ltd was commissioned in September 2001.

13.The CWTF in Mysore by Shree Consultants was commissioned in August 2002.

missioned recently in Belgaum and Hubli-Dhardwad.14 Three additional CWTFs are going intoplace in Karnataka at Gulbarga, Mangalore, andShimoga. All the CWTFs in Karnataka are locatedaway from the city limits, with transportation ofBMWs provided by the CWTF operator.

• Maharashtra. In Maharashtra, there are CWTFs inMumbai, Pimpri Chinchwad, Pune, and Thane. Someof these operate only incinerators, and others inciner-ators along with autoclaves. In addition, procurementis underway for a CWTF in Navi Mumbai.

• Punjab. In Punjab, a CWTF was designed to treatand dispose of BMWs from health care facilities total-

ing 7,000 beds in the Ludhiana area. In response tosubsequent protests by some health care facility man-agers concerned about the level of BMW manage-ment charge, however, the Punjab Pollution ControlBoard allowed them to dispose of their BMWsaccording to their choice, provided that the disposal is performed in compliance with the requirements ofthe Biomedical Waste Rules.

• Rajasthan. In Rajasthan, a CWTF was commissionedfor BMWs from health care facilities in the Jaipur area.

• Tamil Nadu. In Tamil Nadu, CWTFs are in opera-tion for 58 health care facilities in the Salem area and78 health care facilities in the Madurai area.

Chapter 1.The Problem of Health Care Wastes 11

14.The CWTF in Belgaum by Belgaum Doctors’ Association was commissioned in February 2003, and the CWTF in Hubli-Dharwad wascommissioned in July 2003.

The State of Andhra Pradesh and the State of Kerala haveadopted somewhat different strategies for managing BMWs.The key features of their strategies are summarized below.

State of Andhra Pradesh

The BMW management strategy in Andhra Pradesh has several features:• For the Twin Cities of Hyderabad and Secunderabad,

health care facilities are required to segregate their wastesaccording to the Biomedical Waste Rules for transporta-tion to CWTFs that treat and dispose of segregatedBMWs.There are a total of 20,000 beds in 400 health carefacilities in the Twin Cities area.

• For Visakhapatnam or other cities with populationsgreater than 300,000, a scheme similar to that used forhealth facilities in the Twin Cities is anticipated. As aninterim measure, until CWTFs become available, theAndhra Pradesh Pollution Control Board requires healthcare facilities to segregate and disinfect their wastesaccording to the Biomedical Waste Rules, then hand overthe segregated wastes to the municipal corporations fordisposal. During August and September 2001, the AndhraPradesh Pollution Control Board gave permits for the

establishment of two additional CWTFs, one inVisakhapatnam and the other in Vijayawada.

• For health care facilities located in areas with populationsless than 300,000 and with adequate space within theirpremises to set up treatment facilities, disinfection ofBMWs followed by deep burial is required.

State of Kerala

In Kerala, the BWM management strategy applies to theentire state.At least one CWTF is envisioned for each of thefour identified regions that include the following districts:• Region 1: Alappuzha, Kollam, Pathanamthitta, and

Thiruvananthapuram.There are a total of 38,474 beds in873 health care facilities in this region.

• Region 2: Ernakulam, Idukki, and Kottayam.There are atotal of 34,171 beds in 788 health care facilities in thisregion.

• Region 3: Malappuram, Palakkad, and Thissur.There are a total of 20,604 beds in 557 health care facilities in thisregion.

• Region 4: Kannur, Kassargod, Kzhikode, and Wayanad.There are a total of 21,536 beds in 599 health care facili-ties in this region.

Sources: Andhra Pradesh: Onursal and Setlur 2002. Kerala: Government of Kerala Directorate of Health Services n.d.

Box 4. Comparison of Biomedical Waste Management Strategies in Two States:Andhra Pradesh and Kerala


• Kerala. In Kerala, the state’s BMW management strategy involves use of CWTFs in the entire state—for rural as well as urban health care facilities. At leastone CWTF is envisioned for each of the four speci-fied regions (Box 4).

State Guidelines for Health Care Waste ManagementAlthough SPCBs are the designated regulatory authori-ties for the Biomedical Waste Rules in the states, statehealth departments have the leading role in assisting gov-ernment health care facilities to comply with the sched-ules in the rules.A few state health departments in Indiahave prepared guidelines to facilitate implementation ofthe rules at government hospitals.

An initial review of some of the early state guide-lines reveals that these documents do not incorporatestate HCW management strategies, are inconsistent withthe Biomedical Waste Rules, have internal inconsisten-cies, and do not provide clear and detailed instructionsfor implementation. An important current need, there-fore, is to improve the quality of these guidelines andidentify good practices for dissemination across states.

The state guidelines prepared for the Vaida VidhanaParishad Hospitals in Andhra Pradesh and the secondary-level hospitals in Karnataka, for example, have a numberof shortcomings.They do not incorporate the state strate-gies for HCW management; they are in some respectinconsistent with the Biomedical Waste Rules (which arethemselves internally inconsistent); they exhibit inco-herencies among the different sections of the same docu-ment; and they lack necessary details about managementof HCWs. In addition, these state guidelines were issuedmore than two and a half years after the notification of theBiomedical Waste Rules and more than a year later thanthe compliance schedule indicated in the BiomedicalWaste Rules for highest-priority health care facilities.Because of their late publication and possible misinterpre-tation of HCW management requirements, these guide-lines are of limited value and require updating.

State Assistance to Government HealthCare FacilitiesWhile private hospitals in India must comply with therequirements of the Biomedical Waste Rules using theirown resources, the government health care facilities havereceived assistance from their respective states. Some specific examples of HCW management program imple-mentation activities under the World Bank–financed

projects are discussed below (Onursal and Setlur 2002).State health departments in Andhra Pradesh, Karnataka,Maharashtra, Orissa, Punjab, and West Bengal have pro-vided government hospitals with assistance in the areas ofHCW auditing and training of state health officers andhospital staff under the World Bank–financed projects;they also have financed supplies and equipment for hos-pital waste containerization (bins, bags, labels); waste conveyance (trolleys), waste treatment (needle crushers,autoclaves); civil works for disposal facilities at hospitals(deep burial pits); and awareness efforts and additionaltraining of health care facility personnel. In some states,hospital-specific HCW management plans were preparedon the basis of HCW audits by consultants, on-site disposal facilities were constructed by contractors, andsupplies and equipment were procured by suppliers.

Training for Health Care Facility PersonnelUnder the World Bank–financed projects, state healthdepartments offered training on HCW management pro-cedures to government hospitals. The purpose of thetraining was to create awareness and facilitate implemen-tation of India’s Biomedical Waste Rules. The contentand duration of the training program varied with the tar-get audience, whether this involved the administrators,doctors, nurses, or cleaning personnel.• Andhra Pradesh. A three-step approach was adopted

for the training program: awareness training of hospitalpersonnel, development of training materials, and in-house training of hospital personnel. In each step,priority was given to the Twin Cities (Hyderabad-Secunderabad) hospitals, then to the 21 district hospi-tals (with 250–350 beds), and subsequently to the 55area hospitals (with 75–100 beds) and 84 communityhealth centers (with 30–50 beds). Awareness trainingwas provided to the key personnel of all district hospi-tals, area hospitals, and community health centers. Atraining manual prepared by Jyotsna ChauhanAssociates (Jyotsna Chauhan Associates 2000) was keyin the training of health care facility personnel.

• Karnataka. Four training modules were targeted to different audiences at government hospitals (medical officers, nurses, cleaning and waste handlingpersonnel, and patients and visitors). In addition, a fifthmodule was designed for local administrators andheads of key institutions. The key personnel at hospitals (nursing superintendents) were first trainedby resource persons (consultants, NGOs). These keypersonnel, in turn, trained the remaining staff in their

Chapter 3. State Strategies and Activities Related to Health Care Waste 13

respective hospitals (for example, nurses and cleaningand waste handling personnel).

• West Bengal. The awareness training program covered such waste minimization measures as the useof nondisposable sterilized glass syringes instead ofdisposable syringes, and electronic thermometersinstead of mercury thermometers. In general, medicalofficers and doctors were reported to be the group ofhospital personnel who had given the least attentionto the waste management issues.

Supply of Materials for Health Care FacilitiesState health departments have supplied materials forHCW management to government hospitals in Indiaunder the World Bank–financed projects. In AndhraPradesh, more than 90 percent of district hospitals wereprovided with a one-year supply of HCW managementmaterials (colored bins and bags, trolleys, protective gear,and so forth). In Karnataka, waste management materialswere supplied to the Bangalore and district hospitals tocoincide with the delivery of the training program. Inaddition, some district hospitals were provided with nee-dle cutters and needle crushers for testing and evaluation.In Punjab, all government hospitals were provided withpersonal protection equipment (gumboots and gloves)and needle destroyers.

Procurement of Waste Treatment Equipment and Disposal FacilitiesThe Punjab and West Bengal State Health Departmentsprocured autoclaves and microwaves for testing as BMWtreatment equipment. In Punjab, autoclaves were selectedon the basis of test results as the preferred technology forinstallation at 35 hospitals to treat BMWs from these andother hospitals. In West Bengal, autoclaves were installedat three hospitals, where they continue to be used to treatBMWs; and testing of microwaves was planned at twohospitals. In Karnataka, Punjab, and West Bengal, deepburial facilities for on-site disposal of sharps and soiledwastes were constructed on hospital premises.

State Regulatory Agencies’ Enforcementof the Biomedical Waste RulesIndia’s regulatory agencies for the Biomedical WasteRules—SPCBs in the states and Pollution ControlCommittees in the territories—are responsible for issu-

ing initial and operation renewal permits to the entitiesthat generate, store, transport, treat, and dispose ofBMWs. In addition, SPCBs and Pollution ControlCommittees are responsible for determining health carefacilities’ compliance with the Biomedical Waste Rules.

Originally, the schedules for health care facilities tocomply with the Biomedical Waste Rules ranged from1.5 years to 4.5 years.The schedules were based on thetype of health care facility, population size at the localityof the health care facility, and size of the health care facil-ity in terms of the number of beds. Hospitals and nurs-ing homes located in cities with more than 300,000inhabitants, along with hospitals and nursing homes inareas with fewer inhabitants but with higher number ofbeds, were given a higher priority than others—andtherefore less time to comply.

As implementation of the Biomedical Waste Ruleslagged, the rules were amended in March 2000 to post-pone the schedule for the highest-priority health carefacilities to comply by six months—from December 31,1999, to June 30, 2000. All health care facilities in Indiawere required to comply with the rules by dates rangingfrom June 30, 2000, to December 31, 2002, dependingon the type and size of facility.

The States of Andhra Pradesh, Karnataka, andPunjab were ahead of other states in terms of gettinghealth care facilities to comply with the schedule speci-fied in the Biomedical Waste Rules.The Andhra PradeshPollution Control Board announced that those healthcare facilities that did not obtain the board’s permit bythe first deadline indicated in the Biomedical WasteRules would be liable for a fine of Rs. 100,000 (aboutUS$2,000) and/or five years of imprisonment, and Rs.5,000 (about US$100) compounding penalty fee per day.As a result of this announcement, a trickle of permitapplications submitted to the board subsequently grewinto a stream of applications, reaching 320 health carefacilities throughout Andhra Pradesh. Only 80 of thesehealth care facilities received a permit from the board tooperate by that deadline. These observations indicatethat, even with pressure from the regulatory agency, theextent of health care facilities’ compliance was less thansatisfactory.15

Implementation of the Biomedical Waste Rules in the State of Maharashtra—in terms of permit applications,permit granting, and adequacy of treatment facilities—

15. In comparison, the total number of health care facilities in the Twin City area is 375.There are, of course, more health care facilities inother parts of Andhra Pradesh that were required to comply by this deadline.


has been slow. The Comptroller and Auditor General ofIndia’s 2000–01 Audit Reports (TCAG 2001) indicatesthat only a small percentage (16 percent) of the 6,503 gov-ernment and private health care facilities in Maharashtrahad submitted their permit applications (“applied forauthorization”) by December 31, 2000—a situation thatindicates major deficiencies in compliance with theBiomedical Waste Rules.16 Among the defaulting healthcare facilities were some large government hospitals inMumbai City. The report also states that approximatelyone-quarter of the applicants—278 health care facilities—were granted operating permits, and only 22 of the permitted health care facilities had adequate facilities fortreatment of wastes. These observations indicate that thevast majority (98 percent) of the health care facilities that

submitted permit applications lacked proper treatmentprocedures and were thus generating untreated BMWsthat local agencies transported and deposited in dumpinggrounds along with communal waste (TCAG 2001).TheComptroller and Auditor General’s report (TCAG 2001)also stated that not a single hospital of 14 district hospitalssurveyed in Maharashtra was “following safe and effectivepractices in accordance with the rules, such as segregationof waste, treatment of infectious organic, pathologicalwaste and sharp waste and provisions of protective meas-ures for waste treatment. Liquid wastes were released intothe hospital drains without any treatment, which added tothe risk caused by improper solid waste disposal.” Thereport indicated that an action plan was being prepared forsmall, medium, and large hospitals.

16. In urban areas where the population is more than 300,000, all heath care facilities are required to comply with the Biomedical Rules byJune 30, 2000. In urban areas with less population, the compliance schedule for hospitals and nursing homes with more than 500 beds is also June30, 2000; for hospitals and nursing homes with fewer beds, the date for compliance is December 31, 2000.

India’s Biomedical Waste Rules of 1998 make theoccupier (operator) of each health care facilityresponsible for proper management of BMWs.Thus,

although national, state, and local regulations create aframework and incentives for sound HCW managementin India, what is most important is the implementation ofsound waste management practices by health care facilities.

Health care facilities in India increasingly recognizeand accept the importance of incorporating good HCWmanagement practices in their daily operations. In fact,this change in culture—due in part to the assistance pro-vided to government hospitals by state health depart-ments in the form of personnel training, HCW manage-ment auditing, preparation of hospital-specific plans, pro-curement of materials and supplies, and construction ofon-site disposal facilities—is one of India’s majorachievements. As discussed below, however, additionalefforts are needed to bring HCW management to theattention of medical officers and doctors, improve hospi-tal-specific plans, and offer refresher training so thathealth care facility staff can fully internalize these plans.

Health Care Facilities’ Commitment to Managing WastesProper HCW management at a health care facilityrequires full commitment by senior management and acarefully designed HCW management organizationalstructure with clearly defined responsibilities. It alsorequires a good plan for HCW management. Ratherthan rush ahead with a deficient plan that will requirerevisions, it is advisable for hospitals in India to take

the time to develop a comprehensive HCW manage-ment plan.

The 1999 WHO guidelines for the safe managementof waste from health care facilities recommends that the head of the hospital chair the hospital’s HCW management organization and name in writing a wastemanagement officer responsible for the development andday-to-day implementation of a HCW management planfor the institution. Hospital staff who should serve on thehospital’s HCW management committee, under thewaste management officer, should include the heads ofthe hospital’s departments, the nursing superintendent,the head nurse, the sanitary inspector (infection controlofficer), the chief pharmacist, the radiation officer, thesupply officer, and the financial officer of the hospital(Prüss, Giroult, and Rushbrook 1999).The exact compo-sition of the hospital’s HCW management committeedepends on the hospital size and structure. All hospitalstaff—including doctors, nurses, cleaning staff, and soforth—involved in HCW generation and managementwithin the hospital premises are members of the HCWmanagement team.

The following mission statement of one district hos-pital in Karnataka reflects the hospital management’scommitment to HCW management:

“The management of this hospital is committedto providing a comprehensive quality healthcare to the community it serves, through a teamof committed professional health workers whowill keep in their mind the interest of patients

CHAPTER 4

Health Care Facilities’Waste Management Activities

15


at all times and render treatment and carry outprocedures in a clean, healthy and pleasant hospital environment which they pledge tomaintain at all times. ”

This district hospital in Karnataka outlined itsimmediate and long-term HCW management objectivesas follows:• “Immediate objectives:

– To ensure safe, efficient, cost-effective disposal ofhospital waste by developing a waste disposal plan

– To train hospital workers on waste management• Long-term objectives:

– To develop strategies for reduction of waste gener-ation in the hospital

– To create awareness among workers about healthyhospital surroundings

– To create community awareness on environmentalissues in hospital surroundings.”

These objectives suggest a lack of clear understand-ing by the hospital staff of what the implementation ofHCW management in a hospital requires. Awareness ofissues among hospital personnel should be created beforesuch personnel are trained—not after. And strategies forreduction of waste generation in the hospital should bedeveloped early on as part of a waste management plan(not a waste disposal plan)—not just as a long-termobjective. The district hospital in Karnataka did name awaste management officer and form a HCW manage-ment committee, as recommended by WHO, but it didnot make the appointments in writing and there were nowritten management responsibilities for each member.Amanagement organization with joint responsibility for anentire committee undermines accountability. Postinginformation about the HCW management organizationat prominent places within the hospital could strengthenthe image of careful management for the entire institu-tion. Making the entire hospital staff aware of the hospi-tal’s HCW management organizational structure, withlistings of responsibilities for each member, would reflecta well-defined, transparent management system.

Health Care Facilities’Waste AuditsBefore the Biomedical Waste Rules were required at theinstitutions, HCW audits were conducted at 25 govern-ment hospitals with 30–561 beds in three states:Karnataka, Maharashtra, and West Bengal (Onursal andSetlur 2002). The purpose of the HCW audits was to

determine the amount of HCW generated and the com-position of BMW in terms of the categories specifiedunder the Biomedical Waste Rules at each hospital. Toallow for factors affecting fluctuations in waste genera-tion, the HCW audits were carried out around the clockfor a period of 3–31 days.

Results from the HCW audits of the 25 govern-ment hospitals in Karnataka, Maharashtra, and WestBengal are shown in Table 2.As can be seen, there werewide variations in total waste generation rates and wastecomposition at different hospitals. More detailed resultsfrom the HCW audits of these hospitals are presented inAppendix B.

The audit results indicate that BMWs made up19–78 percent of HCWs at these 25 hospitals. In com-parison, in Hyderabad (Andhra Pradesh), the contribu-tion of BMWs is reported to be 15–20 percent of HCWsafter implementation of waste management plans bytrained health care facility personnel. The data forHyderabad are consistent with information commonlycited in the literature that BMWs contribute a maximumof 20 percent of HCWs. The difference between theaudit results and other information may be attributed tothe level of segregation of BMWs from HCWs.Personnel training at health care facilities and implemen-tation of a hospital-specific waste management plan bysuch personnel are key in proper waste segregation.

BMW generation rates depend on such factors aswaste management methods, type and specialization ofhealth care facilities, extent of reusable items employed inhealth care, and proportion of patients treated on a day-care basis (Prüss, Giroult, and Rushbrook 1999). TheBMW generation rates from the audited 25 hospitalswere in the range of 0.05–0.40 kg/day/bed (or0.09–0.50 kg/day/occupied bed).These rates are similarto those obtained through wastes audits (0.11–0.65kg/day/bed) conducted at hospitals in Bhopal andKanpur (Table 3).

The HCW audits conducted in eight hospitals inWest Bengal also included determination of the compo-sition and generation rates for communal waste. Theresults for the eight hospitals, shown in Table 4, indicatethat food and vegetable wastes constituted most of thecommunal waste from these hospitals (66–84 percent).Other constituents of the communal waste from the hos-pitals were paper and cardboard (10–24 percent), plastics(3–12 percent), and glass (0.4–1.3 percent).The genera-tion rates for communal waste ranged from 0.19 to 0.41kg/day/occupied bed (or 0.13–0.37 kg/day/bed).

Chapter 4. Health Care Facilities’Waste Management Activities 17

Information on generation rates of different constituentsof communal waste improves planning for recyclingopportunities, as well as for treatment and disposaloptions (Onursal and Setlur 2002).

Planning for Managing Wastes at Health Care FacilitiesHCW management plans were prepared by private con-sultants or NGOs for government hospitals in India withthe assistance of the state health departments. In the Stateof Karnataka, an evaluation of the implementation of theHCW management plans in government hospitalsrevealed several deficiencies, among them (a) impropersegregation of waste at source, (b) mixing of sharp wastewith other recyclable waste, (c) ambiguity about final

disposal of sharps and plastics, (d) inadequate informationabout the use of landfill and deep burial pits, (e) dispos-ables not being mutilated, (f) inappropriate location ofbins, (g) biodegradable waste in deep burial pits not beingcovered with soil, (h) untrained contractual waste han-dlers handling the waste, and (i) ineffective disinfection ofwaste.These deficiencies were attributed to the attitudesof the administrative medical officers and staff involved inHCW management.The lessons drawn from this evalua-tion were used as the basis of retraining for staff fromthese hospitals.

A review of HCW management practices in Indiareveals wide differences among government hospitalslocated in various states. Appendix A summarizes severalstates’ actual practices for the treatment, containerization,

Table 2. Composition and Amount of Health Care Waste Generated by 25Government Hospitals in 3 States before Implementation of the Biomedical Waste Rules

Karnataka hospitals, Maharashtra hospitals, West Bengal hospitals,

Health care wastes by number of beds by number of beds by number of beds

100 50 30 384–561 127–272 30–46 381–520 100–195 30

Biomedical wastes (%) 19 56 48 41–54 32–78 31–75 37–38 28–40 29

Infectious wastes (%) 8 33 30 21–34 12–43 15–53 31–33 24–36 23

Human anatomical waste (%) — — — — — — 1.3 2–3 4

Plastics (%) 6 17 5 4–19 4–26 5–22 1–3 1–2 1

Sharps (%) 5 6 13 1–8 5–10 3–31 1 0.3–1 0.7

Communal waste (%) 81 44 52 45–59 22–68 25–69 62–63 60–72 71

Kg/day:

Biomedical waste 10.4 4.5 2.9 35–68 41–87 1.8–9.4 37–52 14–31 1.6

Health care waste 55.5 7.9 6.2 77–164 101–211 2.5–16.4 99–141 51–77 5.6

Kg/day/bed:

Biomedical waste 0.10 0.09 0.10 0.09–0.16 0.22–0.40 0.06–0.31 0.08–0.10 0.14–0.16 0.05

Health care waste 0.56 0.16 0.21 0.18–0.39 0.41–1.04 0.08–0.55 0.23–0.28 0.38–0.51 0.19

Kg/day/occupied bed:

Biomedical waste 0.14 0.13 0.21 0.09–0.16 0.24–0.50 0.11–0.50 0.12–0.15 0.14–0.16 0.10

Health care waste 0.77 0.22 0.45 0.21–0.38 0.41–1.31 0.15–0.87 0.31–0.42 0.35–0.57 0.35

Note: For data from West Bengal,“infectious waste” includes animal waste (Category 2), microbiology and biotechnology waste (BMW Category 3), and soiled waste

(BMW Category 6). For data from Karnataka and Maharashtra,“infectious waste”—besides these categories—also includes human anatomical waste (BMW Category 1).


and disposal for specific HCW categories (Onursal andSetlur, 2002); the appendix also summarizes the require-ments of India’s Biomedical Waste Rules and the 1999WHO guidelines for safe management of wastes fromhealth care activities (Prüss, Giroult, and Rushbrook1999). Examples of different HCW management prac-tices in hospitals in various states include (a) treatmentand recycling of plastic materials (this option is not men-tioned under the Biomedical Waste Rules); (b) con-tainerization of sharps (cardboard boxes are used,although puncture-proof containers are required underthe Biomedical Waste Rules); (c) deep burial of infectious(soiled) waste (not authorized under the BiomedicalWaste Rules, but recommended as an option in theWHO 1999 guidelines for safe management of wastesfrom health care activities); (d) returning of discardedmedicines to suppliers (not authorized under theBiomedical Waste Rules, but recommended as an optionin the WHO guidelines); (e) disinfection of infectious(soiled) waste followed by collection by municipality (notprescribed under the Biomedical Waste Rules); and (f)use of a different color container from what is prescribedby the Biomedical Waste Rules. In the case of plastics,disinfection by chlorination at hospitals followed byrecycling through a thermal process (by a recycler) maygenerate hazardous chemicals (for example, dioxins)—ahealth issue that may be at least as serious as exposure toinfectious wastes.

To a great extent, different waste treatment and dis-posal practices in different states reflect differences in the

interpretation of the Biomedical Waste Rules, whichinclude some inconsistencies. State-level HCW manage-ment guidelines are sometimes prepared by local consult-ants and NGOs with no or little experience in otherstates, and such consultants and NGOs may vary in theirinterpretations of the Biomedical Waste Rules. Hospital-specific HCW management plans are often prepared bylocal private consultants or NGOs that vary in their inter-pretations of state-specific HCW management guidelines.

To minimize generation of expired drugs, health carefacilities have instituted measures that involve preparationof a list of drugs with an expiration date of six months andcirculation to other hospitals. A computer-based wasteexchange program may be built upon the existing system,not only to improve the efficiency of the current system(which uses the drugs for a good cause), but to reducewastage and associated environmental problems. For anyexpired drugs generated, disposal at a secure landfill orincineration at a CWTF would be options.

Two issues related to human hygiene at health carefacilities, although not covered in the Biomedical WasteRules, are the quality of water supply and treatment ofsewage. The results of water quality monitoring in dif-ferent states indicate poor water quality in urban areas,mainly as a result of cross-contamination from sewage.Mitigating the adverse effects of poor quality water onthe general population is an important concern thatmust be addressed in the entire country, particularly inurban areas. An immediate need is to reduce adverseimpacts on the sick, who are the most vulnerable

Table 3. Biomedical Waste Generation Rates at Selected Hospitals in Madhya Pradeshand Uttar Pradesh

BMW generation

Hospital, by location Number of beds (kg/day/bed)

Bhopal, Madhya Pradesh

Kasturba Hospital 429 0.14

Ayushman Hospital 65 0.61

Kanpur, Uttar Pradesh

Lala Lajpat Rai Hospital 1,055 0.22

Mariumpur Hospital 210 0.11

Regency Medical and Diagnostic Center 61 0.65

Source: CPCB 2000.

Chapter 4. Health Care Facilities’Waste Management Activities 19

portion of the population. Health care facilities need todevelop and implement water quality monitoring programs at their facilities and, if necessary, take the mitigation measures to comply with national drinkingwater standards. Sewerage is also a problem; prototypedesigns for various groups and types of health care facility facilities could be developed and implemented

for adequate drainage and on-site disposal or treatmentarrangements, as well as a protocol for routine operationand maintenance. Furthermore, instituting a statewidesystematic effort for collection and analysis of informa-tion on hospital effluents, and the associated water quality and health impacts, would improve the basis ofsound decisionmaking.

Table 4. Composition and Amount of Communal Waste Generated by Eight Hospitals in West Bengal

Hospital, by size

520 beds 500 beds 498 beds 381 beds 195 beds 195 beds 100 beds 30 beds

Basic data on hospital:

No of days audited 3 3 3 3 3 3 3 3

Bed occupancy (%) 55 67 89 73 93 113 89 53

Composition of hospital’s communal waste:

Food/vegetable (%) 83 83 81 84 78 81 66 66

Paper/cardboard (%) 13 10 12 11 12 10 22 24

Plastics (%) 3 6 7 4 9 8 12 10

Glass (%) 0.6 1.3 0.5 0.6 1.1 0.5 0.4 0.6

Hospital’s communal waste generation rate:

Kg (in 3 days) 219 269 254 186 135 138 110 12

Kg/day 73 90 85 62 45 46 37 4

Kg/day/bed 0.14 0.18 0.17 0.16 0.23 0.24 0.37 0.13

Kg/day/occupied bed 0.26 0.27 0.19 0.22 0.25 0.21 0.42 0.25

The private sector has become increasinglyinvolved in providing HCW management serv-ices, as discussed below. Still, the public sector is

also involved, typically at rural health care facilities andsome urban government-owned health care facilities.Designated staff in health care facilities, after training, aregenerally involved in the segregation, transfer, storage,treatment, and disposal of waste within their premises.Incinerators in government health care facilities havebeen operated by their own staff. Some governmenthealth care facilities with excess capacity for treatingBMWs have provided services to other health care facil-ities in their vicinity. In Gulbarga, Karnataka, there areindications that an organization funded by theGovernment of India, Center for EnvironmentEducation, plans to build and operate the CWTF forBMWs. In Thane, Maharashtra, a CWTF was establishedin 2003 at a municipal hospital complex (ChattrapatiShivaji Municipal Hospital) through a joint public sec-tor-NGO initiative.17 The CWTF commissioned in 2003includes an incinerator (with an energy recovery feature)and an autoclave to treat segregated BMWs receivedfrom 5 government and 70 private hospitals.The chargesfor waste treatment are reported to be Rs. 5.70/bed/day(about US$0.12/bed/day) for a general hospital or clinicand Rs. 7.70/bed/day (US$0.15/bed/day) for facilitieswith obstetric and gynecological services.

On-Site Waste Management ServicesAs part of the culture change resulting from implemen-tation of the Biomedical Waste Rules in India, the privatesector involvement in providing on-site HCW manage-ment services has gained importance in the Indian healthsector. Some government hospitals have contracted withprivate sector organizations for on-site waste manage-ment services previously performed by health care facil-ity personnel. In West Bengal, for example, cleaning serv-ices in all 75 government hospitals with more than 100beds has been contracted out to the private sector. So far,the experience of using private contractors has been gen-erally positive.The significant improvements in the over-all cleanliness and sanitary conditions are appreciated byhealth care facility personnel, patients, and their visitorsand have led to a positive change in public opinion.Resistance to the privatization of services from healthfacility staff concerned about losing their jobs can beexpected. In West Bengal, in an effort to reduce staffresistance, the contracting out of cleaning services wasextended to indoor areas in only 10 government hospi-tals (Onursal and Setlur 2002).

Off-Site Waste Management ServicesRecently, there has been increasing participation by pri-vate sector firms in the provision of off-site HCW man-agement services. In the Twin City area of Andhra

CHAPTER 5

The Private Sector’s Role in ProvidingWaste Management Services

21

17.The initiative has been between the Thane Municipal Corporation and Enviro-Vigil Corporation, a Thane-based NGO.


Pradesh, for example, the state government has encour-aged the adoption of a scheme in which a private sectorfirm builds, owns, and operates two CWTFs with nodirect subsidies. The government incentive has been aguarantee on the number of health care facilities andassociated beds served by the investors. Accordingly, oneprivately owned CWTF serving the Twin Cities(Hyderabad and Secuderabad) was assigned 125 govern-ment and private health care facilities for a total of10,000 beds (Box 5); the other privately owned CWTFwas assigned 250 government and private health carefacilities with the same number of beds.

Each private CWTF operator in Andhra Pradesh isresponsible for collecting BMWs from the assigned facil-ities, transporting them to the respective CWTF, andtreating and disposing of the treated wastes in compliancewith India’s Biomedical Waste Rules and state require-ments. In Andhra Pradesh, each health care facility servedby the CWTF operated by GJ Multiclave Pvt. in theTwin Cities was required to do the following:• Obtain an operating license from the Andhra Pradesh

Pollution Control Board.This requires payment of anauthorization charge of Rs. 100/bed/year (aboutUS$2/bed/year) (regardless of bed occupancy status)to the Andhra Pradesh Pollution Control Board.

• Sign a one-year agreement with the CWTF for collection, transportation, treatment, and disposal ofBMWs at a fixed rate, irrespective of the type of thehealth care facility (government or private) or bedoccupancy at the health care facility. The rate for hospitals with beds started with Rs. 2/bed/day (aboutUS$0.04/bed/day) in 2001 and increased to the current level of Rs. 3.25/bed/day. For health carefacilities without beds (for example, clinics and bloodbanks), the rate is Rs. 400 to 500/month (aboutUS$8–10/month).

• Purchase and use nonchlorinated yellow bags for safeincineration of anatomical and soiled wastes;18

• Use the waste management schemes according to theguidelines prepared by the state health department;and

• Pay the municipality a monthly flat charge for collec-tion of the segregated communal waste in green bags.

The charge in 2001 was Rs. 1,000 (about US$20) forhealth care facilities with more than 100 beds and Rs.250 (about US$5) for health care facilities with agreater number of beds (Onursal and Setlur 2002).

CWTF operators need to receive properly segregat-ed and containerized BMWs from health care facilities toassure the smooth operation of their facilities. OneCWTF operator in the Twin Cities used his ownresources to improve waste management practices at eachhealth care facility. The operator conducted audits andmade specific suggestions before signing a contract, andsubsequently provided HCW management training tothe health care facility staff and supplied safe HCW man-agement posters.

In Karnataka, the two CWTFs in Bangalore and theone in Mysore all use the private sector build-own-oper-ate model.The rate structure in Karnataka for BMW col-lection, treatment, and disposal services is the same as inAndhra Pradesh. For health care facilities with beds, therates are Rs. 3.25/bed/day (about US$0.07/bed/day) inBangalore and Mysore, and Rs. 1.25/bed/day inBelgaum. For health care facilities without beds (forexample, clinics), the rate is Rs. 300/month (aboutUS$6). The rates are established through negotiationsbetween the CWTF owner and the Indian MedicalAssociation–Private Doctors’Association.

In Kerala, the state government constituted an advi-sory committee19 to select private sector investors forCWTFs through a competitive bidding process. Underthe adopted scheme, the private sector builds, owns, andoperates or leases CWTFs in four identified regions ofthe state (both urban and rural areas).The private sectoris also responsible for collecting and transporting BMWsfrom the designated facilities to the CWTF.There are nosubsidies involved, except for a grant from the state gov-ernment of five acres of land for each CWTF. In addi-tion, the state government provides incentives to the pri-vate sector by guaranteeing the number of health carefacilities and beds to be involved and by training thehealth care facility staff on HCW management. Havingfixed the user charge for private health care facilities, thestate chooses private investors to build and operate

18. Nonchlorinated bags are more expensive than regular bags. Nonchlorinated bags cost Rs. 65–85/kg (about US$1.3–1.7/kg) and regularbags cost Rs. 40/kg (about US$0.8/kg).

19.The advisory committee constituted by the state government in Kerala is led by the health department and includes representatives fromthe Urban Development Department and the State Pollution Control Board. Kerala’s health department is responsible for ensuring consultation withall stakeholders, including the Indian Medical Association, and for developing a joint project implementation plan.

Chapter 5.The Private Sector’s Role in Providing Waste Management Services 23

In the Twin Cities (Hyderabad and Secunderabad) area ofAndhra Pradesh, GJ Multiclave Pvt. owns and operates aCWTF that BMWs generated from 125 health care facili-ties—private, semi-private, and government hospitals as wellas nursing homes—with a total of 10,000 beds.The CWTF,established in mid-2000, is located about 55 km from the cityof Hyderabad on a 12-acre parcel of land purchased for Rs.3.8 million (about US$76,000).

The equipment at the CWTF consists of two auto-claves, a microwave, and an incinerator, all made in India. Inaddition, an effluent treatment plant and a secured landfill arepart of the CWTF. The total investment for structures andequipment amounts to about Rs. 12.5 million (aboutUS$250,000). After initial operation, use of the microwavewas discontinued as it was found not to be as economical asthe autoclave and not suitable for handling metals.

GJ Multiclave has two trucks that collect the segregat-ed BMWs from all subscribed health care facilities during theday (6 am–4 pm) and bring these BMWs to the CWTF atabout 6 pm.The trucks have four separate chambers—eachchamber dedicated to a waste category—and a disinfectantstorage tank to handle any spills.The CWTF operates witheight workers only at nighttime. At the CWTF, the wastebags are removed from their barrel and checked. If wastes areobserved not to be properly segregated, then GJ Multiclavebrings this problem to the health care facility’s attention. Ifthe problem persists, then GJ Multiclave informs the AndhraPradesh Pollution Control Board for enforcement.

Two 30- and 60-liter capacity autoclaves at the CWTFare used for treatment of recyclable HCWs (glass and plasticssuch as gloves, aprons, syringes, catheters, I.V. tubing, bloodbags—all received in red bags). Each autoclave operates at121˚C temperature and 15 psi pressure, and has a residencetime of one hour. During the first year of the CWTF’s oper-ation, sharps (received in puncture-proof containers after dis-infection at health care facilities with a 1 percent hypochlo-rite solution) were also autoclaved before being encapsulatedin manufacturing bricks—for wall construction at theCWTF—on an experimental basis. Although encapsulation

is not listed as an option under India’s Biomedical WasteRules, it is one of the options considered under the WHO’s1999 guidelines for the safe management of HCWs (Prüss,Giroult, and Rushbrook 1999).After inauguration of the firstsecure landfill in Andhra Pradesh, sharps are sent to thissecure landfill.

Following autoclaving, the bags are opened and thecontents are transferred into a large tub for segregation ofglass and different types of plastics.a The segregated plasticsare then shredded and sold to the manufacturer for recycling.Recycling involves first converting the plastic into granulesand then molding the granules into the desired forms. GJMulticlave is planning to purchase a granulating machine.

The anatomical and soiled wastes are received innonchlorinated yellow bags for incineration.The incineratorhas a capacity of 100 kg/hr and is equipped with dual cham-bers operating at temperatures of 850–900˚C in the primarychamber and 1,050–1,100˚C in the secondary chamber.Theresidence time in the incinerator is about 1.0–1.5 seconds.The flue gases from the incinerator are removed with a dilutecaustic solution in a wet scrubber. The scrubbed gases areemitted to the atmosphere through a 30-meter-high stack.Temperatures in the primary and secondary chambers as wellas the discharged pollutants are continuously monitored.Theincinerator ash is disposed of in a secure landfill.

At the CWTF, the bins are washed with water and dis-infected, the trucks are washed with hot water, and concretefloors are disinfected.All wash waters and the scrubber waterare collected in the effluent treatment plant designed for acapacity of 6,000 liters/day, but operated only at 25 percentof this capacity (1,500 liters/day).The wastewater is treatedwith caustic and alum, aerated at a pH of 7, clarified, and fil-tered.The treated water is used for scrubbing the incineratoroff gases, and the balance is used for gardening.

GJ Multiclave has engaged an environmental consult-ant.The weekly samples collected from the scrubber off gasesare analyzed for HCl, particulate matter, and SO2. In addi-tion, the consultant collects weekly samples of the effluenttreatment plant.

a.The plastic types include low-density polyethylene (LDPE such as plastic IV bottles), high-density polyethylene (HDPE such as syringes), polyvinyl chloride

(PVC such as blood bags), and rubber (rubber tubing from syringes).

Source: Onursal and Setlur 2002.

Box 5. A Privately Owned CWTF in the Twin Cities Area of Andhra Pradesh


CWTFs based on the lowest charge bid for the govern-ment health care facilities.20 After the CWTF is con-structed, it is to be granted a provisional permit for a trialperiod of three years, and during this trial period, theCWTF is expected to be operating in full compliancewith the Biomedical Waste Rules. In the event theauthorization is not renewed, the operator would beoffered the price of the CWTF after depreciation.

The Jamalpur CWTF in Punjab is another exampleof the private sector build-own-operate scheme forHCW management.The private sector is responsible fortransporting about 5,000 kg/day of BMWs from theLudhiana area health care facilities (with a total 7,000beds) to the CWTF.The selected treatment technologiesat the CWTF are incineration and autoclaving.The cap-ital investment of the CWTF is Rs. 10 million (aboutUS$200,000). The established charge to the health carefacility is Rs. 2.7/bed/day (about US$0.05/bed/day) andfree transportation up to a distance of 25 km to theCWTF. The transportation cost increases to Rs.0.5/bed/day (about US$0.01/bed/day) for up to 100 kmand to Rs. 1.0/bed/day (about US$0.02/bed/day) forgreater distances.

In Sewri, Maharashtra, a CWTF was established atGuru Teg Bahader Hospital’s premises by the private sector21 on a build-own-operate-transfer basis under a10-year contract with the Brihanmumbai MunicipalCorporation.This facility, which required an investmentof Rs. 57 million (about US$1.1 million) to treat 3.5tons/day of BMWs, includes an incinerator for humananatomical and animal wastes, discarded medicines, andcytotoxic drugs and an autoclave for other BMWs.Theprivate sector was guaranteed a fixed fee for BMW treat-ment, whether BMWs come to the CWTF or not.Brihanmumbai Municipal Corporation engaged a trans-port service provider for collection and delivery of seg-regated BMWs from health care facilities to the CWTFas well as the disposal of the treated wastes.A total of 425health care facilities (214 municipal and 211 private) havesigned a memorandum of understanding withBrihanmumbai Municipal Corporation to send theirBMWs to the CWTF.The charges to health care facili-ties are Rs. 3.50/kg (about US$0.07/kg) for transporta-tion of the segregated BMW to the CWTF, and Rs.18/kg (about US$0.36/kg) for treatment at the CWTF

and land disposal of the residual wastes. Since the intro-duction of the billing system in August 2001, the amountof BMWs received by the CWTF has diminished drasti-cally to 1.5 tons/day (most companies reduced theirBMWs by 50 percent).The state authorities involved arespeculating that health care facilities are deliberately mix-ing BMWs with communal wastes to escapeBrihanmumbai Municipal Corporation’s charges.

This experience illustrates the importance of carefulconsideration in defining the structure of the charge sys-tem to the health care facilities, as well as the specific roleof the CWTF operator. A fixed-charge structure usingRs./bed/day for health care facilities with beds andRs./month for health care facilities without beds wouldhave eliminated the observed problem. In addition, inclu-sion of the CWTF operator in waste collection serviceswould have improved interaction between the CWTFand health care facility operators in achieving the desiredwaste quality. In Andhra Pradesh, this interaction resultedin the CWTF operator providing training to the healthcare facility personnel for joint benefits. The lessonslearned from the Sewri experience were incorporatedinto the Thane CWTF project in Maharashtra.

The draft guidelines for CWTFs, issued by theCPCB, provide clear guidance for BMW managementfor health care facilities located within a 150-km radiusof urban areas in India. Accordingly, installation of newincinerators at health care facilities will be subject tomuch greater scrutiny with the CPCB’s special approvalprocess. Human anatomical and animal wastes, whichrequire incineration in large urban areas, will probably besent to CWTFs for incineration wherever possible. Forsoiled, microbiology, and biotechnology wastes, on-siteversus CWTF options will need to be evaluated, consid-ering the state or local BMW management strategy aswell as the relative costs. For example, the Tata MumbaiMemorial Hospital in Mumbai voluntarily closed downits on-site incinerator because its air emissions were notin compliance with the Biomedical Waste Rules. Humananatomical wastes are now sent to a crematorium, chem-icals to a municipal incinerator, and other BMWs to anew hydroclave on the hospital premises. In New Delhi,there are at least eight hospitals (including the SanjayGandhi Memorial Hospital) operating autoclaves forBMW treatment.

20.The financial analysis assumes a charge of Rs. 3.50/bed/day (US$0.07/bed/day) for private health care facilities with beds, Rs. 2.00/bed/day(US$0.04/bed/day) for public health care facilities with beds, and Rs. 6.67/day (US$0.13day) for public health care facilities without beds.

21.This is a joint venture between Environmental Monitoring Services and the Canadian-based Anderson Operation, Inc.

Chapter 5.The Private Sector’s Role in Providing Waste Management Services 25

The initial approaches described here show interest-ing ways of tackling the “chicken and egg” problem ofencouraging private provision of CWTFs before thecommercial market for such facilities is fully demon-

strated. Experience gained from these systems, after thefirst few years of operation, will be useful in expandingthe coverage of properly operated and regulatedCWTFs.

CHAPTER 6

Lessons from India’s Experience

27

India has made significant progress in managingHCWs, despite delays in the implementation of itspolicies caused by weaknesses in the country’s legal

and institutional framework for HCW management.Thecentral government has strengthened the legal frameworkfor HCW management through the Biomedical WasteRules and national guidelines. States have devised theirown HCW management strategies and guidelines andprovided assistance to government hospitals to imple-ment HCW management initiatives. NGOs have playeda major role in bringing HCW management issues to theattention of government officials and the public. A cul-tural change has occurred at many health care facilities,which now accept the need to adopt good HCW man-agement practices and to purchase HCW managementservices from the private sector. Finally, successful expe-rience with privately built, owned, and operated CWTFshas led to increasing acceptance of CWTFs as the way tomanage hazardous BMWs in urban areas. Coupling thecurrent HCW management knowledge base with moreeffective use of information technology could helphealth care facilities in India internalize good HCWmanagement practices as an essential component of theiroperation.

Several major lessons can be drawn from India’sexperience:• Initiating HCW management legislation and

practice without adequate background workresults in delay and costly readjustments.Preparing background studies with a situation analysis,evaluating alternatives, and involving key stakeholders

in the process are integral steps to establishing a soundlegislative basis for HCW management legislation.India did not take all these steps—and the result was arather convoluted process, with delays in the prepara-tion and implementation of India’s HCW manage-ment legislation. In 1995, the Ministry ofEnvironment and Forests drafted rues for managingBMWs that identified incineration as the BMW tech-nology of choice for health care facilities, failing totake into account growing concerns about hazardouspollutant emissions from municipal and BMW incin-erators. A subsequent order from the Supreme Courtled to the installation of 60 incinerators in the NewDelhi area, only one of which—after re-engineeringby the CPCB—could meet today’s national norms. Inmany urban areas of India, the situation with respectto investments in substandard incinerators at healthcare facilities has not been much different from that inNew Delhi.A local NGO’s efforts revealed unsanitarypractices and associated risks in dealing with HCWsand opened a forum about the consideration of alter-native technologies to incineration—such as autoclaveand microwave treatment technologies. As a result, in1998, the Ministry of Environment and Forests issuedthe Biomedical Waste (Handling and Management)Rules.These rules (amended twice in 2000) are a sig-nificant improvement over the 1995 draft legislationand have been instrumental in raising awareness inIndia about the health risks and good managementpractices of HCWs among the health care facility per-sonnel; government officials at the central, state, and


local levels; and the general public. Nonetheless, theBiomedical Waste Management Rules do containsome internal inconsistencies and deviate in somerespects from the 1999 WHO guidelines for the safemanagement of HCWs (Prüss, Giroult, andRushbrook 1999).

• HCW guidelines must be timely and informedby field experience. HCW guidelines are an impor-tant tool for the implementation of the BiomedicalWaste Rules by health care facilities, BMW trans-porters, and BMW treatment and disposal facilityowners and operators. National guidelines for imple-menting the Biomedical Waste Rules were publishedat a rather late date and were not comprehensive.Thissituation, along with internal inconsistencies in theBiomedical Waste Rules themselves, resulted in con-siderable implementation difficulties. Weak institu-tional capacities at the state level compounded thesedifficulties. HCW management guidelines prepared atthe state level suffered from internal incoherencies; didnot specify detailed procedures; did not incorporatethe state HCW management strategies; and wereinconsistent in some respects with the BiomedicalWaste Rules. In addition, the state-level guidelineswere issued too late to assist health care facilities inmeeting the implementation schedules prescribed inthe Biomedical Waste Rules.A positive development isthat CPCB recently issued two new sets of guidelinesthat were prepared taking into account the findings ofa national survey of health care facility incinerators inIndia, views of the national experts based on experi-ences regarding the incineration technology andCWTFs, and related international experience. One setof guidelines issued by CPCB pertains to the treat-ment of BMWs at CWTFs (CPCB, n.d.-a), and theother pertains to the design and construction ofBMW incinerators (CPCB, n.d.-b).

• Many approaches and tools are necessary toinform opinions and change actions. Notificationand implementation of India’s 1998 Biomedical WasteRules were instrumental in raising awareness in Indiaabout the health risks and good management practicesof HCWs among the health care facility personnel;government officials at the central, state, and local lev-els; and the general public. NGOs in India have playedan important role in guiding the policymakers throughsituation analyses, sharing international experiences,creating awareness of HCW management issues among

the general public, conducting training related toHCW management, and providing consulting servicesto health care facilities. In addition, the HCW man-agement information presented by the media (televi-sion, radio, newspapers) and by SPCBs through theInternet has raised public awareness. National andregional workshops, along with training programs, havebeen instrumental in creating awareness of and sharingknowledge about HCW management among the gov-ernment officials, the scientific community, and per-sonnel at health care facilities.

• Hospitals can change their culture and improveHCW management practices. The culture at manyhealth care facilities in India has changed to recognizethe importance of hygiene and HCW management asessential to good hospital management practices.Thisculture change is attributable in part to assistance pro-vided to government hospitals by state health depart-ments (in part through World Bank–financed projects)in the form of personnel training, HCW managementauditing, preparation of hospital-specific plans, pro-curement of materials and supplies, and constructionof on-site disposal facilities.The application of a “trainthe trainers” approach was beneficial in imparting aleadership role for key hospital staff and obtainingtheir commitment to implement the HCW manage-ment programs at the health care facilities. It is impor-tant to note, however, that even though health carefacilities have made progress, there is still room forimprovement in bringing HCW management to theattention of medical officers and doctors, enhancinghospital-specific plans, and conducting refresher train-ing so that health care facility staff can fully internal-ize these plans. Private hospitals in India, which mustcomply with the requirements of the BiomedicalWaste Rules using their own resources, have hadmixed results in terms of changing their culture andimproving HCW management practices.

• The private sector’s role in on-site HCW man-agement is becoming increasingly important.The private sector’s involvement in providing on-siteHCW management services has gained importance inthe Indian health sector since implementation of theBiomedical Waste Rules and subsequent changes inculture at health care facilities. Some government hospitals have contracted with private sector organiza-tions for on-site waste management services previous-ly performed by health care facility staff. So far, the

Chapter 6. Lessons Learned from India’s Experience 29

experience of using private contractors has yieldedsignificant improvements in the overall sanitary condi-tions for health care facility staff and a positive changein public opinion. Some resistance during the privati-zation process may be expected from health care facil-ity staff concerned about losing their jobs.

• Effective state strategies for CWTFs, with private sector involvement, are emerging.Management of BMWs at a CWTF has recentlybecome an integral part of a state HCW managementstrategy in some states in India.The credit for spurringthis development goes to state officials in AndhraPradesh.That state’s success in convincing health carefacility representatives to pay for off-site treatment anddisposal of BMWs at a privately built, owned, andoperated CWTF has led other states to emulate itsapproach. A similar CWTF approach to HCW man-agement has been adopted in Karnataka, Maharashtra,Punjab, Rajasthan, Tamil Nadu, and there are nowplans for CWTFs in Gujarat (in Surat), Kerala, NewDelhi, Uttar Pradesh (in Noida), and West Bengal (inHowrah). In most states, the CWTF scheme servesonly health care facilities at selected urban areas; inKerala, however, it serves all health care facilities in theentire state, both urban and rural. In Sewri,Maharashtra, a charge system to health care facilitiesbased on BMW weight (that is, Rs./kg) has resulted innearly a 50 percent reduction in the expected amountof BMWs received at the CWTF. This experienceillustrates the importance of selecting the most appro-priate structure for waste charges to facilitate the flowof properly segregated BMWs to CWTFs. India’srecent experience with CWTFs is also reflected inCPCB’s two recently issued sets of draft guidelines:one set bringing close scrutiny to on-site incinerationat health care facilities and the other detailing require-ments for CWTFs for BMWs.

• Strong and clear regulatory commitmentimproves implementation of the BiomedicalWaste Rules. SPCBs in the states and PollutionControl Committees in the territories are the regula-tory agencies in India responsible for enforcing therequirements of the Biomedical Waste Rules. Thecapacity of these agencies to act—and their determi-nation to do so—has made a major difference in the

effectiveness of implementing the Biomedical WasteRules. In Maharashtra, about 98 percent of health carefacilities that submitted permit applications in 2001did not have proper BMW treatment schemes inplace. As compliance with the Biomedical Rules byhealth care facilities lagged and no drastic measureswere taken by SPCBs, the implementation schedulespecified in the Biomedical Waste Rules was amend-ed. In Andhra Pradesh, the SPCB announced its toughstand of fines to noncompliant health care facilities,and a trickle of permit applications grew into a streamof permit applications, although the level of compli-ance was still unsatisfactory.

• Information technology has a crucial role toplay in HCW management. Information tech-nology has great potential for creating public aware-ness of HCW management issues and for sharingknowledge about HCW management practices athealth care facilities. Currently, CPCB uses its Web siteto present the draft guidelines on incinerators andCWTFs. In addition, some SPCBs—including theAndhra Pradesh Pollution Control Board and theKarnataka Pollution Control Board—use their Websites to disseminate information on HCW manage-ment, including lists of permitted health care facilitiesand downloadable HCW permit application forms.Information technology has the potential to be usedmore extensively at the central environmental agenciesfor disseminating information on national programs(for example, training programs, workshops, sym-posia) or coordinating BWM management activitiesin states (for example, compliance status, research pro-grams, and national database compiled from state-level health care facility, CWTF, and BMW-relatedinformation). Information technology also has thepotential to be used at the state level to increase pub-lic awareness of regulatory requirements, environ-mental concerns, technology options, and good man-agement practices; to publicly disclose informationabout permits for health care facilities and CWTFs; toprovide health care facilities with downloadable per-mit forms; and to offer news about state training pro-grams, workshops, conferences, best practices, andclose-to-expiration medicine exchange programsamong health care facilities.

CPCB (Central Pollution Control Board). June 1996.Hospital Biomedical Wastes: Environmental Standardsand Guidelines for Management. New Delhi, India.

CPCB (Central Pollution Control Board). March 2000.Information Manual on Hospital Waste Management.New Delhi, India.

CPCB (Central Pollution Control Board). n.d-a. “DraftGuidelines for a Common Biomedical WasteTreatment Facility.” New Delhi, India.

CPCB (Central Pollution Control Board). n.d.-b.“DraftGuidelines for Design and Construction of aBiomedical Waste Incinerator.” New Delhi, India.

Government of Kerala Directorate of Health Services.n.d. “Common Biomedical Waste ManagementSchemes.”Thiruvananthapuram, Kerala.

Jyotsna Chauhan Associates. July 2000. Getting to KnowHospital Waste Management—A Step by Step Guide forHealth Care Establishments. Secunderabad, India.

Ministry of Environment and Forests. July 1998. “TheBio-Medical Waste (Management and Handling)Rules 1998.” New Delhi, India.

Onursal, B., and B. Setlur. June 2002. EnvironmentalReview of the Health Sector Portfolio in the South AsiaRegion. Environment and Social Development Unit,South Asia Region (Draft),World Bank,Washington,D.C.

Prüss, A., E. Giroult, and P. Rushbrook. 1999. SafeManagement of Wastes from Health-Care Activities.Geneva:World Health Organization.

Srishti. March 1996. “Be Careful with that Cure!” NewDelhi, India.

TCAG (The Comptroller and Auditor General of India).2001. “Audit Reports on the State Governments.Maharashtra. Implementation of Environmental Actsand Rules in Relation to Air Pollution and WasteManagement (Environment Department) for theYear Ending March 31, 2001.” New Delhi, India.

WHO (World Health Organization). September 2000 .Aide Mémoire for a National Strategy for Health-CareWaste Management. Geneva, Switzerland.

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nges

are

di

spos

ed w

ith

Cat

egor

y 6

was

tes

Col

or o

f pl

astic

B

lue

Whi

teT

rans

luce

nt

Car

dboa

rd b

ox

Tra

nspa

rent

B

lue/

Whi

te

Yello

w P

PCba

g/co

ntai

ner

PPC

5pu

t in

blu

e ba

gbl

ue P

PCtr

anslu

cent

PPC

5D

isca

rded

W

aste

s co

mpr

is-E

ngin

eere

d D

ispos

al i

n La

ndfil

ling

Ret

urn

to

Inci

nera

tion/

Inci

nera

tion/

—Sm

all q

uant

ities

m

edic

ines

in

g ou

tdat

ed,

land

fillin

gth

e sh

arps

-pit

supp

lier

Secu

red

Des

truc

tion,

and

may

be

colle

cted

an

d c

ytoto

xic

cont

amin

ated

in

hos

pita

l la

ndfil

ling

drug

s di

spos

al i

n w

ith i

nfec

tious

dru

gsan

d di

scar

ded

prem

ises

secu

red

land

fills

was

te.

med

icin

es—

Larg

e qu

antit

ies

shou

ld b

e re

turn

ed

to p

harm

acy

for

disp

osal

.

Col

or o

f pl

astic

ba

g/co

ntai

ner

Bla

ckB

lack

Bla

ckB

lack

Appendix A. India’s Health Care Waste Managment Practices and Requirements 35

Was

te M

anag

emen

t R

equi

rem

ents/G

uide

lines

Was

te

Was

te M

anag

emen

t Pra

ctices

in

Fiv

e Sta

tes

Indi

a’s

WH

O G

uide

lines

C

ateg

ory

And

hra

Bio

med

ical

(Prü

ss,G

irou

lt,an

d N

o.1

Typ

eExa

mpl

esK

arna

taka

Pun

jab

Pra

desh

2W

est Ben

gal

Mah

aras

htra

Was

te R

ules

3R

ushb

rook

199

9)

6Soiled

was

teIt

ems

such

as

Dee

p bu

rial

Disi

nfec

tion

In T

win

Citi

es:

Aut

ocla

ve i

f av

ail-

Aut

ocla

ving

/In

cine

ratio

n—In

cine

ratio

n/Sa

fe

cotto

n,dr

essin

gs,

and

colle

c-in

cine

ratio

n at

ab

le.U

rban

—de

ep

Mic

row

avin

g/Ye

llow

buri

al a

t ho

spita

l so

iled

plas

ter

tion

by

CW

TF

buri

al a

t m

uni-

Che

mic

al

prem

ises

cast

s,lin

ens,

mun

icip

ality

In r

ural

are

as:

cipa

l lan

dfill

trea

tmen

tA

utoc

lavi

ng/M

icro

-an

d be

ddin

g de

ep b

uria

lR

ural

—de

ep

wav

ing—

Red

cont

amin

ated

bu

rial

at

hosp

ital

with

blo

od o

r pr

emise

sbo

dy f

luid

s

Col

or o

f Ye

llow

Red

Yello

wR

edR

edYe

llow

/Red

Yello

wpl

astic

bag

/co

ntai

ner

7Solid w

aste

Was

tes

from

D

isinf

ectio

n/

Mut

ilatio

n,In

Tw

in C

ities

:A

utoc

lavi

ng i

f A

utoc

lavi

ng/

Disi

nfec

tion

by

Inci

nera

tion/

disp

osab

le i

tem

s m

utila

tion/

disin

fect

ion,

Shre

ddin

g/A

uto-

avai

labl

e.M

icro

wav

ing/

chem

ical

tre

atm

ent/

Che

mic

al d

isinf

ec-

such

as

othe

r R

ecyc

ling

and

sani

tary

cl

avin

g at

CW

TF

Urb

an—

disp

osal

C

hem

ical

A

utoc

lavi

ng/M

icro

-tio

n/M

icro

wav

ing/

than

sha

rps

land

fillin

g by

In

rur

al a

reas

:in

a m

unic

ipal

tr

eatm

ent/

wav

ing

and

mut

ila-

Safe

bur

ial o

n (f

or e

xam

ple,

mun

icip

ality

Des

truc

tion/

Dis-

buri

al p

itR

ecyc

ling

tion/

shre

ddin

gho

spita

l pre

mise

s/tu

bing

,cat

hete

rs,

infe

ctio

n w

ith

Rur

al—

deep

Sa

nita

ry la

ndfil

ling

bloo

d ba

gs)

a bl

each

ing

buri

al a

t ho

spita

l po

wde

r so

lutio

n/ p

rem

ises

Rec

yclin

g

Col

or o

f pl

astic

B

lue

Red

Red

Red

Blu

eB

lue/

Whi

te

Yello

wba

g/co

ntai

ner

tran

sluce

nt P

PC/

Red

8Liq

uid

was

teW

aste

gen

erat

ed

Disi

nfec

tion

Disi

nfec

tion

Will

be

Disi

nfec

tion

by

from

labo

rato

ry

by c

hem

ical

by

che

mic

al

colle

cted

in

chem

ical

tre

atm

ent

and

was

hing

,tr

eatm

ent

and

trea

tmen

t an

d le

ak-p

roof

an

d di

scha

rge

into

cl

eani

ng,h

ouse

-di

scha

rge

into

di

scha

rge

into

bu

cket

s an

d dr

ains

keep

ing,

and

drai

nsdr

ains

neut

raliz

ed

disin

fect

ing

befo

re d

is-ac

tiviti

esch

arge

int

o dr

ains

.


Was

te M

anag

emen

t R

equi

rem

ents/G

uide

lines

Was

te

Was

te M

anag

emen

t Pra

ctices

in

Fiv

e Sta

tes

Indi

a’s

WH

O G

uide

lines

C

ateg

ory

And

hra

Bio

med

ical

(Prü

ss,G

irou

lt,an

d N

o.1

Typ

eExa

mpl

esK

arna

taka

Pun

jab

Pra

desh

2W

est Ben

gal

Mah

aras

htra

Was

te R

ules

3R

ushb

rook

199

9)

9In

ciner

atio

n

Ash

fro

m i

ncin

-D

ispos

al o

f in

cin-

Will

be

Disp

osal

at

a as

her

atio

n of

any

er

atio

n as

h fr

om

colle

cted

in

mun

icip

al la

ndfil

lbi

omed

ical

was

teC

ateg

ory

6 w

aste

s bl

ack

plas

tic

in a

sec

ured

ba

gs f

or d

is-la

ndfil

lpo

sal i

n se

cure

la

ndfil

l

10C

hem

ical

C

hem

ical

use

d in

N

eutr

aliz

e an

d W

ill b

e C

hem

ical

tre

atm

ent

was

tepr

oduc

tion

of

disc

harg

e in

to

colle

cted

in

and

disc

harg

e in

to

biol

ogic

als;

drai

nsbl

ack

plas

tic

drai

ns f

or li

quid

s;ch

emic

al u

sed

bags

for

disp

osal

se

cure

d la

ndfil

ling

in d

isinf

ectio

n,in

sec

ure

for

solid

sas

ins

ectic

ides

land

fills.

Sour

ce:O

nurs

al a

nd S

etlu

r 19

92.

1.W

aste

Cat

egor

y Ty

pe 2

:Ani

mal

was

tes—

not

addr

esse

d by

hea

lth c

are

faci

litie

s su

rvey

ed a

nd n

ot i

nclu

ded

in t

his

asse

ssm

ent.

2.In

form

atio

n ob

tain

ed f

rom

GJ

Mul

ticla

ve (

Indi

a) P

vt.L

td.,

a co

mm

on w

aste

tre

atm

ent

faci

lity

in H

yder

abad

.

3.N

otes

for

Ind

ia’s

Bio

med

ical

Was

te R

ules

:

•C

hem

ical

tre

atm

ent

usin

g at

leas

t 1

perc

ent

hypo

chlo

rite

sol

utio

n or

any

oth

er e

quiv

alen

t ch

emic

al r

eage

nt.

•M

utila

tion/

shre

ddin

g sh

ould

pre

vent

una

utho

rize

d re

use.

•T

here

will

be

no c

hem

ical

pre

trea

tmen

t be

fore

inc

iner

atio

n.C

hlor

inat

ed p

last

ics

shal

l not

be

inci

nera

ted.

•D

eep

buri

al s

hall

be a

n op

tion

avai

labl

e on

ly i

n to

wns

with

pop

ulat

ion

less

tha

n 50

0,00

0 an

d in

rur

al a

reas

.

4.T

he l

abor

ator

y gl

ass

was

te a

nd t

he b

iolo

gica

l m

ater

ial

afte

r th

e la

bora

tory

tes

ts a

re d

econ

tam

inat

ed b

y co

mpl

ete

imm

ersio

n in

a 1

0 pe

rcen

t bl

each

sol

utio

n an

d le

ft to

sta

nd o

vern

ight

.T

he f

ollo

win

g m

orni

ng,t

he d

econ

tam

inat

ed s

olid

s in

the

buc

ket

are

put

in t

he r

ed b

in,a

nd t

he li

quid

is

disc

harg

ed t

o th

e se

wer

.

5.PP

C:p

unct

ure-

proo

f co

ntai

ner.

HC

W A

udit R

esults

in K

arnat

aka

Hosp

ital

s

100

beds

50 b

eds

30 b

eds

Hea

lth c

are

was

te (

HC

W)

Kg

%K

g%

Kg

%

Bio

med

ical

was

te (

BM

W)

321.

018

.712

9.4

56.3

91.1

47.6

Plas

tics

108.

96.

339

.117

.08.

84.

6

Shar

ps81

.94.

814

.86.

424

.712

.9

Infe

ctio

us w

aste

130.

27.

675

.532

.957

.630

.1

Gen

eral

(co

mm

unal

) w

aste

1,40

0.0

81.3

100.

443

.710

0.1

52.4

Tot

al H

CW

1,72

1.0

100.

022

9.8

100.

019

1.2

100.

0

No.

of d

ays

audi

ted

3129

31

Bed

occ

upan

cy (

%)

7272

46

Kg/

day

BM

W10

.44.

52.

9

HC

W55

.57.

96.

2

Kg/

day

/bed

BM

W0.

100.

090.

10

HC

W0.

560.

160.

21

Kg/

day

/occ

upie

d b

ed

BM

W0.

140.

130.

21

HC

W0.

770.

220.

45

AP

PE

ND

IX B

Res

ults

of

Hea

lth C

are

Was

te A

udits

for

Gov

ernm

ent

Hosp

ital

s in

Thre

e Sta

tes

37


HC

W A

udit R

esults

in M

ahar

ashtr

a H

osp

ital

s

561

beds

426

beds

406

beds

384

beds

272

beds

241

beds

202

beds

127

beds

Hea

lth c

are

was

te (

HC

W)

Kg

%K

g%

Kg

%K

g%

Kg

%K

g%

Kg

%K

g%

Bio

med

ical

was

te (

BM

W)

1,66

5.8

54.4

1,75

5.3

41.1

1,05

5.4

43.5

1,09

1.3

47.4

2,60

9.5

77.8

1,55

6.9

32.3

2,39

9.7

62.1

1,21

7.0

40.2

Plas

tics

482.

615

.780

6.8

18.9

181.

17.

597

.54.

287

3.5

26.1

636.

213

.223

3.7

3.7

284.

89.

4

Shar

ps21

0.0

6.9

44.9

1.1

187.

67.

714

1.4

6.2

290.

08.

631

4.9

6.6

288.

04.

528

8.5

9.5

Infe

ctio

us w

aste

973.

231

.890

3.6

21.1

686.

728

.377

5.8

33.7

1,44

6.0

43.1

599.

012

.41,

878.

029

.764

3.7

21.3

Phar

mac

eutic

al w

aste

0.0

0.0

0.0

0.0

0.0

0.0

76.6

3.3

0.0

0.0

6.8

0.1

0.0

0.0

0.0

0.0

Gen

eral

(co

mm

unal

) w

aste

1,39

6.2

45.6

2,51

7.0

58.9

1,37

1.6

56.5

1,21

1.6

52.6

745.

022

.23,

268.

067

.73,

931.

037

.91,

812.

059

.8

TO

TA

L H

CW

3,06

2.0

100.

04,

272.

310

0.0

2,42

7.0

100.

02,

302.

910

0.0

3,35

4.5

100.

04,

824.

910

0.0

6,33

0.7

100.

03,

029.

010

0.0

No.

of d

ays

audi

ted

3026

3030

3030

3030

Bed

occ

upan

cy (

%)

6410

196

7810

075

8013

6

Kg/

day

BM

W55

.567

.535

.236

.487

.051

.980

.040

.6

HC

W10

2.1

164.

380

.976

.711

1.8

160.

821

1.0

101.

0

Kg/

day/

bed

BM

W0.

100.

160.

090.

090.

320.

220.

400.

32

HC

W0.

180.

390.

200.

200.

410.

671.

040.

80

Kg/

day/

occu

pied

bed

BM

W0.

150.

160.

090.

120.

320.

290.

500.

24

HC

W0.

280.

380.

210.

260.

410.

891.

310.

58

Appendix B. Results of Health Waste Audits for Government Hospitals in Three States 39

HC

W A

udit R

esults

in M

ahar

ashtr

a H

osp

ital

s,C

ont.

46 b

eds

30 b

eds

30 b

eds

30 b

eds

30 b

eds

30 b

eds

Hea

lth c

are

was

te (

HC

W)

Kg

%K

g%

Kg

%K

g%

Kg

%K

g%

Bio

med

ical

was

te (

BM

W)

252.

373

.78

252.

853

.111

7.2

31.1

203.

374

.755

.073

.328

0.5

57.1

Plas

tics

74.2

21.7

86.5

18.2

25.0

6.6

37.0

13.6

4.0

5.3

36.0

7.3

Shar

ps89

.726

.256

.011

.835

.09.

322

.08.

123

.030

.715

.03.

0

Infe

ctio

us w

aste

88.4

25.9

110.

023

.157

.015

.114

4.0

52.9

28.0

37.3

229.

546

.8

Phar

mac

eutic

al w

aste

0.0

0.0

0.3

<0.

10.

2<

0.1

0.3

0.1

0.0

0.0

0.0

0.0

Gen

eral

(co

mm

unal

) w

aste

89.6

26.2

223.

046

.926

0.0

68.9

69.0

25.3

20.0

26.7

210.

442

.9

Tot

al H

CW

341.

910

0.0

475.

810

0.0

377.

210

0.0

272.

310

0.0

75.0

100.

049

0.9

100.

0

No.

of d

ays

audi

ted

2930

3030

3030

Bed

occ

upan

cy (

%)

7270

100

6055

63

Kg/

day

BM

W8.

78.

43.

96.

81.

89.

4

HC

W11

.815

.912

.69.

12.

516

.4

Kg/

day/

bed

BM

W0.

190.

280.

130.

230.

060.

31

HC

W0.

260.

530.

420.

300.

080.

55

Kg/

day/

occu

pied

bed

BM

W0.

260.

400.

130.

380.

110.

50

HC

W0.

360.

760.

420.

500.

150.

87


HC

W A

udit R

esults

in W

est

Ben

gal H

osp

ital

s

520

beds

500

beds

498

beds

381

beds

195

beds

195

beds

100

beds

30 b

eds

Hea

lth c

are

was

te (

HC

W)

Kg

%K

g%

Kg

%K

g%

Kg

%K

g%

Kg

%K

g%

Bio

med

ical

was

te (

BM

W)

131.

937

.615

5.6

36.7

154.

137

.810

9.8

37.1

87.0

39.1

93.0

40.3

42.3

27.8

4.8

29.0

Plas

tics

5.3

1.5

7.6

1.8

9.4

2.3

5.3

1.8

3.6

1.6

4.2

1.8

1.4

0.9

0.2

1.4

Shar

ps3.

91.

13.

80.

94.

91.

22.

70.

92.

41.

11.

20.

50.

50.

30.

10.

7

Infe

ctio

us w

aste

113.

032

.213

2.3

31.2

133.

332

.798

.033

.174

.933

.782

.635

.836

.824

.23.

923

.3

Hum

an a

nato

mic

al w

aste

9.8

2.8

11.9

2.8

6.5

1.6

3.8

1.3

6.0

2.7

5.1

2.2

3.6

2.4

0.6

3.6

Gen

eral

(co

mm

unal

) w

aste

219.

062

.431

6.5

63.3

253.

662

.218

6.2

62.9

135.

460

.913

7.7

59.7

109.

772

.211

.971

.0

Tot

al H

CW

350.

910

0.0

424.

110

0.0

407.

710

0.0

296.

010

0.0

222.

410

0.0

230.

710

0.0

152.

010

0.0

16.7

100.

0

No.

of b

eds

520

500

498

381

195

195

100

30

No.

of d

ays

audi

ted

33

33

33

33

Bed

occ

upan

cy (

%)

5567

8973

9311

389

53

Kg/

day

BM

W44

.051

.951

.436

.629

.031

.014

.11.

6

HC

W11

7.0

141.

413

5.9

98.7

74.1

76.9

50.7

5.6

Kg/

day/

bed

BM

W0.

080.

100.

100.

100.

150.

160.

140.

05

HC

W0.

230.

280.

270.

260.

380.

390.

510.

19

Kg/

day/

occu

pied

bed

BM

W0.

150.

150.

120.

130.

160.

140.

160.

10

HC

W0.

410.

420.

310.

350.

410.

350.

570.

35

Health Care Waste Management in India - World Bank€¦ · iv Healthcare Waste Management in India....

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Transcript of Health Care Waste Management in India - World Bank€¦ · iv Healthcare Waste Management in India....