Waste management in a crisis - Healthcare waste improvements in Kosovo
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In many poor countries, the difficulties of healthcare waste management become
especially acute during emergencies. The experience of Kosovo after NATO's
interventions illustrates the problems and challenges faced, and offers insights into how
improvements could be made.
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Sarah Gayton |
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The management of healthcare waste in many low- to middle-income countries
is often poor and fraught with difficulty.1, 2 In times of emergency or disaster
this problem is exacerbated. However, quick improvements can be made if the
right assistance and commitment are given to tackle the situation. Kosovo
provides an example of the problems faced in an emergency, post-conflict
phase, and how sustainable improvements can be made to the situation. This
article will focus on the specific challenges posed by the management of healthcare
wastes after emergencies, and on the specific challenges posed in Kosovo after NATO
interventions in 1999.
The challenge
The need for improvements in healthcare waste management in low- to middle-income
countries is well documented by the World Health Organization (WHO).3 It is common
to observe a mixture of potentially infectious and non-infectious wastes overflowing
from containers, or lying around hospital grounds with animals, pests and insects
feeding from it. This accumulated waste is then openly burnt in the hospital grounds
and/or collected and taken away to the nearest uncontrolled municipal or ad hoc
dumpsite. Both approaches are hazardous, and the potential for transmission of
communicable diseases is very high.
Mixed hazardous and non-healthcare wastes at
Gjakove/JakovicaRegional Hospital in late 1999
In emergency situations, this problem becomes even more difficult. Any previous
waste collection services are likely to have ceased or are operating on a very restricted
schedule. Waste management equipment could have been destroyed or stolen, and the
speed of replacement is normally slow. Such disruption exaggerates the problems that
healthcare institutions face prior to the emergency; this situation occurred in Kosovo
after the NATO interventions. The following quotations
from Kosovo in late 1999 and early 2000 illustrate the point
clearly:
We have 32 placentas a day to dispose of. We put them in
the freezer for temporary storage. However, the electricity
keeps going off and they are becoming infested with worms.
- Technician, Gjilani/Gnjilane hospital
We had nowhere to dispose of the hospital waste other than
the river.
- Technician, Gjakove/Jakovica hospital.
I looked up and saw a dog running off with a placenta
trailing behind it!
- International Administrator, Gjakove/Jakovica hospital.
The challenge was to provide focused technical and financial
assistance to allow low-cost interventions to quickly improve
the situation (see photos on this page). These interventions
include:
- introducing waste segregation of general and potentially
infectious waste into colour-coded bags or containers
- collection of sharps into rigid containers
- provision of a separate facility for treating potentially
infectious and used-sharps waste
How Kosovo met the challenge is described below.
The approach in Kosovo
The quick return of the refugees back into Kosovo in the end
of August 1999 put unbearable pressure on all public
services within the Province. Most public services were
unable to cope with the pressure, as a result of the combined
effect of the internal conflict, NATO's intervention and years
of neglect and under-investment. The provision of
healthcare and waste management services were no
exception. Medical institutions (6 hospitals, 30 health clinics
and over 250 small health centres) carried on with their
duties, aided by donations of equipment and supplies from
international humanitarian organizations. However, they
had very few provisions for waste management and no
treatment facilities existed for the healthcare waste.4 Health
institutions face numerous problems, including:
- very limited or no waste collection and disposal service
- no treatment facilities for infectious healthcare waste
- no colour-coded waste management consumable items
(such as plastic bags or sharps boxes) and very few skips
- accumulation of waste during the NATO interventions
- mixed wastes dumped and burnt in hospital grounds
- no waste segregation - placentas, needles and food
waste were all mixed together
- dogs, vermin, horses and goats were seen feeding on
healthcare wastes on hospital grounds
- lack of awareness of the risks of potentially infectious
wastes on the part of all stakeholders
- lack of management capacity at health clinics
- no regular electricity or water supply
- difficult procurement procedures
- lack of money for transport of any type of wastes
The situation was unacceptable
and posed significant risks to
patients due to the risk of
infection acquired within the
hospital, and to public health.
Co-ordination
The United Nations Mission in
Kosovo (UNMIK) Department
of Health together with the
WHO Humanitarian Mission in
Kosovo assessed this problem as
a priority intervention in their
initial strategy to improve
environmental health in the
Province.5 WHO co-ordinated an
approach that offered an
immediate interim solution, as
well as ensuring the potential for
a long-term strategy to be
developed at a later date. Project
proposals were submitted to
donors for funding, with the German aid organization GTZ
providing the pivotal funds to get the programme started.
Subsequently, further support came from the following
donors:
Implementation
Immediate interim solution |
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Backlog of used sharps overflowing in hospital room in Gjilini/Gnjilane Regional Hospital in 2000
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The immediate interim solutions adopted include the
introduction of simple healthcare waste segregation to
remove the relatively small quantities of infectious materials
from general wastes, procurement of disposable items (that
is, plastic bags and sharps containers) for waste
management, construction of waste treatment facilities, and
training of medical and auxiliary personnel. |
Incineration provided a
technically and financially
sustainable disposal option |
The De Montfort incinerator, for burning potentially infectious wastes and used sharps
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The WHO three-container system for waste segregation
was swiftly introduced - yellow bags for potentially
infectious waste, black bags for general waste and ridged
containers for sharps. These items were procured both
locally and internationally. The system quickly reduced the
quantity of potentially infectious wastes that needed to be
treated.
The potentially infectious wastes - yellow-bag and sharps
wastes - were then treated via burning in locally constructed
De Montfort Incinerators. These brick incinerators are
single-chamber incinerators lined with fire bricks and are
capable of burning at temperatures up to 850°C.6 (The
design of the incinerator is illustrated in the photo on the
right). They were installed quickly and could destroy
infectious waste effectively, with little visible gaseous
emissions. The resulting ash from the combustion process
was placed into metal dustbins and taken away with the
general wastes. As an interim measure, they were a
significant improvement over open dumping and open
burning. Waste paper or wood were used to preheat the
incinerator chamber, with the contents of the healthcare
waste becoming the fuel.
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The incinerators have now been constructed at health
clinics and in minority enclaves in Kosovo, with 38 in
operation by 2001. Some of the health clinics have initiated
their own collection service to take the waste to the health
houses from the surrounding small health clinics. The
incinerators provided a technically and financially
sustainable disposal option, which was suitable to the
prevailing economic situation in Kosovo. The cost of
constructing one incinerator in Kosovo was approximately
¿3700. The incinerators are now operating in several other
countries, where the price has been reduced considerably
due to cheaper raw materials.
Waste management co-ordinator for Gjilini/Gnjilane
Regional Hospital making a presentation at 'Regional
Healthcare Waste Management Improvement Seminar',
and audience at the regional seminar, comprising
managers, nurses, cleaners and incinerator operators
from other health institutions in Kosovo
Specific training materials on healthcare waste
management were translated into Albanian and Serbian7
and were specifically developed for Kosovo. These include
training notes specially aimed at doctors, nurses and
cleaners, and a video that explained the importance of
segregating healthcare wastes to improve hygiene and
infection control in hospitals. WHO initially led the
training seminars with responsibility being quickly passed
on to Kosovan healthcare staff. Regional seminars were
organized and they acted as a forum for personnel to
discuss problems they were facing, and solutions to resolve
them. Such seminars resulted in the quicker adoption of
the system.
Medium- to long-term strategy
Four, double-chamber engineered healthcare waste
incinerators were installed in Kosovo by different donors. It
is envisaged that these 'regional' incinerators will in time
treat all the infectious waste produced by the medical
institutions in Kosovo, and the simple, De Montfort
machines will be held in reserve in case of breakdowns.
However, this will only occur if there are financial resources
made available to run and maintain the machines, as well as
to meet the increased cost associated with waste collection
and transport to these central locations. It is understood that
local maintenance of these incinerators has been a
challenge.
The Ministry of Environment and Spatial Planning is
currently developing hazardous waste regulations with the
support of the Danish International Development Agency
(DANIDA), to ensure healthcare wastes are regulated in the
near future.
Programme evaluation
A questionnaire was designed in 2001 to evaluate the use of
the incinerators and the introduction of the three-container
system. The following quotations summarize the feelings
about the new improved system of waste management at
health facilities:
We want more advice on cleaning and to continually
improve our job.
- Hygienist from Mitrovica/Mitrovice health house
The De Montfort incinerator is practical for our current
situation.
- Gjakove/Jakovica, Chief Technician
I was called by the technician at Itog/Istok health house;
he had a small problem with the De Montfort incinerator.
I quickly went to sort out the problem.
- Incinerator Engineer
You take this waste management seriously.
- Rahovec/Orahovec health house technician at a regional waste
management seminar
We visited the local dumpsite, and were horrified to see the
waste pickers. We make a special effort now to ensure the
entire yellow bag waste is treated in the incinerator.
- Chief Nurse, Pristina/Prishtina University Hospital
Overall improvements have been made in waste
management, hospital hygiene, and to the cleaning staff 's
safety and hygiene conditions at the health institutions.
Continued improvements are still needed and will be further
encouraged by the Ministry of Health and regulated by the
Ministry of Environment and Spatial Planning.
Lessons learnt
Lessons learnt from the implementation of the programme
in Kosovo suggest that the following actions could improve
the management of healthcare waste in the province:
- use of low-cost intermediate technology (for example,
the De Montfort incinerator) can provide swift, marked
improvements in emergency and post-conflict situations
- use local engineering contractors
- assess both
healthcare and
waste management
facilities that exist
in the country
affected by the
emergency
- establish strong
co-ordination
amongst donor
agencies or NGOs
- engage the
commitment of
directors or chief
nurses by
explaining to
them what
improvements can
be made
- seek the waste champions who want to improve hospital
hygiene, and empower them to change the system and
provide training at other institutions
- establish good relationships with supplier of disposable
waste management items (plastic bags and sharps
containers)
- translate training notes and programmes into local
languages
- refer to key documents as detailed in references 2, 3, 7,
8 and 9 or at www.healthcarewaste.org
- respect local customs or traditions when dealing with
hospital wastes
- engineer treatment facilities with good planning and
allocate enough time for managing all aspects of these
installations
- ensure follow-up support by the Ministry of Health and
by the Ministry of Environment
- last but not least - a strong stomach, good sense of
humour and lots of energy!
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Cleaner at health clinic with 240-litre yellow wheelie bin for safer transportation and storage of potentially infectious wastes
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Wastes Management in Emergencies Group |
In 2003, the 'Wastes Management in Emergencies Group'
was established to give a new focus to improve the
professionalism of wastes management in emergencies.
The group was established through an initiative taken by
leading waste managers working in the humanitarian sector
who seek to improve the professionalism of waste
management in emergencies. It is intended that the group
will become the focus for waste management issues in
emergencies, and provid
e advice and experience to
agencies, donors and recipient countries, with assistance
given to these stakeholders in the following:
- development of sound, appropriate and affordable
waste management systems for communities in
emergencies
- sustainability of the implemented waste management
systems, including empowerment and training of
beneficiaries and strengthening institutions
- clean-up works following natural disasters or civil
unrest/conflicts, including rehabilitation of collection and
disposal systems
- working with donor and reconstruction agencies to focus
their investments towards sustainable and affordable
solutions
- source of advice and information for fieldworkers on
household, rubble and hospital wastes
The group is actively supported by Engineers for Disaster
Relief as well as the Chartered Institution of Wastes
Management in the UK.
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Outlook
Improved waste management conditions at local health clinic
Low-cost interventions do exist for quick improvements
in healthcare waste for low- to middle-income countries.
They can be deployed in post-conflict or emergency
situations to reduce the risk of communicable infectious
diseases. Quick empowerment of healthcare staff and
provision of effective training materials will allow the swift
improvement of the situation. Assistance programmes
should continue in the country after the initial emergency
phase to ensure that healthcare wastes management is
continually improved.
Acknowledgements
Special thanks is given to Dr Philip Rushbrook for his support
to the WHO Mission in Kosovo; also, to Professor Jim Picken
and Mike Bennett for the development and promotion of the
De Montfort Incinerator; and Sian Fisher for her professional
support on healthcare waste management practices. Particular
acknowledgements go to Fekrije Hasani of the Ministry of
Health in Kosovo, Nezakete Hakaj of the Ministry of
Environment and Spatial Planning, Sadri Bersiha, the Kosovan
incinerator engineer, for his dedication, to Hamza Rama for the
manufacture of bins and plastic bags, and all chief nurses and
technicians within the Kosovan Health Institutions who have
improved the system.
The views expressed in this paper are those of the author
and not those of the WHO, UNMIK or any other organizations.
The author is happy to provide further information and
assistance if required.
References
- UNEP. International Source Book on Environmentally Sound
Technologies for Municipal Solid Waste Management. International
Environmental Technology Centre. 1996.
- Pruess, A. Giroult, E. Rushbrook, P, et al. Safe management of
wastes from health-care activities. Geneva, World Health
Organization. 1999.
- Rushbrook, P. Chandra, C. & Gayton, S. Starting healthcare
waste management in medical institutions - a practical approach.
Copenhagen, Practical Health care Waste Management
Information Series No. 1, WHO Regional Office for Europe.
2000.
- Rushbrook, P. 'Kosovo - Starting From Scratch', column article
'On the Other Side - Waste Matters From Across the Water',
Wastes Management. September 2001.
- Rushbrook, P. & Lingwood, P. Environment and Health (EH) in
Kosovo: An initial strategy and programme of activities to support the
improvement of EH in the territory. Kosovo. WHO. September
1999.
- Cole, E & Rushbrook, P. Health care waste management within
hospitals - training notes for healthcare personnel in central and
eastern European countries. Copenhagen. WHO Regional Office
for Europe. 1996.
- Health Care Waste Practical Information Series No 2: Basic Steps in
the Preparation of Health Care Waste Management Plans for Health
Care Establishments. WHO Regional Office for the Eastern
Mediterranean, Regional Centre for Environmental Health
Activities (CEHA). Amman, Jordan. 2002.
- Guidelines for Safe Disposal of Unwanted Pharmaceuticals in and
after Emergencies. WHO et al. March 1999.
- Rushbrook, P. Guidance on Minimum Approaches to Improvements
in Existing Municipal Waste Dumpsites. Copenhagen.
WHO. 2001.
Sarah Gayton, MSc is Member of the Chartered Institute
of Wastes Management, Wastes Management in
Emergencies Group. She was awarded the Chartered Institute
of Wastes Management Medal for outstanding work on
healthcare wastes in Kosovo.
e-mail: sarahgayton@yahoo.co.uk
web: www.redr.org
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