Mozambique - HIV/AIDS Response Project : environmental assessment

E630 September 2002 REPUBLIC OF MOZAMBIQUE World Bank MULTISECTORAL PROJECT FOR FIGHTING AGAINST HIV/AIDS IN MOZAMBIQUE HEALTH CARE WASTE MANAGEMENT PLAN Executive Summary and Final report Mbaye Mbengue FAYE September, 2002 FILE COPY 1 EXECUTIVE SUMMARY BACKGROUND AND OBJECTIVE OF THE STUDY The proposed project is a part of the Multi Sectoral Project to fight against HIV/SIDA in Mozambique and the development objective will be to reduce HIV/SIDA prevalence and its impacts on persons infected or affected by HIV/SIDA. In this frame, the handling, the collection, the evacuation and the management of wastes affected by the HIV/AIDS constitute the most important environmental question of this program. In relation to this, the objective of this present study is to identify the level of health Care Waste Management that will be relevant to help implement and enforce proper health and environmentally sound, technically feasible, economically viable, and socially acceptable systems for management of health care waste in Mozambique. PRESENTATION OF REPUBLIC OF MOZAMBIQUE The republic of Mozambique is located at the sub-eastern of African Continent. Tanzania borders it at the North; Malawi, Zambia, Zimbabwe and Swaziland at the West; South Africa at the South and Indian Ocean at the East. There are 799,380 km2 of national territory including inland bodies of water. The country is relatively flat particularly in the coastal regions. Mozambique's population is approximately 17, 600,000 and the natural growth rate is 2.4%. Administratively, the country is divided into 10 provinces and Maputo City, the national capital, which has the status of a province. THE HEALTH CARE SYSTEM The Mozambican National Health Service comprises the public sector, the private profit-making sector and the private non-profit-making sector. It is organized into four levels : level I and 2 are the most peripheral, implementing the Primary Health Care strategy and receiving referrals for clinical conditions which cannot be treated at level 2; level 3 and 4 are fundamentally designed for more specialized curative care, and can receive referrals from the low levels. The health facilities network include 4 Central Hospitals, 12 Provincial or General Hospitals, 25 Rural Hospitals, 276 Health Centres and 736 Health Posts. In 2000, health human resources is as follows: 583 Higher, 1 489 Medium, 4635 Basic, 1679 Elementary, 5 030 Auxiliary and 1 510 other agents. HEALTH CARE WASTES (HCW) The quantity of HCW was estimated 2 214 kg/day. The composition is as follows: syringes, needles; empty bottles; plastic objects (gloves, blood pockets, urine pots, tubes etc...); cotton, compresses, empty bags ; other wastes (plaster, human organs, etc...).; and liquids waste. HEALTH CARE WASTES MANAGEMENT ASSESSMENT Institutional and legislative aspects There is no specific policy, laws and technical regulation on HCW management. However, a proposed law on medical waste management is being to be approved and should be improved by specific technical guidelines. Actors mainly involved in the HCW management Many categories of actors are involved in HCWM - Technical services of the State (Ministry of Public Health and Ministry of Environment): their responsibility is to set on foot an environmental and healthcare policy; they generally have at their disposal competent human resources in health and environment issues, and master the management techniques, but they have no important and specific actions about HCWM in health facilities, and they action are a bit limited because of lack of material and financial means; - Health facilities : they are the main HCW generators, but health staff has little concern for the daily management of the HCW, which is seen a second priority besides medical emergencies; 2 - Local collectivities: they are responsible for household littering management but their landfills disposal often receive HCW which constitute infection sources for scavengers and children; - Private sector: intervenes in household littering collection in some institutions, and even some healthcare facilities; but is not yet motivated enough to get involved in HCW management; - NGO and Community Based Organizations: most of them intervene in environmental and health field, and have a great experience in population awareness, mainly about HIV/AIDS; they could support the project in these issues; - Donors : most of them intervene in the field of health. Even if all of them recognize the importance and the interest linked with HCW, and the necessity to lead actions in this way; very few of them have specific programs for HCW. HCW management in health facilities: segregation, collection, transportation and treatment Many constraints are noticed in HCWM in health facilities, among them : the HCW mingling with household littering; the lack of efficient HCW segregation; the healing staff carelessness and the training lack about HCWM; and the helpers of nurses, lack qualification; the lack of security equipment for cleaners and waste collectors; the lack of pre collection, collection and storage dustbins; the lack of efficient treatment system in general (90% of the hospitals dispose their wastes inside the hospital, 7% transport their wastes in a municipal landfill and 15% use incineration). The lack of waste segregation is certainly the main constraint and it is necessary to built the HCWM strategy on this principle in order to reduce strongly the volume of infectious wastes to be collected and treated. KNOWLEDGE, BEHAVIOR AND PRACTICES IN HCWM The actors directly exposed to infection risks of HCWM are : health establishments staff (medical staff, paramedical, help-nurses, the cleaners); collectors staff; scavengers; population using recycled objects or living near landfills disposals. Medical and paramedical staff has fairly acceptable knowledge about HCWM. But it is even worse with help-nurses and cleaners, who are in daily contact with the HCW, and whose knowledge and education level are generally weak. The same is noticed in private and municipal collectors, scavengers, and mostly, street children playing on disposal sites. ENVIRONMENTAL AND HEALTH IMPACT Impacts on the staff The persons mainly exposed in the process of HCWM are : the medical and paramedical staff; the helps and others cleaners, charged of wastes collection or incineration in the health facilities, etc.; the wastes collection agents of private societies; the informal scavengers and populations in general, living by the side of the landfills (mainly the children) or using recycled objects from wastes. The risk linked with bad HCWM are: risks of accident for health staffs, children and scavengers; serious intoxication and infections, such as HIV/AIDS, Viral Hepatitis. Impacts on biophysical environment The most negative practices for the environment concerns the HCW treatment methods: landfill disposals, burial, burning at open air and craft incineration. Globally, the waste potential impacts on biophysical environment are : esthetical pollution, air pollution and unease during waste open air burning; waters pollution. So, for incinerator installation, it is better to choose, inside the health facilities, places distant from the admission rooms and health care rooms; concerning the noise and harms in operation, it is better to start incineration by night, to reduce harm caused by smokes. In addition, the promotion of the use of non-chlorine plastic containers is a recognized means of reducing the pollutant products from solid waste incineration. In this way, they should be recommended as dustbins for waste collection. As for the large central disposal sites, wire fencing and lock could be realized to reinforce security and to minimize the access of scavengers and children. 3 Social and cultural impacts The execution of the HCWM Plan might have negative social impacts on scavengers earning their daily living at landfills, mainly when segregation is done at the source. It is possible, through partnership with health centres, to give non-infectious reusable objects (such as empty bottles) directly to scavengers, or at least authorize them to come and collect them according to well-defined modalities. There are cultural issues relating to disposal of anatomical wastes (amputated body parts, placenta, etc.), about which communities may be strongly sensitive. These cultural aspects should be taken into account in the action plan, to better ensure the populations involvement in the implementation. ASSESSMENT AND CHOICE OF HCW TREAMENT SYSTEMS Solid HCW treatment systems The technological choices should be done according to the following criteria: technical efficiency; environmental viability; easiness and simplicity in settling and operating; availability of exchange parts; investments and operation costs; social acceptability. The main systems analyzed are: Autoclave, Microwave irradiation, Pyrolyse, Pyrolitic incinerator (modern incinerator), craft incinerator made in local materials, Chemical disinfection, burial in municipal landfills, Burial in the premises of health centres, Open air burning, encapsulation. The comparative analysis, based on the above mentioned economic and technical criteria, allows the recommendation of : modern incinerators in Central, general and provincial hospital, because of its fairly low cost; craft incinerators in rural hospital, health centres and health posts, because of its very low cost and small quantities of HCW produced in these facilities. However, inadequate incineration, or incineration of non-incinerable (halogenated plastic, radioactive waste, reactive chemical waste, silver salts or radiographic waste, mercury or cadmium, heavy metals, etc.) waste can release pollutants into the air and causes diseases. That is why waste incineration is fundamentally based on segregation at source, to reduce maximally the infectious wastes and prevent the contamination of other wastes (papers, plastic objects, etc.). Whenever incinerators become an increasingly difficult option to use, the following treatment systems should be proposed : Chemical disinfection, which gives a highly efficient disinfection, but requires highly qualified technicians for operating and it is inadequate for pharmaceutical, chemical and some types of infectious waste; Disposal at municipal landfills: In case hazardous health-care waste cannot be treated or disposed elsewhere, direct burying in the municipal landfill should be recommended. It is a temporary solution before more suitable treatment methods are found; Burying inside hospital premises: In health centres where the HCW production is rather little, a ditch should be dug. Anyway, in all cases, the principle of waste segregation at their sources of production must be seriously respected, to minimize the contamination of general wastes by the infectious ones. The other systems (autoclave, microwaves, etc.) are too expensive and need highly qualified staff to handle them, though they are more secure for the environment. In case of malfunction, the exchange parts are not always available locally. So, these types of technologies should not be recommended in Mozambique, given the present economic situation. Liquid HCW treatment system As for the liquid wastes, there are many treatment systems among which: physic and chemical treatment; intensive biological systems (activated mud system; biological disk; bacterial field, etc.); septic pits; disinfection; decanting and digesting basin; lagooning, etc. Disinfection is clearly the most efficient way to deal with liquid infectious wastes. That is why this option should be favored among the other interventions, because the HCWM plan is focused especially on HIV/AIDS related waste management. Consequently, a combined system (disinfection then storage in septic pits) is recommended for the provincial hospitals, district hospitals and health centres, which don't produce much liquid waste. For the central and general hospitals, a physic and chemical treatment, comprising a disinfection system, is recommended. The implementation of this option requires a feasibility study. PRAVATES INVOLVEMENT AND FUNDING 4 To allow the HCWM market to be attractive enough to interest private collection societies, there should be safe guaranteed payment of the collecting service. In fact, if it is not matter with health private cabinets in general, it is not the same with public health establishments, the budget of which are somewhat limited. To ensure the HCWM sustainability, it is necessary to provide, toward this activity, sufficient financial resources to health facilities. PARTNERSHIP FRAMEWORK Actors Potential field of intervention The technical services - inform the local and national authorities of the State - facilitate the co-ordination of the project's activities (MOH/MOE) - supply technical expertise - execute control and monitoring activities - train the health staff - supervise the training process, monitoring and evaluation The Municipalities - participate at the mobilization of populations - participate in the HCWM in their landfill - participate in training, monitoring and evaluation The public health - participate at the training activities facilities - put their staff aware and supply them security equipment - elaborate internal plans and guidelines about HCWM - forecast financial resources allotted to HCWM - ensure their HCW management Private health facilities - participate at the training activities - put their staff aware and supply them security equipment - elaborate internal plans and guidelines about MHCW - ensure collection and treatment of their HCW Private collection - participate at the training activities operators - put their staff aware and supply them security equipment - ensure HCW collection in private cabinets The NGOs and CBO - inform, educate and put population aware acting in health and - participate at the training activities environment The community based - serve as "go-betweens" among the populations, the project and others actors organizations and - participate in information and populations awareness other environmental - help in the mobilization of populations associative movements - participate in training activities 5 HCWM PLAN The HCWM Plan will focus the positive actions, which, in the long term, will allow a change of behavior, a sustainable HCW management, and a protection of actors against risks of infection. In this line, the strategy of intervention should axed on the following measures : lead training activities for actors concerned (health staff, HCW handlers, municipal collectors of wastes, managers of publics landfills, etc.); lead information and education campaigns for populations about HCW; reinforce the institutional and technical capacities and better the existing regulations; support initiatives of partnership between public, privates and civil society .in HCWM. These actions should be accompanied by complementary measures, mainly initiated by governmental programs, in terms of HCWM bettering in health facilities (segregation and collection materials; protection equipments; systems of treatment). Logical framework Objectives - Results - Activities Indicators Objective I : Improve the organizational and technical framework in HCWM Result 1.1. The HCWM organizational and technical framework is bettered Activities Regulate the HCW management in health facilities Regulation adopted Set up procedures of control in HCW management Procedures of control Objective 2 : Population awareness rising Result 2.1. The populations are conscious of risks linked with HCWM Activities Inform population of dangers linked with bad HCW management and reuse of Posters, radio and scavenged objects televised messages, public animations sessions, etc. Objective 3 Train the hospital staff and wastes operators in HCWM issues Result 2.1 : The actors involved are conscious of risks and have good practices and behavior in HCWM Activities Elaborate training programs and train trainers Programs elaborated Number of trained trainers Train all the health staff acting in HCW % of trained staff Evaluate the training program implementation in health facilities Appraisal reports Objective 4 Support the private initiatives and partnership in HCWM Result 4.1 The privates are motivated and involved in HCWM Activities Reinforce the managing capacities of privates societies involved in solid waste Training programs management Settle a partnership between public sector, privates and civil society for Chart of responsibility HCWM Frame of partnership Objective 5 Better HCWM in health facilities 6 Result 5.1 All the HCW are collected and treated in a secure way Activities Equip the health services with adequate HCW collection equipments (boxes for Number of boxes and syringes and dustbins for care rooms) dustbins supplied Supply the health services, appropriate HCW storage containers Number of container Acquire modem incinerators in central, general and provincial hospitals Number of incinerators Build artisanal incinerators in rural hospitals, health centres and health posts Number of incinerators Promote the use of recyclable materials Recycled materials Result 5.2 The HCWM staff have appropriate protection equipment Activity Equip the staff of cleaners and HCW managers, with boots, gloves, masks and Number of equipment I blouses Objective 6: Ensure that HCW from home care are well-managed Result 6.1: Home HCW are well-managed Activities Boxes or bottles for needles, HCW sterilization, double bagged in standard Boxes for sharps, HCW I plastic bags, etc. mixed with general waste Objective 7 : Support the execution of HCWM Plan Result 7.1: The project activities are approved, planned, implemented, monitored, evaluated and documented Activities Validate the HCWM Plan Prepare operational activities Study reports Follow the execution up, and evaluate the HCWM Plan Evaluation reports MONITORING PLAN Components and Activities Execution Control Supervision Improvement of Regulate the management of HCW at Consultants DEH/MOH MOE HCWM the level of health facilities organizational Set up procedures of control in the Heads of Health PHD and DHD DEH/MOH and and technical management of HCW centres MOE framework Elaborate training programs and train Consultants PHD and DHD DEH and Training trainers TD/MOH Train all the health acting in HCW Supervising staff still Heads of Health DHD and DHD trained centres Evaluate the training program Heads of Health PHD and DHD DEH implementation centres Public awareness Televised messages National Television DPE DEH/MOH Messages radio local Radios DPE DHD and DHD Posters in Health centres Printers societies DPE DHD and DHD I Health centres Public animation sessions NGO and CBO DPE DHD and DHD Support the Validate the HCWM Plan Actors involved DEH MOH execution of Plan activities National Consultants PHD and DHD DEH/MOH HCWM Plan Monitor the execution (national and, PHD and DHD DEH DEH (national local level) level) Evaluation of the HCWMP (halfway International PHD and DHD DEH/MOH and and final) Consultants MOE HCWM PLAN IMPLEMENTING COSTS These measures concern the activities, which should be realized in the HIV/AIDS program 7 Activities Total cost (USD) Improve the organizational and technical framework in HCWM 75 000 Training programs 660 000 Public awareness 284 000 Support the execution of HCWM Plan 158 000 TOTAL 1 177 000 USD COSTS OF HCWM PLAN COMPLEMENTARY MEASURES These measures concern the activities for bettering the HCWM in all the health facilities. Activities Total cost (USD) Supply health services with adequate HCW collection equipment (baskets for 226 000 syringes, Dustbins in health care rooms, Boots for cleaners, Masks for cleaners, Glovers for cleaners Acquire modem incinerators for central, general and provincial hospitals 240 000 Build artisanal incinerators in rural hospitals, health centres and health posts 800 000 TOTAL 1 266 000 USD REPUBLIC OF MOZAMBIQUE e World Bank MULTISECTORAL PROJECT FOR FIGHTING AGAINST HIV/AIDS IN MOZAMBIQUE HEALTH CARE WASTE MANAGEMENT PLAN Final report Mbaye Mbengue FAYE Septemer, 2002 2 CONTENTS IN TR O D U C T IO N ...................................................................................................................................... 6 1. B ackground .................................................................................................................................. 6 2. Project D escription ...................................................................................................................... 6 3. O bjective of the study.................................................................................................................. 6 4. M ethodology of the study...................................................................................................... 6 B. PRESENTATION OF THE REPUBLIC OF MOZAMBIQUE ...............................................7 1. G eographical situation .......................................................................................................... 7 2. Socioeconomic and sanitary indicators ................................................................................. 7 C. THE NATIONAL HEALTH SYSTEM...................................................................................... 8 1. H ealth sector Policy ..................................................................................................................... 8 2. H ealth sector organization ...................................................................................................... 8 3. Health sector Situation and Health facilities......................................................................... 8 D. HEALTH CARE W ASTES ........................................................................................................... 10 1. D efinition .................................................................................................................................... 10 a. The liquid wastes................................................... 10 b. Solid wastes....................................................... 10 2. Production and characterization........................................................................................... 10 a. Production ........................................................ 10 b. Characterization of biomedical wastes................1.....1.. .............II E. HEALTH CARE WASTES MANAGEMENT IN HEALTH FACILITIES .......................12 F. HEALTH CARE WASTES MANAGEMENT APPRAISAL...............................................13 1. Institutional and legal aspects of HCWM..........................................................................13 a. Policy and legal framework in HCWM............................... ...... 13 b. Actors involved in HCWM ................................... .......... 14 2. Organizational and technical aspects of HCWM...............................................................17 a. Organization ....................................................... 17 b. Wastes segregation- collection and transportation ............................... 17 c. Treatment - disposals.............. . .............................. 18 3. Knowledge - Behaviour and Practices ................................................................................. 19 3 a. Health Care facilities Staff.............................................20 b. Solid Wastes Collection Staff ........................ ...................20 c. Scavengers........................................................21 d. Traditional Healers...................................................21 e. Populations.......................................................21 f.Tranmng and Public Awareness Rising Needs................................... 22 G. ENVIRONMENTAL AND HEALTH IMPACTS...............................23 1. Health impacts...................................................... 23 2. Social and cultural aspects in HCWM...................................... 24 3. Biophysical Impacts................................................... 25 H. HEALTH CARE WASTES MANAGEMENT PLAN................................................................ 26 1. Problem atic ts ............................................................................................................................ 26 a. There is no operational strategy in the HCWM................................................... ...... 26 b. The legal framework has HCWM deficiencies................................................... ................... 26 c. The knowledge and good behavior in HCWM are generally insufficient..................... 26 d. The private societies are not involved in HCWN ........................................................ 27 2. Strategic Objectives of HCW M Plan....................................................................................... 27 3. The components of the Action Plan............................... .........28 a. Objective Improve the organizational and technical framework in HCWM deficincies.........28 b. Objective 2 Population awareness rising......................................................... ...... 29 c. Objective 3 : Train the hospital staff and wastes handlers .......... ..............30 d. Objective 4 Support the private initiatives and partnership in HCWM ...... ........30 e. Objective 5 : Improve HCWM in health facilities .............................30 f.Objective 7: Ensure that HCW from home care are well-managed ......... .......... 31 g. Objective 6 : Support the execution of HCWM Plan...........................32 4. Logical Fram ew ork ................................................................................................................... 33 5. Training and Awareness Strategy......................................................................................... 34 a. Health agents and collectors training: ............................... .......34 b. Population awareness ....................................... .........34 6. Treatment Systems and Technologies ................................................................................. 35 a. Appraisal criteria........................................ ...........35 b. Solid HCW treatment systems ..........................................35 c. Comparative analysis of solid HCW treatment systems .....................37 d. Recommendations..................................................37 e. Sharps and needle treatment................................... ...........40 f. Liquid wastes collection and treatment ...................l..... .............41 g. Choice of landfills sites...............................................41 7. Partnership framework and funding .................................................................................. 42 a. Involved actors' potential field of intervention ...............................42 b. Involvement of private societies in HCWM. ...................... ............42 4 8. Environmental and social Measures ..... ............................................................43 a. Measures for reduction of incinerators and landfills negative impacts .. ................43 b. Social measures ....................................................43 9. The M onitoring Plan ................................................................................................................ 44 a. Principles..........................................................44 b. Methodology ......................................................44 c. Responsibilities in the implementation .............................. .......45 d. Institutional arrangements for the implementation ........................ .....45 e. Timetable..............................................................47 10. the HCW M Plan Costs ............... ................................................................ 48 11. Measures accompanying the HCWM plan costs...................................................................49 ANNEXES ............................................................................................ 50 1. List of Acronyms ...................... ................................................................ 50 2. Persons interviewed .................... ................................................................ 51 3. Bibliography ......................... ................................................................ 52 4. HCW M in Health Facilities ................................................................53 5. Summary of the proposed law about MWM ..................................................................... 60 6. Model of craft incinerator ............. ........................................................... 61 7. Terms Of Reference ................... ................................................................ 62 5 LIST OF TABLES Table I Health facilities network ...........9..................................9 Table 2 Human resources in the National Health Service ........................9 Table 3 HCW Production in health facilities. ............................. ..............11 Table 4 Discrimination and code of colors for HCWM .............I...........18 Table 5 Knowledge, Behavior and Practices Assessment ......................... .....22 Table 6 Training and awareness needs, and strategy...........................22 Table 7 Risks for neighboring populations.........................................24 Table 8 Risks of contraction of HIV/AIDS through HCW ................... ...............24 Table 9 Logical framework ......................................... .........33 Table 10 Comparative analysis of solid HCW treatment systems........... ..............37 Table II Comparative analysis of the different technologies (liquid wastes) ................41 Table 12 Potential field of intervention ..........................................42 Table 13 Costs of the accompanying measures .....................................49 LIST OF BOXES Box I Central Hospital of Maputo............................................53 Box 2 General Hospital Jose Macamo-Maputo...................................54 Box 3 Xipamanine Health Center - Maputo......................................55 Box 4 Private Clinic "Clinica Da Sommerschield " - Maputo...........................55 Box 5 Private Clinic "Clinica Cruz Azur "- Maputo................. ...............56 Box 6 Provincial Hospital of Gaza - Xai Xai...................... ...............56 Box 7 Rural Hospital of Chicumbane..........................................57 Box 8 Health Center of Macia...............................................58 Box 9 Health Center of Manhiga.............................................58 Box 10 Health Center of Marracuene............................................. 59 6 INTRODUCTION 1. BACKGROUND The Mozambique HIV/AIDS Response project will support the goal of the national HIV/AIDS strategy of the Government of Mozambique, which is to reduce the spread of HIV infection in the country. As a means of achieving this goal, the project will also support the following areas : (i) mitigation of the health and socio-economic impact of HIV/AIDS at individual, household and community levels thus sustaining an economically productive population and; (ii) build strong and sustainable national capacity to respond to the epidemic. The handling, collection, disposal and management of HIV/AIDS infected materials are the most significant environmental issue in this project. A Medical Waste Management Plan, which will be appropriately costed with clear institutional arrangements for its execution, will be prepared during project preparation. Inappropriate handling of HIV/AIDS infected materials constitute a risk not only for the staff in hospitals and other health care centers, but also for families and street children who scavenge on dump sites. Some aspects of project implementation (HIV/AIDS voluntary counseling and testing clinics, purchase of equipment by communities for home care of people living with HIV/AIDS, promotion of the use of condoms) could potentially constitute an increase in the environmental and health risk associated with handling of HIV/AIDS infected waste. 2. PROJECT DESCRIPTION The project will have the following components: (i) Capacity Building; (ii) Public Sector Initiatives with the two sub-components of a) National Initiatives and b) Municipality Initiatives; (iii) Civil Society and Private Sector Initiatives; and (iv) Project Coordination. The Capacity building component will support capacity building for both the public sector and the civil society/private sector initiatives. The public sector initiative component will support the HIV/AIDS activities of line ministries and municipalities while the civil society /private sector initiatives component will support the activities of civil society organizations and the private sector. The project coordination component will support the functions of the National Committee to combat AIDS and its Secretariat, including the Project Coordination Unit (PCU). 3. OBJECTIVE OF THE STUDY The objective of the study is to identify the level of Health Care Waste Management that will be relevant to help implement and enforce proper health and environmentally sound, technically feasible, economically viable, and socially acceptable systems for management of health care waste in Mozambique. The examination of the current practices with regard to the handling of hospital waste will verify both the management of waste within the hospitals, clinics and other health care centres as well as the management by local authorities once the waste has left the source. It will also look into the level of knowledge among health care staff and local authorities about safe disposal practices to be adopted for medical waste and into the availability of capacity to deal with this type of waste. 4. METHODOLOGY OF THE STUDY The adopted methodology has been structured around the following research axis : (i) collection of document already published about HCWM in Mozambique: laws; legislative texts; regulations; technical documents, etc.; (ii) meetings with categories of actors mainly involved in HCWM, at central as well as at provincial levels (technical services of the state, technical services of local communities, private societies, health facilities staff, etc.). Meetings are in a form of individual or collective interviews; (iii) visiting sites: health facilities, on the grounds of samples reflecting their typology (public, private) and the hierarchical level (central level, provincial and local) ; public and wild landfills. 7 B. PRESENTATION OF THE REPUBLIC OF MOZAMBIQUE 1. GEOGRAPHICAL SITUATION The republic of Mozambique is located at the sub-east of African Continent. Tanzania borders it at the North; Malawi, Zambia, Zimbabwe and Swaziland at the West; South Africa at the South and Indian Ocean at the East. There are 799,380 km2 of national territory including inland bodies of water. The country is relatively flat particularly in the coastal regions. From the coasts to the interior in an east- west direction, there is a coastal plain (40% of the territory with the highest population density); plateaus with altitudes of 200 to 1000 meters and finally high plateaus and mountains over 1000 meters high. Mozambique's Indian coastline stretches for approximately 2500 km. Mozambique frequently suffers from floods, cyclones and droughts that some times reach disastrous proportions, causing death of people and animals, mass population displacement, negative effects on agricultural production, etc. The proximity of the sea and the richness of the Mozambican River basins favor small scale and industrial fisheries. The country is rich in wildlife and natural resources, such as coal and natural gas. Mozambique's population is approximately 17, 600,000' and the natural growth rate is 2.4%. The proportion of children under 15 years old, projected for 2001, is 44.5% of the population and about 75% of the population lives in rural areas, but in the past 10 to 15 years, there has been significant migration to cities due to the war (19976-1992). The groups that formed around the cities and towns have been settled there, causing problems of urban organization, sanitation and waste management. Administratively, the country is divided into 10 provinces and Maputo City, the national capital, which has the status of a province. 2. SOCIOECONOMIC AND SANITARY INDICATORS The Gross Domestic Product (GDP) per capita in Mozambique was estimated at 230 USD in 2000. Agriculture, manufacturing industry and commerce are the largest areas in the primary, secondary and tertiary sectors. The variables that determine poverty are : (i) slow economic growth until the beginning of the 1990s; (ii) low educational level of economically active household members, particularly women; (iii) high rates of dependency within households; (iv) low family agricultural productivity; (v) lack of work opportunities both within and outside the agricultural sector; (vi) poor development of infrastructure, particularly in rural areas. Some indicators illustrate this situation : the incidence of poverty is 69.4% (72.2% in rural zone and 62% in urban zone); the number of doctors for 100 000 inhabitants is 6; Up to the end of 1998, there were 1 140 000 persons infected by HIV with a prevalence of 14.5% among the adult'population (over 15 years old). 'Annual Population Projections by Province, 1997-20 10 8 C. THE NATIONAL HEALTH SYSTEM 1. HEALTH SECTOR POLICY The health policy goal of the government is for all Mozambicans to have access to quality health care. The national health policy sets out the following objectives for the health sector : (i) reduce mortality, morbidity and suffering, specially among high risk groups such as women, children and those displaced due to war and natural disasters; (ii) keep primary health care as the basis for the provision of good quality and sustainable health care and make it accessible to the majority of the population; and (iii) develop the Ministry of Health's technical and managerial capacity for planning, implementing and evaluating health care and support services. The Health Sector Strategy Plan defines the health sector's contribution to poverty reduction through interventions: health care provision; strengthening individuals and communities; and advocacy. 2. HEALTH SECTOR ORGANIZATION The Mozambican National Health Service comprises the public sector, the private profit-making sector and the private non-profit-making sector. Until now, the public sector is the National Health Service's major health care provider at the national level. It is organized into four levels : level I and 11 are the most peripheral, implementing the Primary Health Care strategy and receiving referrals for clinical conditions which cannot be treated at level I (complications in childbirth, etc.); level Ill and IV are fundamentally designed for more specialized curative care, and can receive referrals from the low levels. Over the past ten years, the referral system has been distorted, resulting in the poor performance of the most peripheral units. These levels operate below the minimum standards, mainly due to the war and the economic situation in the country over the past two decades. In the health units, this situation is characterized by chronic shortages of supplies essential for health care provision, which has negative repercussions on quality, particularly in rural areas. The weakness of the most peripheral levels (health centers and rural/general hospitals) can also be attributed to (i) inequalities between health teams, particularly the poor qualifications of professionals working in the most remote regions; (ii) continual and chronic lowering of employees' morale, motivation and professional ethics, as result of difficult working and living conditions and low salaries; (iii) unhygienic infrastructure in poor state of repair; (iv) a lack of basic equipment, or poorly functioning equipment; (v) inadequate supervision by higher levels; (vi) users' perceptions that health care is of poor quality. The profit-making private sector is developing gradually, especially in the great cities. There has been a growth in private individual and collective practices specializing in different areas. The continued growth of these businesses is dependent on an increase in household incomes. Foreign Non-Governmental Organizations (NGOs) and some religious groups, in agreement with MOH essentially provide health care in the non-profit-making private sector. 3. HEALTH SECTOR SITUATION AND HEALTH FACILITIES The health system in Mozambique served some 2 millions people in 1997, through a network of 4 central hospitals, 12 provincial hospitals, 25 rural hospitals, 276 health centres and 736 health posts. It is estimated that about 50% of the population have access to basic preventive and curative health services and live within 10 km of a facility. The National household survey of 1996/97 indicates that the closest medical service is the traditional healer, located an average 1.5 km from the rural household. In the other hand, doctors are an average 46 km away, and a health post 19 km away. Traditional healers treat 94% of the people in the villages; nurses treat 17%, midwives 20% and 9 doctors only 2%. The following boards indicate the health facilities network and the human resources in the national health system. Table 1 Health facilities network Province Central Provincial or Rural Hospital Health Health Post Hospital General Hospital Centre Niassa 1 1 15 90 Cabo Delgado - 1 3 43 37 Nampula 1 1 4 45 106 Zambesia 1 3 24 138 Tete 1 3 30 50 Manila I - 14 61 Sofala 1 - 4 17 99 Inhambane - 1 2 47 26 Gaza - 1 4 11 69 Maputo Province - 1 1 14 43 Maputo City 2 3 - 16 17 TOTAL 4 12 25 276 736 (Source: Management Sciences for health, 1999) Table 2 Human resources in the National Health Service 2000 Number % Higher 583 3.7 Medium 2489 15.6 Basic 4635 29.1 Elementary 1 679 10.5 Auxiliary (Health unit functionaries) 5 030 31.6 Others (also include basic level employees such as drivers) 1 510 9.5 15926 100 (Source: Strategic Plan for the Health Sector (PESS), 2001-2005-2010, Ministry of Health) 10 D. HEALTH CARE WASTES 1. DEFINITION The health care wastes are biomedical ones and are constituted of liquid or solid wastes presenting risks of infection as they are generated by: products for diagnostics; treatment, prevention, or researches in matter of health. In the sanitary structures, we identify two types of biomedical wastes: the liquid wastes and the solid ones. a. The liquid wastes They are composed of blood remnants, of liquid chemical products, and are generally treated like the used domestic waters: they are evacuated through bottomless pits, or on the nature without being treated before hand. These wastes are sometimes toxic and need special care despite their weak quantity. b. Solid wastes We can identify two categories: - The wastes comparable to household littering, produced by the health staff or those who watch over the patients (generally members of their family) : they can be remnants of food, papers and bags unspoiled, hygienic papers, wastes from administrative services, etc. - The wastes produced in special services in health establishments such as : hospitals, health centres, clinics, medical cabinets, laboratories for medical analysis, centres making products for chemistries and veterinary cabinets; they are composed of: - Anatomic wastes (tissues from human organs; fetus, placentas, amputated organs, and other physiologic liquids, etc.) - Toxic wastes (chemical substances from diagnostics, cleaning or disinfecting (mercury and mercury compositions, radiographic films, etc.) - Sharp wastes (saw blade, needles, syringes, lancet, tubes for blood perfusion, glasses having contained blood, or any other object able to cause a wound) - Remnants of bandages (cotton and spoiled compresses, blood pockets, and the plasters) - Pharmaceutical wastes (chemistry products, expired and unused medicines). Those types of solid wastes are mainly the category, which presents risks of infection by HIV/AIDS, particularly the sharp wastes. The present study will focus it in priority. 2. PRODUCTION AND CHARACTERIZATION a. Production Biomedical wastes generation depends on numerous factors, such as established waste management methods, type of health-care facility, the proportion of patients treated daily, the degree of specialization of the health facility. For a correct estimation of the waste production, the following parameters need to be considered: number of hospital beds; number of in-patients and out-patients; range of services provided; any other activity causing biomedical wastes generation. According to the study realized by the DEH of the MOH in some hospitals, nearly 1100 kg of health care wastes are generated in 4 hospitals during 2 weeks. That represents approximately a daily rate of 20 kg by hospital. In this line, if we take into account the results of field mission in health facilities, we can estimate the daily rate generation in the other health establishments, as follows: - Central hospital : 40 kg/day - General and Provincial hospital : 20 kg/day - Rural hospital : 10 kg/day - Health centre : 3 kg/day - Health post : 1 kg/day 11 The following board indicates the health wastes generation in the health centres. Table 3 HCW Production in health facilities Province Central Provincial or Rural Health Center Health Post Production Hospital General Hospital Hospital Niassa 1 1 15 90 Cabo Delgado 1 3 43 37 Nampula 1 1 4 45 106 Zambesia 1 3 24 138 Tete 1 3 30 50 Manila I - 14 61 Sofala 1 - 4 17 99 Inhambane - 1 2 47 26 Gaza - 1 4 11 69 Maputo Province - 1 1 14 43 Maputo City 2 3 - 16 17 TOTAL 4 12 25 276 736 PRODUCTION Ratio 40 kg/day 20 kg/day 10 kg/day 3 kg/day I kg/day Production 160 kg/day 240 kg/day 250 kg/day 828 kg/day 736 kg/day 2214 kg/day b. Characterization of biomedical wastes Generally, the composition of biomedical wastes is the same in the health facilities, with some variations in central and general hospitals, where the wastes specifically abound because of high production in these centres. The most courant items seen are: syringes, needles; empty bottles for injection liquid; plastic objects (gloves, blood pockets, urine pots, tubes etc...); cotton, compresses, empty bags ; other wastes (plaster, human organs, etc...). 12 E. HEALTH CARE WASTES MANAGEMENT IN HEALTH FACILITIES The collection of field information in the health centres has been realized on the grounds of a sampling reflecting the types of health facilities (public and private) and the hierarchical level (national, provincial and local). So, the boxes in the annex 1.4 describe the situation of HCWM in some health facilities in Mozambique: Maputo City, Province of Maputo and Province of Gaza. The results of these field visits globally indicate that: - nearly 80% of health facilities mix the HCW with the other non-infectious wastes; - up to the half of health facilities mix the needles with the other wastes; - only one health facility uses an incinerator for HCW treatment; - nearly 30% of the health facilities burn their HCW at open air; - nearly 70% of health facilities dispose their HCW in the nature or in an open hole; - nearly half of the health facilities have appropriate and sufficient dustbins for HCW storage; - nearly 70% of the health facilities staff have got security equipment for HCW collection. In urban hospital (such as in Maputo city) and in rural and provincial health centres, the situation is nearly the same : no selection at the source; general mixing of the HCW with the non-infectious ones; lack of collection and treatment equipment; lack of security equipment for the staff charged to manage the HCW. These field results confirm the main conclusions of the study realized by MOH and MOE, in 2001, on HCWM, in some hospitals located in the following provinces: Niassa, Nampula, Zambezia, Tete, Maputo Province, Gaza, Inhambane, Maniqa and Sofala. The main conclusions of this study are: Waste segregation and staff training: - in nearly 34% of HCW points of generation, the selection of waste is done, while in nearly 15 % of these points, it is partially done and in nearly 47%, the selection is not done at all; - in nearly 32% of hospitals where selection is done, it (selection) is done in an appropriate manner - in 84% of cases, a waste management audit has been performed - nearly 25% of the staff in the hospitals have received a training about the management and correct handling of medical wastes - only 20% of the staff in the hospitals (including cleaners) have received a training about safety in the correct handling of toxic products - only 17% of the staff in the hospitals (including cleaners) have received a training about safety in the containerization of wastes - only 28% of the staff are trained in the selection of wastes Handling, treatment and disposal: - in 52% of the hospitals, there is not an adequate supply of safe containers for medical waste - 83% of the hospitals manage sharp objects inside their frame - 90% of the hospitals manage HCW inside their frame - in 59% of the hospitals, only re-useable needles are used - in 89% of the hospitals, there is no separate containers for sharp objects - only 4% of the hospitals use coded colors on waste containers, or other forms of labeling to distinguish hazardous from non-hazardous wastes - only 10% of the hospitals have nominated a person who coordinates wastes management - 7% transport their wastes in a municipal landfill - 15% use incineration method for the HCW treatment - 22% store their wastes more than 48hours - up to 62% have accidents register for the staff - injuries caused by needle occur in 55% of cases, while injuries due to sharp or cutting objects are 47%. Annex 1.4 presents health care waste management in health centres visited during the field mission. 13 F. HEALTH CARE WASTES MANAGEMENT ASSESSMENT 1. INSTITUTIONAL AND LEGAL ASPECTS OF HCWM a. Policy and legal framework in HCWM Presently, there is no specific policy of HCWM in Mozambique. The Strategic Plan for the Health Sector does not specifically include the HCWM issues. However, this plan has some dispositions about quality assurance : gradual introduction of quality management at all levels of the National Health Strategy, definition of norms to adopt appropriate instruments and increase provincial capacity, encouragement of the creation of quality assurance groups in the central and provincial hospitals, etc.. But these dispositions are theoretical in general and little implemented in reality. However, in 2001, the MOH and the MOE have realized a waste management audit in some hospitals of Mozambique. The audit concerned the staff training in waste management, the handling, treatment and disposal of wastes, security and accidents. As for the legal aspects, there are no specific texts about legislation and regulation, presenting dispositions in terms of collection, treatment and disposal of biomedical wastes. Only the environmental law no 20/97, of October 1, 1997 deals with this question. This law (prepared in July 30, and approved in October 1, 1997), defines some legal basis for a correct use and a viable management of environment and its components, in order to establish a system of sustainable development in Mozambique. This law forbids storing or disposing toxic pollutant products on the ground, the underground, on waters and in the atmosphere. It also recommends the Government to establish environmental quality standards in order to ensure the sustainable use of the Nation's resources. This law contains chapters about environmental pollution and environmental quality standards. It focuses the necessity of realizing environmental impact assessment (EIA) for projects and programs having negative effects on environment or public health. In this field, the MOE had elaborated directives about EIA, including the main component of the study and the approval procedure. Globally, this law deals with general principles, and the text suffers a lack of application. It does not include specific dispositions on HCWM. That's why the MOH and the MOE have elaborated a proposed law about a rational management of biomedical wastes. The document is presently in the process of being approved (according to the responsible of the DEH of the MOH, the text will be approved later at the end of July 2002). The objective of this regulation is to ensure compliance with the environment act and its subordinate regulation for the protection of the environment, health care workers and the public, by establishing systems of management for medical wastes to minimize the impact of medical wastes on the environment, on the safety and health of population and on workers' health. The proposed law determines the institutional competence in biomedical wastes management: the MOH must (i) determine a system of management of medical wastes, with the other institutions involved (ii) guarantee that contagious and infectious wastes will be treated before destruction, (iii) approve the plans of biomedical wastes management elaborated by the health facilities, (iv) guarantee that the dispositions will be taken to avoid negative impacts from final disposal of medical wastes, on the environment and public health, (v) organize training and capacity building in medical waste management; the MOE must (i) elaborate and disseminate obligatory directives for the health facilities in HCWM, including transportation and disposal, (ii) give authorization, in agreement with MOH and municipalities, for the installations and areas for the medical wastes transportation, treatment and disposal. In addition to this, all health care facilities must develop a medical waste management policy, as part of their compliance with the environment act. Some articles include important dispositions among them : the choice of a responsible in each facility to manage medical wastes and to provide 14 training and guidance for the other staff; the segregation of medical wastes; the storage of medical wastes in specific containers; the disposal methods; the storage and transportation of medical wastes. If this law is approved, it will allow a rational management of HCW in the health centres. Nevertheless, the proposed law has some shortcomings: the liquid wastes management is not mentioned and good practices of medical waste management are not enough defined, mainly those concerning staff in the health centres. The technical aspects are not always practical and directly applicable. The document does not include the following detailed specifications: legal framework covering safe health-care waste management, hospital hygiene and occupational health safety, limitation for the emissions of atmospheric pollutants and protection of water resources; responsibilities of the heads of the health- care facilities, those of the scattered smaller health-care waste producers, and of the heads of any public waste disposal agencies involved ; details of application of safe practices for waste minimization, segregation, handling, storage and transportation of health-care waste; recommended treatment and disposal methods for each health-care waste category and wastewater. That is why it is necessary to improve the proposed law by elaborating specific technical guidelines about HCWM. b. Actors involved in HCWM The HCW management sector gets many categories of actors involved: i) The technical services of the State The technical services of the State, particularly the Ministry of Health (MOH) and the Ministry of Environment (MOE) have the responsibility to define and to elaborate an environmental and healthcare policy. At the central level, these two ministries generally have got competent human resources in environmental health issues. For example, the experts of the Department of Environmental Health (DEH) of the MOH and the National Direction of Environmental Impact Assessment of the MOE, who have elaborated the proposed law about medical waste management (MWM) and the environmental law. These specialists master fairly well the environmental health management issues, but their scope of action is a bit limited because of lack of material and financial means to carry out all their mission, mainly on medical wastes management. The MOH supervises health care facilities, which are the main producers of infectious biomedical wastes. The DEH is responsible of sanitation issues, hygiene and environment. However, the level of competence in MWM is not very high in provinces and districts. The MOE has not any decentralized services yet, while the MOH has got them in provinces and districts, but they often don't have enough competent human resources. According to the Strategic Plan for the Health Sector (2001-2010), human resources problems in the health sector can be summarized as follows : disproportional repartition of professional, with most qualified staff concentrated in urban areas; poorly qualified work force, where only 18% of staff have higher and medium level training; low quantity and quality of professionals in the management field. About health facilities, the sector still has a significant shortage of qualified staff. The shortage is particularly acute in the areas of general and specialized hospital health care. Shortages are even more severe in management and administration fields, where the situation has globally, negative effects on the National Health Service efficiency, particularly at district level. Another illustrated fact is that the proportion of elementary staff has not changed significantly and the reduction of the proportion of basic level staff is mainly due to their promotion to the medium level by means of formal training. This has had consequences for the health units, which employ, at this basic level nurses and other staff who, unfortunately, leave to participate in medium level courses". 15 Though these two ministries' missions have been clearly defined, their mutual services neither take enough initiatives nor perform field actions in HCWM. This situation reveals their limited vision and understanding of responsibilities in HCWM. In the MOH, the DEH has an organization covering quite all the sectors of hygiene and sanitation (water sanitation and hygiene promotion, health and urban development, environmental health impact assessment, occupational hygiene and chemical safety, etc.). The staff comprises agents specialized in environmental health, but their activities are mainly led at the central level. The agents generally stick to daily administrative tasks and don't really support the provincial services and municipalities in HCWM issues. But, in some health facilities, the MOH has built craft incinerators, with the support of development partners or NGOs. In addition, the Central Hospital of Maputo has got two modern incinerators with the financial support of the African Development Bank. Despite of this, the HCW collection and treatment equipment needs are far from being covered in the health facilities. The MOH has got a department charged of staff training (Department of Training), but its mission is more oriented to the bettering of the professional capacities in field of health care. The training sessions aim at recycling health staff for a better health care performance: they don't sufficiently take into account environmental and sanitation issues, such as HCWM. However, in the framework of struggle against HIV/AIDS program, the Department of Training has elaborated a strategic document (draft) with includes a component about human resources training based only on issues related to HIV/AIDS (characterization of the virus, mode of transmission, impacts of HIV/AIDS on health, tests, etc.), but not to HCW. As for information and public awareness, the MOH has a service (Department of Public Education) charged of public education about health. This structure has got qualified staff and appropriated materials for conceiving didactic elements for information and awareness. It helps the health facilities and the provincial health services to elaborate and diffuse health messages (posters, radio messages, etc.). The activities, hardly cover the public education needs, and most of the time, they pretext the lack of means. The actions led in the HCWM are insignificant and are most often oriented to sickness prevention. The Ministry of Environment's mission is to elaborate and to implement an environmental policy, which will serve as a strategic orientation framework. This ministry has elaborated a National Environmental Action Plan, an environmental law and guidelines on environmental impacts assessment. These strategic documents hardly refer to the HCWM. In the health care waste management process defined by the proposed law, this ministry has a role of control and monitoring. Particularly, it must follow the procedures of Environmental Impact Assessment up. In this process, the National Direction of Environmental Impact Assessment is the mainly involved structure, but this direction does not bring enough HCWM support to provincial services, municipalities and health facilities. ii) The health establishments The health facilities are the principal HCW producers, but the healing staff has little concern for the daily management of the HCW, which is considered as a second priority besides the huge medical emergencies. In fact, the medical staff (mainly doctors, nurses and midwives) is little involved in HCWM, while it should be the basic element in the sustainable HCWM process. As well in urban health facilities as in provincial ones, there are no technical guidelines permitting to the staff to manage correctly the health care wastes, or to have safe behaviours. Despite of this situation, nearly all the health centres are characterized by a remarkable state of cleanliness. However, certain health facilities have a bio-security commission, which is very involved in infection prevention 16 and security, and sometimes, an agent is appointed to follow the waste management up. Finally, the lack of financial resources constitutes limiting factor to the ensuring of a good health care waste management (no specific budget for this management). iii) The municipalities The municipalities are responsible for the management of household littering and legally, they must not manage the HCW. However, in the practice, the landfills (or the publics containers) of household littering, which they manage, often receive the HCW from health facilities or domestic cares. In Maputo for example, the Municipal Council collects irregularly the containers of general wastes (mixed with health care wastes) in the Central Hospital, and all these wastes are disposed in the public landfill. In this way, the municipalities must be involved in the HCWM, even if their interventions in this field are somewhat weak. In Maputo city, an area is reserved in the public landfill to receive the HCW, but there is no specific treatment of these wastes. This situation constitutes a serious threat both for the public health (neighboring populations, scavengers, etc.) and the environment. iv) The private sector In Maputo City, there are three main private companies working in littering collection within the institutions, private services and private clinics, but they don't intervene in household littering collection. However, even if they collect in private clinic, none of them is specialized in HCW collection. They have no adequate equipment for that, and the infectious nature of the wastes from the clinics, don't motivate them enough to get involved in the HCW management. v) The scavengers The level of poverty (nearly 70% of the population overpasses the margin of monetary poverty) and the lack of economic alternatives push a large part of the populations towards survival strategies, mainly in suburban zones. In this framework, informal scavenging or recycling activities in the littering disposals, are opportunities for poor masses to earn a living, and the sector of recycling is too lucrative, to justify such an interest. The scavengers are mainly present in the public landfills, (such as that of Maputo City), but they are also active in general waste public containers and many other wild sites, in which they often find HCW mixed with general wastes. That is why their activity includes serious sanitary risks: infection, cutting and other injuries caused by sharp objects. vi) The traditional healers In Mozambique, the non-allopathic sector includes practitioners of traditional medicine, herbalists, etc. That is why the national health policy includes in its strategy, the collaboration with that sector, but in fact, little progression has been made apart from some research actions into medicinal plants. The MOH does not have the instruments to fulfill its mission of protecting citizens against certain practitioners who pretend to be able to treat illnesses such as AIDS. These traditional healers are mostly frequented by a large part of the population, particularly the poor people. In these fields, the practices of scarification and excision are very often. So, the instruments used can be infected, and the risk of infection by HIV/AIDS is highly potential, if the patient bears the virus. The awareness of these traditional doctors of the risks linked to the handling of their instruments is not obvious. That is why they must be targets of information and education programs. vii) The NGOs and Community Based Organizations The national NGOs are gradually developing and implementing essential community health care programs in the field of prevention, disease control, education and information. They have developed partnership with the MOH, but their activities do not cover the most disadvantaged regions. Health care could be theoretically increased by the involvement of health informal actors, such as retired people, supported by MOH. Many national NGOs and Community Based Organizations (CBO) are actively interested by environmental and health issues. Generally, they don't either intervene in the waste 17 management, or in the HCWM. Nevertheless, some NGOs and CBO are very active in public awareness and training programs about environment and health, mainly in activities of struggle against HIV/AIDS. They have great experience in this field. They could be very useful during the implementation of the activities of this project, particularly when it is necessary to involve the local populations in the HCWM. The CBO are more inclined to act in local development. They have the advantage of residing in the locality, and enjoy the trust of local populations. The civil society must be an important partner for the project, and the emergency of this category of actors, doing social and proximity activities, constitutes an opportunity in the implementation strategy of the HCWM. viii) The partners for development Most of partners for development act in the field of health. Even if all of them recognize the importance of interests linked with HCW and the necessity to lead actions in this way, very few of them have got specific programs about HCW. Only some interventions are noted in terms of infrastructures and equipments. For example, the African Bank for Development has financed the acquisition of two modern incinerators in the Central Hospital of Maputo. But these equipments are not working presently because the administration has not decided their localization. The World Health Organization (WHO), in its biennium 2001-2003, intends to support the Environmental Health Department of the MOH, by recruiting a consultant charged of the elaboration of a Health Care Waste Management Plan in three Central Hospitals. The cost of this support amounts to 23 000 USD. But, the Terms Of Reference of these studies are not yet elaborated. 2. ORGANIZATIONAL AND TECHNICAL ASPECTS OF HCWM a. Organization The sector of HCW is characterized by a multitude of production sources, difficult to spot mainly the private cabinets and the health care at home. In nearly all the health facilities, there is no plan or procedure of HCWM. And, few facilities (10% of hospital, according to study realized by the MOH), have designated an agent to look after the biomedical waste management, which is not enough. In addition to this, all over the national territory is noticed an absence of liable information about the quantity of biomedical wastes produced, though good initiatives of characterization and waste management appraisal have been realized by the MOH and the MOE in some hospitals. b. Wastes segregation- collection and transportation In the health centres, major constraints (in pre-collection, collection and evacuation) are the following: - no efficient segregation of HCW; - HCW mixing with household littering mainly by help-healers, the care takers, cleaners; - The carelessness of nurses and the deficiency or lack of training about HCWM; - The lack of qualification of cleaners and helpers charged of the handling of HCW dustbins; - dustbin for needles are inappropriate and lack security; - The insufficiency of pre-collection bowls (needles dustbins, dustbins for cotton, etc.) - The lack of enough and appropriate protection equipments for the cleaning and collecting staff. If these results illustrate the situation in some main hospitals, we can say that the waste management at local level is more deplorable, particularly in rural hospitals, health centres and health posts. Among these constraints, the absence of an effective discrimination (segregation at the source) of HCW, is a major preoccupation not only at the technical field, but also at the environmental and sanitary one. In fact, in the health facilities, it has been noticed a mingling of all types of HCW contaminated or infectious, along with non-toxic ordinary wastes, (comparable to household littering). Separation is not always done to avoid this dangerous blend which increases the volume of contamination. 18 According to the study realized by the MOH/DEH, in nearly 34% of HCW points of generation, segregation of waste is done, while in nearly 15 % of these points, it is partially done and in nearly 47%, segregation is not done at all; in nearly 32% of hospitals where segregation is done, it (selection) is done in an appropriate manner. The separation of wastes minimizes this volume, maximizes the protection of public health, and makes easy the process of treatment to be adapted. When we know that the wastes contaminated, represent nearly 20 % of the total production generated, (against 50 % for the other non-toxic wastes), we understand easily the lost efforts, in terms of material and financial means of collection of the whole spoiled wastes. Until this situation is seen and understood as a paradox and a real danger for all, it is certain that the HCW will still be thrown in public or savage landfills, while no appropriate measure is taken to protect the sites, the managers of landfills and the scavengers. In these conditions, the infectious wastes are collected carelessly as if they were household littering. Most of littering landfills have no restriction in terms of access or admission of wastes, and the managers don't give any report on the nature and quantity of wastes handled. The absence of vigilance about these landfills certainly means, for the managing staff and scavengers, an absence of danger linked with the wastes. And this perception can prevent them from protecting themselves correctly. In addition to this, there is no special disposition, taken to master the risk generated by contaminated medical wastes and toxic waste on the environment. Added to this, the use of recyclable materials (drug containers and other plastic materials) is a serious option in minimizing the volume of waste, because it would potentially reduce the solid waste to be incinerated. The discrimination of these kinds of wastes can be more formal if a cooperation between scavengers active in landfills and the responsible of health centres is set up. This option will help to reduce infectious risks in the landfills. Table 4 Discrimination and code of colors for HCWM Containers with Containers with Containers with Littering Containers Designation dangerous wastes highly dangerous sharp objects wastes Type of Containers or Containers or Hermetic box Plastic Containers or receptacle plastic bags plastic bags metallic containers Color Yellow Yellow with a Yellow with a Black label "highly label "needles" infectious" Categories of Infectious and Sharp wastes Sharp objects Wastes comparable to wastes sharp wastes highly infectious household littering c. Treatment - disposals According to the study realized by the MOH/DEH, 90% of the hospitals dispose their wastes inside the hospital, 7% transport their wastes in a municipal landfill and 15% use incineration. i) The wastes burning at open air When incinerators are not available, the burning method constitutes the most adopted practice in most of the health centres. It is performed by 30% of health facilities visited during the mission, in urban hospitals as well as in rural ones, and is done at open air, into holes or on the ground. This practice has negative effects on the environment because it pollutes the air and disturbs the populations around (when burning, plastic elements release much carbon dioxide). In addition to this, such a method leaves 19 a good deal of wastes unburned; so the problem of elimination is not totally solved, because it is hardly if 30 % of wastes are really burned. ii) The burial of wastes The wild burial, which consists in digging holes without any care, is practiced by 66% of health facilities, during the field mission, mainly in Health Centres and very probably in Health Posts. Once the hole is full, another is dug nearby. With this practice, there are real threats of polluting the underground waters, particularly the very shallow napkin easily reached. By the way, there can be real risks of being prickled by needles or other sharp objects, since the burial is executed in an anarchical way by care staffs or cleaners (there is no sign or visible indicator to show burial places). In this case, not only there are risks of being hurt and affected by "tetanus", but also one can be infected if the germs or virus are alive in the burial ground. iii) Collection by a structure and wild disposal This practice is noticed in big cities, essentially in Maputo, where the general wastes of some private clinics are collected by private structures, in a paid collection service. In these clinics, HCW are mixed with general wastes, and stored in public disposals or littering holes. In the Central Hospital of Maputo, the municipality collects in the same containers, general and health care wastes. At provincial and local level, there are no private collection structures and HCW are eliminated by the mean of other systems. iv) Wild disposal The direct rejection of biomedical wastes in the nature, on the ground, sometimes mingled with household littering, at the verge of inhabited areas, is a very common practice in the health facilities, particularly in provinces and districts. This practice constitutes an environmental and sanitary risk both for nature and population, mainly the children and the scavengers who frequent these savage disposals. v) Incineration Incineration is practiced by 15 % of hospitals (only one health centre, during field mission), and this percentage is certainly lower in the health centres and health posts. The reason for this situation can be explained by the fact that efforts of equipment implementation, mainly incinerators, concern the central and provincial hospitals. In the other hand, the cost of these incinerators (the modern ones) is rather high, and cannot be supported by the weak budget of the health facilities in Mozambique. During the mission, we have identified two new modern incinerators in the Central Hospital of Maputo, but they have not been installed because the administration has not decided on the spot. The same model is found in the Provincial Hospital of Gaza, but it was not working because of unknown breakdown. Concerning the craft incinerators built with local material, they are not efficient and do not work normally: manufacturing defects, inadequate stabilized materials, lack of care, lack of follow up, unburned wastes, etc. Cement is used as basic material and generally the structure is broken because of high temperatures. Recently, the WHO has tested a new model of craft incinerator, very efficient, able to reach high temperatures, at a low cost (800 USD). However, the incinerated wastes contain needles and other sharp objects, which can be not melted in the incinerator. Even if these metallic wastes are sterilized and deprived of infectious elements, they remain dangerous and can cause wounds with risks of tetanus when they are disposed in areas near the population (children are more exposed). In health facilities, with craft incinerators having got holes for ashes, the needles and other sharp objects are thrown in the hole. What might happen in this case is a premature filling up of the hole. In this case, another hole should be dug. In case the place was already used, there may be risks of wound by dug out sharp objects. Nevertheless, given the small amount HCW incinerated in the health centres (provincial and local level), the holes could stay longer before being filled. 3. KNOWLEDGE - BEHAVIOUR AND PRACTICES 20 The categories of actors directly concerned by the risk of being affected by HIV/AIDS contaminated HCW are: (i) the staff of health establishments (medical staff, paramedical one, helps care takers, cleaners, etc.); (ii) the collection staff (municipal employees, private collectors); (iii) The scavengers; (iv) the populations near the disposals. It is also necessary to evaluate their awareness about HCW. a. Health Care facilities Staff The health staff is composed of medical agents, paramedical staff, helpers and cleaners. These persons are the first to be in direct and permanent contact with HCW. This cohabitation in the long run makes the agents careless about the HCW, (despite of acquired experience). Generally, the medical and paramedical (doctors, nurses, midwifes) staff is conscious of risks linked with HCW handling, even if the great majority has not been trained in HCW management. Nevertheless, in the practical field, one can notice some carelessness or sometimes blame worthy behaviours mainly in paramedical agents whose knowledge and consciousness of HCWM is visibly less high than that of the doctors. According to the study realized by the MOH of the DE-I : (i) some 25% of the staff in the hospitals have received training in the management and correct handling of medical wastes; (ii) only 20% of the staff in the hospitals (including cleaners) have received training in occupational safety with respect to the correct handling of toxic products; (iii) only 17% of the staff in the hospitals (including cleaners) have received training in occupational safety with respect to the safe containerization of wastes; (iv) only 28% are trained in segregation of wastes. The basic training of this staff does not include the topic of biomedical waste management. In fact, health employees (medical and paramedical staff) are preoccupied by more urgent medical tasks, and that explain the little interest accorded to HCWM, which is not seen as an absolute priority, regarding to the high number of patients to be consulted daily. If we add to this the necessity of tackling all these problems together with HCW, the result is that the management of wastes is a second plan activity. It is nearly too much to ask them to treat the sick and to manage correctly the HCW. Facing such a situation, there is an emergent need and necessity to get a responsible involved in the HCWM (only 10% of the hospitals have nominated a person who coordinates waste management). The helpers and cleaners (who are in charge of the collection of HCW dustbins) have a slight idea of dangers in the handling of HCW, and generally ignore the sickness or diseases they might contract. Their awareness rising often does not overpass the immediate perception of danger during the handling of wastes. Though they have received a superficial awareness, most of them don't always respect the advice and indications helping them in the separation of wastes. These employees are the most exposed of the health centres, because they have no qualification when recruited, and their level of education is generally weak. The most often, these agents are not supplied protection equipments (gloves, boots, uniforms, masks, etc.). b. Solid Wastes Collection Staff Two categories of actors intervene in waste collection outside the health facilities: municipality staff and private societies staff (mainly in Maputo). Concerning the private societies, which assure a paid collection service for private clinics, the technical staff understands the gravity of the HCW problematic, even if they haven't received any training in the sanitary field. This staff is relatively conscious of the risks, but their financial efforts are very modest in terms of investments to acquire adequate materials or safe protection equipments for field workers. The financial profit seems to be their major preoccupation and nobody motives them to be interested in the HCWM. 21 In the municipalities, the solid wastes collectors and the managers of municipal disposals (such as public landfill of Maputo), who are in permanent contact with infected wastes, are unqualified hand workers whose education level is very low and often practice scavenging. Most of them don't see any difference between the household littering and HCW, and they work in precarious hygienic and protection conditions: the equipments are neither enough nor secure. The possibility of risks is all the larger than, the private medical cabinets and health-care home practitioners mix the HCW with the household littering. The technical staffs of collecting teams are aware of risks in the daily handling of solid wastes mixed with littering. But the collectors themselves do not perceive all the risks and they receive no training or awareness programs about the dangers linked to HCW handling. c. Scavengers The scavengers frequent these disposal sites looking for reusable or recyclable objects (empty bottles, etc.), not only in the public landfill (such as in Maputo), but also in the public containers reserved for household littering. With their so low standard of living and their weak education level, they hardly realize the dangers in the handling of wastes and don't accept to leave the wastes in which they earn their daily living. They have got mean protection equipments and seem to be at ease in the undesirable situation. The absence of protection of the landfill areas lessens the perception of danger so scavengers don't feel the need to protect themselves correctly. d. Traditional Healers They are mostly required by a large part of the population, particularly the poor ones. In these fields, the practices of scarification and excision are very useful. So, the instruments used can be infected, and the risk of infection by HIV/AIDS is highly potential, if the virus contaminates the patient. The awareness of these traditional doctors is not evident concerning the risks linked to the handling of their instruments. That is why they must be aimed in information's programs. e. Populations Populations mainly involved are : the scavengers looking for useful objects, children playing on the landfill or looking for toys, the population using recycled objects, the population performing or receiving home health care, populations living near the landfills and these ones using recycling objects. As for the public in general, its knowledge of risks linked with the handling of HCW is particularly weak. Populations living close to the wild and public landfills (in Maputo, the landfill is located inside the urban area, between houses) are generally ill informed of the dangers the face in cohabiting with the wastes. Though these people are conscious, they can't do without this situation for they haven't got the means to go somewhere else. Their children are the most exposed, because they often play on landfills and are hardly exposed to infections. For these actors, it is necessary to elaborate a program of Information, Awareness rising and Education about risks linked with HCW. 22 f. Training and Public Awareness rising Needs The following board indicates the level of appreciation of knowledge, behavior and practices of the categories of actors involved in the HCWM. These assessments have been realized on the basis of the field visits during the mission. Table 5 Knowledge, Behavior and Practices Assessment Categories of actors Knowledge Behavior Practices Health facilities Medical staff Fairly good Fairly correct Fairly good staff Paramedical staff Not enough medium Medium good Help-nurses Little acceptable Acceptable Cleaners None acceptable Acceptable Collection Technical staff Not enough acceptable Acceptable services staff good Collectors None Wrong Bad Population Scavengers None Wrong Bad Populations neighboring None Wrong Bad landfills, children, home health care performers (Source: field visits) Table 6 Training and awareness needs, and strategy Categories of actors Drawbacks Strategies Health facilities staff Unawareness of risks linked with HCW and Information, education careless behaviors Lack of basic training about the HCWM Training of the staff noticed in health agents The health services don't reinforce enough Training of trainers in the Knowledge, Behavior and Practices, Management of HCW with training about management of HCW The collectors are not informed enough Information, education Collection services about the risk linked with HCW staff Lack of training about HCW collection Training of technical staff techniques Ignorance of HCW notions Information, education Population through media Leaders of opinion have not given enough Information, pleading information about the risks linked with HCW (Source: field visits) 23 G. ENVIRONMENTAL AND HEALTH IMPACTS 1. HEALTH IMPACTS The persons mainly exposed in the process of HCWM are: (i) the medical and paramedical staff (ii) the helps and cleaners, charged of wastes collection or incineration in the health facilities ; (iii) the wastes collection agents of private societies; (iv) the scavengers and (v) populations in general, living by the side of the landfills (mainly the children), or people using recycled objects from wastes. The risks linked with bad management of health care wastes are globally the following: - accidental wounds : risks of accident for health staffs, for children playing on disposals and for unaware scavengers; - serious intoxication and infections, affecting the health staff and collectors. As for infections, we can cite three categories: - viral sickness such as HIV/AIDS; Viral hepatitis B (VHB) and viral hepatitis A. For these sicknesses, the exposed persons are the health agents, those who watch over the sick, the care takers and populations near the disposals (children, scavengers, etc.); - microbial or bacterial sickness such as tuberculosis, streptococci, typhoid fever etc.; - parasite sicknesses, (caused by dung coming from health centres and thrown in public disposals near habitations) such as dysentery, etc.; Concerning the risks of wounds, sharp objects (comprising syringes, broken glasses and blades) can tear open human bodies and cause infections. For example, the used syringes can be recycled by unconscious practitioners, or used as toys by children. This may be potential source of HIV transmission. Other types of harm might affect people, for example cancer (by radio active products); the burns and skin irritation (by radioactive and toxic chemical products), but they present no risk of HIV/AIDS infection. The savage disposals in popular districts are often used as toilets (mainly by bare foot children), which exposes the users to contamination and mostly to accidents caused by needles and other sharp or cutting objects. In the same way, informal health cabinets, home health care performers and healers exercising at home, certainly throw HCW in household littering containers, which exposes the members of their families, and first of all children playing with used medical instruments. The risks of wounds have increased mainly with enlarged vaccination programs, which generate important quantities of needles because of the new "single injection syringes". According to the study realized by MOH and MOE in HCWM in some hospitals, injuries caused by needles occur in 55% of cases, while injuries due to sharp or cutting objects are 47%, and up to 62% register accidents. Another category of impact concerns the potential contamination of the food chain. In fact, the ignorance of the waste handlers (in health facilities), the insufficiency of collection and storage equipments, lead to a mixing of HCW with other non-infectious wastes, particularly in the landfills which are very frequented by domestic animals looking for food. Such a situation can cause sicknesses and contaminants introduction through the food chain. At last, winds can transport dangerous germs coming from inappropriate waste storage inside the health facilities and the open landfills. The following boards indicate the risks for neighboring populations, and the risks of contraction of HIV/AIDS through HCW. 24 Table 7 Risks for neighboring populations Category Level of risk Explanations Population Average high -Weak consciousness - Precarious habitations and living conditions - Unavoidable cohabitation with wastes disposals - Inhabited districts near disposal sites - Contamination of the environment - Fluent home health cares Children Very high - No consciousness at all of dangers - Absence of protection (they are generally naked) - daily contact with HCW Table 8 Risks of contraction of HIV/AIDS through HCW Persons exposed Situation Risks of infections Category of risk by HIV/AIDS - Carelessness Production Medical staff - Ignorance of risks Wounds by sharp Major - Mingling with and cutting objects littering Segregation at the Absence of selection Acciden o ts Major source Medical staff (mixing of all HCW) objects sotsharp obycs Storage Helpers and cleaners Non protected Wounds by sharp Major wastes objects -Mixing with Wounds by sharp or Major littering scavenging cutting objects Collection and Muicities - Means of transportation privatocs collection hardly Wounds by sharp Major adequate objects - scavenging Treatment and Helpers and cleaners - No protection disposal Children, populations Wounds Major Scavengers 2. SOCIAL AND CULTURAL ASPECTS IN HCWM The average poverty rate is 69.4% in Mozambique. With this high poverty level, scavenging activities provide daily financial resources for the numerous scavengers. The disposal sites are their working places. The implementation of an efficient system of waste management can disturb their activities and reduce their earnings, because reusable objects don't reach them any longer. Another cause of perturbation is : when regulations are issued to forbid scavenging; or when they are victims of measures adopted to dismiss them from disposals sites. The social and cultural aspects linked with HCWM should be taken into account in the strategic action plan, to ensure populations' involvement in the program implementation. For example, in case they are driven away, the action plan should propose measures, taking into account these social issues. Those populations should be helped by the management plan, to get new opportunities of earning their living. To avoid loss of incomes for scavengers, the management plan should devise measures such as authorization of scavenging at the source (in health centres) and forbidding waste collecting staff to scavenge. 25 At last, populations are generally sensitive with certain types of wastes, mainly the anatomic ones (body amputation, placenta, etc.). Often they are very watchful about how such kinds of wastes are eliminated, and it is unacceptable to throw them in littering disposals. In most of the health centres, there are pits to receive these types of wastes. These social and cultural beliefs should be seriously taken into account in the process of HCWM to be proposed; and this not only to respect the culture and traditions of the persons concerned but most of all to ensure their involvement in the project. 3. BIOPHYSICAL IMPACTS In Mozambique, the most negative practices for the environment concerns the HCW treatment methods: landfill disposals, burial, burning at open air and craft incineration. Landfill disposals, (or rejection in public household littering containers), constitute an easy solution requiring few efforts. With this method, the risk of infection is shifted from one point to another and also increases. In addition, the contact of HCW with other wastes stretches the chain of environmental contamination and the transmission of sicknesses. The savage burial in a hole dug inside the health centres is very current too, particularly of the needles and sharp objects. This method can have negative impacts on the environment if the holes are not protected and stabilized to avoid water napkin contamination. If the holes are not well covered, the HCW so buried will become a source of harm to the direct environment, mainly for children looking for toys. The open air burning is very often done in health facilities. It is surely the most polluting method for the atmosphere because of.emanations of gas and particles containing toxic substances (chlorine acid, sulfur oxide, dioxin, furans, benzene chlorine), if waste segregation is not done at the source. Incineration is a also practiced because of its efficiency, but it can be a source of pollution and harm if technical dispositions are not taken. For example, waste segregation must be done to avoid burning plastic elements, chemical products and heavy metals. Also, localization, smoke purifying system, length of the chimney, and operating periods must be seriously studied. Globally, the potential impact of wastes on biophysical environment are: (i) esthetical pollution, pollution of the atmosphere and unease during open air waste burning; (ii) pollution of water surfaces and underground waters; mainly the shallow water napkin in some zones; and (iii) pollution of the soil, with a consequence for its use for agriculture. 26 H. HEALTH CARE WASTES MANAGEMENT PLAN 1. PROBLEMATIC a. There is no operational strategy in the HCWM The institutional framework is characterized by a lack of national strategy in HCWM: there is no policy document or any formal management procedure in health care wastes. The proposed law on HCWM is being prepared without a proper policy framework. That is why it is necessary to get an institutional and legal package including policy document which should outline national goals and the key steps to achieve these goals. It must contain the following : description of health and safety risks resulting from mismanaged health-care wastes; reasons for safe health-care waste management practices in health facilities; listing of approved methods of treatment and disposal for each waste category; warning against the most unsafe practices, such as disposing of hazardous health-care waste in municipal landfills; management responsibilities inside and outside health-care facilities; assessment of health- care waste management costs; the keys steps of health-care waste management: waste minimization, separation, identification, handling, treatment, final disposal. Technical specifications for the implementation of each step could be describe in separate technical guideline; record keeping and documentation; training requirement; rules governing workers health and safety protection. b. The legal framework has HCWM deficiencies The legal framework deficiencies, stressed mainly by an absence of internal regulations in the health facilities, do not ensure a sustainable HCWM. That situation doesn't help to determine in a clear and precise way, the roles, responsibilities and field competency of actors involved in the HCWM. The present laws and regulations don't allow a standardization of HCW collection, transportation, storage and treatment procedures. To make these legal documents more operational, they must reinforce the technical guidelines about HCWM, implement a specific regulation for each health facility and settle procedures of control. In addition, the laws and regulations, elaborated at the central level, should allow the municipalities to legislate locally about the HCWM. c. The knowledge and good behavior in HCWM are generally insufficient In general, we notice an insufficiency of knowledge, good behavior and practices in hospital staffs, wastes collectors and populations, as far as HCWM is concerned. If the paramedical staff (doctors, midwives, nurses) has knowledge and fairly good behavior in HCWM, efforts will be necessary, to train and make the other staff aware, such as cleaners, etc. For these types of employees, HCW are not well known, that is why very little attention is paid to their handling. This is very often source of accidents causing wounds and infection. The level of ignorance of people handling the wastes in hospitals and clinics, the inappropriate and weak storage equipments, collection and HCW disposal, cause an extraordinary mixing of HCW with other solid wastes (less toxic). Also, winds full of dust can carry dangerous pathogen germs coming from inappropriate HCW storage in hospitals, clinics and open-air landfills. For this sake, we should inform the health staff, the public agents and populations in general of dangers related to a bad management of HCW. Apart from this, HCW management must be included in the training programs for agents involved in the handling of HCW (hospital staff, wastes handlers, municipal collectors, landfills managers, etc.). There should also be an implementation of a national program for training trainers about sanitary risks, good behavior and practices linked with HCW management. 27 As for the public in general, its knowledge of risks linked with the handling of HCW is very weak, particularly : (i) the scavengers looking for useful objects, (ii) children playing on the landfill or looking for toys, (iii) population using recycled objects, (iv) population performing or receiving home health care, (v) people living near the landfills. For these actors, it is necessary to elaborate an information and awareness rising programs about risks linked with HCW. In this field, the proximity information should be given a priority, mainly with the support of NGOs and BCOs enjoying a large experience in proximity communication and health activities; in addition, very often, they know what is going on in the localities and are trusted by the population. d. The private societies are not involved in HCWM In Mozambique, very few private societies intervene in solids wastes collection: municipalities generally manage the households littering. In Maputo, only three private societies are active in this field. That is a constraint in the process of health care wastes managing in a professional manner. So, the proposed management plan must develop a professional approach generating incomes and profit. It should also support private initiatives and develop a partnership between public and private sector with civil society. In the same way, the solid waste management suffers a lack of financial support from the state and local collectivities. This is the reason why major constraints are met through all the process: collectors are not motivated, equipments are hardly replaced, collection is irregular, etc. Without a regular budget allotted to HCWM (mainly in health facilities), it is nearly impossible to improve the management. Presently, the financial resources for HCWM are symbolic in health centres: priority is given to the health care services (they prefer to buy medicines rather than dustbin or incinerator). To solve this problem, it is necessary to develop specific financial resources. In addition to this, the technical and management capacity of public and private partners should be reinforced, to motivate them in get involved in HCWM. The use of private services in HCWM system is necessary because of inability of health care facilities to raise needed capital. In addition, they expected greater experience than public facilities. But the main advantage is the increased efficiency resulting from competition among service providers on the market. 2. STRATEGIC OBJECTIVES OF HCWM PLAN To better the HCWM in a sustainable way, the plan should take into account the main constraints met during the field mission : absence of specific operational policy about HCW; lack or insufficient regulations; weakness of budgetary resources; limited qualified human resources; absence or deficiency of management equipments; insufficient knowledge about HCW; undesirable behavior and practices, etc. The HCWM plan should initiate a process and support the national response to these questions. It focuses preventive measures, mainly the initiatives to be taken in order to reduce the health and environmental risks related to present practices. It will also focus the positive actions, which, in the long term, will allow a change of behavior, a sustainable HCW management, and a protection of actors against risks of infection. In this line, the strategy of intervention should axed on the following measures: - lead training activities for actors concerned (health staff, HCW handlers, municipal collectors of wastes, managers of publics landfills, etc.); - lead information and education campaigns for populations about HCW; - reinforce the institutional and technical capacities and better the existing regulations; - support initiatives of partnership between public, privates and civil society .in HCWM. These actions should be accompanied by complementary measures, mainly initiated by governmental programs, in terms of HCWM bettering in health facilities (segregation and collection materials; protection equipments; systems of treatment). 28 3. THE COMPONENTS OF THE ACTION PLAN a. Objective 1 : Improve the organizational and technical framework in HCWM The policy and legal framework will be bettered with the adoption of the proposed law on HCWM. However, this proposed law has some shortcomings (detailed in section F.1.a), that is why it is necessary to elaborate specific technical guidelines for the health centres in terms of responsibilities definition, good practice of HCW, reduction, selection and separation at the source, storage, handling, transformation, treatment and disposal. The technical guidelines should be practical and directly applicable, and include the following specifications, with a sufficient degree of detail : legal framework covering safe health-care waste management, hospital hygiene and occupational health safety, limitation for the emissions of atmospheric pollutants and protection of water resources may also address here; responsibilities of health-care facilities' heads, of the scattered smaller health-care waste producers, and of the heads of any public waste disposal agencies involved; safe practices for waste minimization; segregation, handling, storage and transport practices of health-care waste; recommended treatment and disposal methods for each health-care waste category and waste water. As for the institutional responsibilities, presently, there is no sufficient clarification of the roles of the MOE and the MOH in HCWM. However, the proposed law, which is being approved, says that inside the hospitals, HCWM depends on MOH while HCWM outside depends on MOE. But, it is not specified what departments of MOE or MOH are involved, and what kind or roles they must play. That is why the roles of the MOE and MOH at central level need to be more clearly defined. Activity 1.1 Regulate the HCW management in health facilities - Define the roles and administrative responsibilities in the HCW management; - Implement, for each health facility, a internal HCW management plan; - Implement and adopt procedures of positive and negative sanctions of the staffs, according to their practice in the HCW management; - Schedule financial provision for HCWM in the health centres budget Activity 1.2. Set up procedures of control in HCW management - Elaborate specific guidelines of EIA for wastes management, including HCW - Implement clear directives for health control agents; - Set up a registering of HCW quantities produced by health centres; - Define the mechanisms of control in needles and sharps collection and disposal process; - Organize regular monitoring by technical staff in Provincial and District Health Directions. It is necessary to clarify the conformity of the HCWM Plan with the governmental strategy, mainly the institutional framework and the responsibilities of institutional actors involved. i) Institutional framework At the institutional level, the HCWM Plan is included in the governmental strategy of struggling against HIV/AIDS of which it is an important component. The implementation must be coordinated by the MOH, in concordance with the National Committee to combat AIDS (CCS-SIDA) and its Secretariat, including the Project Coordination Unit (PCU). The MOE and the local collectivities must participate to supervision activities. 29 ii) Responsibilities Improving the HCWM means to clarify the responsibilities and the fields of competencies of each institutional actor involved in this process. - At the central level, the MOH is responsible of the national health policy and ensures the guardianship of the health facilities, through the National Health Direction. In this Direction, the Department of Environmental Health should lead the implementation of the plan, because (i) it is part of their mission, (ii) it has already realized activities in HCWM, (iii) it has competent staff in this field, and (iv) it has decentralized services at provincial level. This direction may be supported in the MOH, by the service charged of Health Education, concerning all the activities of public information and awareness rising, and by the Training Department. In the other ministries, it can be helped by the MOE. The MOI is responsible of HCWM only within health facilities. - At provincial and local levels, the coordination of the monitoring will be exercised by the Health Direction in Provinces and Districts. - The Director of each health facility is responsible of HCWM in his establishment. He must watch over the respect of procedures and regulations for good practices. He must designate the teams charged of HCW segregation, collection, transportation and treatment. - The MOE is responsible of HCWM out of the health facilities. It must watch over the means of collection, transportation and destruction of the wastes. In addition to this, the MOE must watch over the respect of environmental norms and procedures, mainly the Environmental Impacts Assessment. - The municipalities must take some dispositions to make sure that, in their public landfills, the HCW are not mixed with general wastes. This in concordance with the health facilities and private societies of solid wastes collection. They should also give their opinion about all the activities of the HCWM Plan, which may have negative impacts on population's health. b. Objective 2 : Population awareness rising Concerning information and population awareness, no public education in the field of HCWM is covered within other health education programs, which are often oriented in health issues, rather than HCWM. The actions led in the HCWM are insignificant and are most often oriented to the prevention of infections and on some diseases such as HIV/AIDS, tuberculosis, diarrhea, etc. All these programs about population awareness do not include HCW issues and the hazardous linked with them and they need strengthening in the way to cover these aspects. Awareness programs should mainly aim scavengers, children playing on the landfills, population performing or receiving home health care and those using recycled objects people living near the landfills. NGOs and BCOs enjoying a large experience in proximity communication and health activities must conduct them. Activity 2.1. Inform population of dangers linked with HCW bad management of and reuse of scavenged objects - monthly messages on television (about dangers related to the handling of HCW) - weekly radio messages (mainly in local languages); - national awareness rising campaign (posters in health facilities, banderoles, monthly public animation sessions in the provinces and districts). 30 c. Objective 3 : Train the hospital staff and wastes handlers Activity 3.1. Elaborate training programs and train trainers - Identify the training need and the groups to be trained in the health facilities and train trainers. Activity 3.2. Train all the operators acting in solid waste management - Train leading agents, doctors, nurses, health and sanitation technical teams at provincial and district level, municipal technical services supervisors and supervisors of private societies involved in wastes collection; - Train wastes handlers in health facilities (nurses, midwives, nurses' helps, cleaners, etc.). Training modules should be adapted specifically to each category of concerned staff. Activity 3. 3. Evaluate the training program implementation Effective HCW control and monitoring in health facilities should be carried out regularly to supervise periodically the training programs implementation, in order to improve waste management and to ensure that good practices are actually performed after the training. Measures should be adopted to ensure that problems and risks involved are identified while enhancing safety and preventing the development of future problems. Enforcement and compliance with legislation shall be ensured through a co-ordinating and regulatory body. Supervision should concern the following : segregation, collection routines and labelling, internal treatment system, internal storage of HCW, transportation, worker safety measures, disposal at sanitary landfill, etc. In addition to this, it is recommended to update pedagogical references of training institutions in medicine, midwives and nurses schools, by taking into account HCWM issues in the programs. d. Objective 4 : Support the private initiatives and partnership in HCWM Activity 4.1. Reinforce the managing capacities of privates societies involved in solid waste management Support the training of top ranking staffs in the following fields: choice of appropriate collection equipments; efficient waste collection system; HCW handling; mastering of technologies' costs. Activity 4.2. Set up framework and partnership mechanisms between public sector, privates and civil society involved in HCWM - Define the intervention fields and actors responsibilities in HCWM. e. Objective 5 : Improve HCWM in health facilities Activity 5.1. Supply health facilities materials and equipments for HCWM - Supply the health facilities HCW appropriate collection and storage materials; - Implement an efficient HCW treatment system (for example modem incinerators for central, general and provincial hospitals; craft incinerators in the rural hospital, health centre and health posts); - Realize liquid waste treatment systems in health facilities (septic pits with a chemical disinfection system for the provincial hospitals, district hospitals and health centres; as for central and general hospitals, a physic and chemical treatment is recommended). 31 Note: The health centres must be supplied specific boxes for needles and other sharp objects. Already used empty bottles (flacons, mineral water bottles, etc.) could replace these boxes. Plastic containers for temporary storage should be supplied to health care rooms. Activity 5.2. Promote the use of recyclable materials The use of recyclable materials (drug containers and other plastic materials, flacons, empty bottles, etc.) is a serious option in minimizing the volume of waste, because it would potentially reduce the solid waste to be incinerated or treated in other ways. Packaging materials can be recycled (paper and cardboard, glass, metal containers, plastic wrapping, etc). However, consideration should be given to segregation of recyclable materials, according to the market opportunities. In this view, the discrimination of these kinds of wastes can be more formal if a cooperation between scavengers active in landfills and the responsible of health centres, is set up. This option will help to reduce infectious risks in the landfills. Materials should only reused if they are designed for re-used. Plastic syringes should discarded after use. The use of non-chlorine containing plastics will help to reduce the pollutant products of solid wastes incineration. f. Objective 7: Ensure that HCW from home care are well-managed The HIV/AIDS project would support community based and multisectoral activities outside the health sector. Presumably, home based care and community care would be supported. Advances in medicine now allow monitoring health family and treating some sickness at home. Such activities do have the effect of introducing infectious wastes closer to households. These health care wastes include : used needles, syringes and lancets, medicine unused or outdate, broken thermometers, etc. They must also be managed at home where health cares are practiced, to avoid their mingling with household littering and hazard risks. For example, it is noticed that razor blades are widely used at home (scarification, etc.) and they can be sources of infection if they are not well managed. For this sake, it is necessary to elaborate information and awareness programs (radio televised) towards the health agents or the amateurs (professionals and clandestine) who exercise in the houses. The targeted actors must be advised to have specific containers for needles, sharp objects (box, empty bottles, etc.) and other HCW (cotton, gloves, bandages, etc.) and not to mix the HCW with the general wastes. Used needles, syringes, lancets and other sharp may be safely disposed with other home solid wastes, provided that special care is taken while packaging them. The safe packaging of these wastes may be done very simply at home : one can use rigid plastic bottles (with a tight fitting lid), such as empty laundry detergent bottle; and one must not put sharp objects in any container to be recycled or returned to a store; needles and syringes don't need to be recapped. The rigid bottle will minimize possible needle pricks and when they are full, the lid should be tightly fixed and the bottle placed with other solid waste for disposal. Unused and outdated medicines stored at home are considerable risks for children and careless people. These medicines may be safely disposed when thrown into toilet. A thorough cleansing of empty medicine containers with warm water should be done. After that, put the lid tightly then dispose with other home solid waste. Medicines should be out of reach of children who should not play with unclean empty medicine containers. Contaminated bandages, pads, gloves, etc., may be double bagged in standard plastic waste bags and securely fastened. This material may then be combined with other household waste for disposal. As for condoms, they are not considered as Health Care Waste (they are protection materials against HIV/AIDS infection). Anyway, it is possible, in the programs for public awareness rising, to draw people's attention on the necessity of managing very well these wastes : not to throw the condoms 32 everywhere; after use, throw them into toilets, bury them safely or keep them in an appropriate place and ensure that they will be destroyed after. More specifically, health agents who exercise at home must have collection containers, which they must carry to their health centre or in the nearest one. They should also have sterilizing product. The amateurs (populations, non-professional, clandestine, etc.) must sterilize all the HCW before their disposal. The needles must be buried if there is place for this inside the house; if not, they must be put into bottles or other closed boxes, then evacuated to the public landfills. The other HCW (cotton, gloves, bandages, etc.) could be disposed in the public landfill after sterilization. The gloves must be torn to prevent people from re-using them. g. Obiective 6 : Support the execution of HCWM Plan Activity 6.1. Validate the HCWM Plan - Organize a national workshop to inform actors and to validate the HCWM Plan; Activity 6.2. Plan activities - starting evaluation (wastes characterization and identification of needs); - documents for activities implementation. Activity 6.3. Follow the execution up, and evaluate the HCWM Plan - monthly control and monitoring at regional and national level; - halfway appraisal (end of 2nd year); - final appraisal (end of 5Ih year). 33 4. LOGICAL FRAMEWORK Table 9 Logical framework Objective - Result - Activities Indicators Objective I : Improve the organizational and technical framework in HCWM Result 1.1. The HCWM organizational and technical framework is bettered Activities Regulate the HCW management in health facilities Regulation adopted Set up procedures of control in HCW management Procedures of control Objective 2 : Population awareness rising Result 2.1. The populations are conscious of risks linked with HCWM Activities Inform population of dangers linked with bad HCW management and Posters, radio and reuse of scavenged objects televised messages, public animations sessions, etc. Objective 3 : Train the hospital staff and wastes operators in HCWM issues Result 2.1 : The actors involved are conscious of risks and have good practices and behavior in HCWM Activities Elaborate training programs and train trainers Programs elaborated Number of trained trainers Train all the health staff acting in HCW % of trained staff Evaluate the training program implementation Appraisal reports Objective 4 : Support the private initiatives and partnership in HCWM Result 4.1 : The privates are motivated and involved in HCWM Activities Reinforce the managing capacities of privates societies involved in solid Training programs waste management Settle a partnership between public sector, privates and civil society for Chart of responsibility HCWM Frame of partnership Objective 5 : Better HCWM in health facilities Result 5.1 All the HCW are collected and treated in a secure way Activities Equip the health services with adequate HCW collection equipments Number of boxes and (boxes for syringes and dustbins for care rooms) dustbins supplied Supply the health services, appropriate HCW storage containers Number of container Acquire modern incinerators in central, general and provincial hospitals Number of incinerators Build artisanal incinerators in rural hospitals, health centres and health Number of incinerators posts Promote the use of recyclable materials Recycled materials Result 5.2 The HCWM staff have appropriate protection equipment Activity Equip the staff of cleaners and HCW managers, with boots, gloves, Number of equipment Actiit - masks and blouses Objective 6: Ensure that HCW from home care are well-managed Result 6.1: Home HCW are well-managed Activities Boxes or bottles for needles, HCW sterilization, double bagged in Boxes for sharps, HCW standard plastic bags, etc. mixed with general waste Objective 7 : Support the execution of HCWM Plan Result 7.1: The project activities are approved, planned, implemented, monitored, evaluated and documented Activities Validate the HCWM Plan Pre are operational activities Study reports Follow the execution up, and evaluate the HCWM Plan Evaluation reports 34 5. TRAINING AND AWARENESS STRATEGY a. Health agents and collectors training: The training and awareness program aims at : making operational the HCWM strategy; promoting the emergence of experts and professionals in HCWM; raising the sense of responsibilities of people acting in HCWM; safeguarding health and security of health staff and waste handlers. The training strategy will be articulated around the following principles: - Training trainers: it means to train the top responsible in health centres (doctors, sanitation agents, and technical services' supervising staff in municipalities and private societies).The training sessions will be held in every health region; - Training health care staffs in health centres (medical staff, paramedical), by the already trained responsible above mentioned. These training sessions will be held province by province and will be performed by the already trained key staff; - Training HCWM staffs in health centres (nurses, helps caretakers, cleaners). These training sessions will be held in health centres and will be performed by already trained key staff. The training modules will deal with risks in the handling of HCW : sustainable management process (collection, storage, transportation, treatment, disposal) ; good behaviors and practices ; caring for installations ; protection measures. The training of medical and paramedical staffs remains a priority if we want it to have a major impact in HCWM. The following axis will indicate the content of these training modules: Training module for wastes management operators - Information on the risks; advice about health and security - Basic knowledge about procedures of wastes handling, including the management of risks. - The use of protection and security equipments. Training module for wastes transportation staff - Risks linked with waste transportation; - Procedures of wastes handling: loading and unloading; - Equipments such as vehicles for wastes transportation; - Projection equipments. Training module for treatment systems operators - treatment and operating process guidelines; - health and security related to the operating system; - procedures in emergency cases and help; - technical procedures; - caring for equipments. - control of wastes productions; - watching over the process and the remnants. Training module for disposals managers - Information about health and security - Control of scavenging activities and recycling of used instruments; - Protection equipments and personal hygiene; - Secure procedures for the management of wastes at the disposals; - Measures concerning, emergency cases and help. b. Population awareness The awareness rising strategy will aim at the population and scavengers. They must be informed about dangers in HCW handling. This objective can be reached through information and awareness campaigns through local radio and television, but mostly, by animation sessions in popular districts (organized by NGOs and CBOs acting in the health and environment management). These actions can be reinforced by education campaigns (banderoles, posters) in highly frequented places. 35 6. TREATMENT SYSTEMS AND TECHNOLOGIES a. Appraisal criteria The HCW treatment systems should be efficient, environmentally sound and accessible, so as to protect persons from voluntary or accidental exposition to waste during the treatment process. Technology choices should de done according to the following criteria: - Performance and efficiency of treatment - Environmental viability. - Easiness and simplicity in the settling, the operating and care. - The exchange parts should be available, easy to get. - Costs of investments and operating. - Social acceptability In addition to this, proximity criteria must be taken into account. In fact the HCW treatment must be done, as near the places where they are produced, as possible, whenever it is technically and environmentally realizable. b. Solid HCW treatment systems i) Microwave disinfection This method is used to disinfect bio-medical waste in stationary or mobile plants. The waste is heated by means of microwave energy. This option needs high investment and operating costs and therefore not recommended for use in health facilities. ii) Autoclave sterilization This type of treatment is used in health facilities (medical analysis laboratories) for the sterilization of reusable medical equipment. In this process, a dry heat sterilizer is used and heat of I800C is made to act for 30 minutes or longer, for activating vegetative microorganisms and most bacterial spores. It allows for only limited quantities of waste and therefore commonly used only for highly infectious waste such as microbial cultures from clinical or researches laboratories. Autoclaving is environmentally sound, requires fairly high investment and moderate operating costs and ensure good disinfection efficiency under appropriate operating conditions. However, it cannot be used for all type of waste and generates contaminates wastewater. In addition, operation requires qualified technicians and shredders subject to frequent breakdown. iii) Incineration Waste incineration is a thermal treatment, which aims to destroy waste organic parts, by oxidation. It consists in burning correctly the HCW . We notice: - Pyrolyse: its treatment capacity is from 500 to 3 000 kg wastes daily, at a combustion temperature of 12000 or 16000 C ; it costs very expensive when investment and care taking are considered. Also, highly qualified staff is needed. The remnants of wastes are sent to the disposals; - Pyrolitic incinerator (modern incinerator): its treatment capacity is from 200 to 10 000 kg/daily, with a combustion temperature from 800 to 9000 C ; its investment and care taking are somewhat high; it needs qualified staff ; the remnants are sent to the disposal sites; - The incinerator with combustion room (Incinerator realized in a craft way, with local materials); Its investment and care taking costs are relatively low; it can work, even with a little qualified staff. Incineration provides very high disinfection efficiency and drastic reduction of weight and volume of waste, is relatively low costed and no need qualified staff for operating. But it generates significant pollutants emissions. 36 iv) Chemical disinfection Chemical disinfection, frequently used in health facilities to destroy microorganisms on medical equipments, floors and walls, is now being extended to the treatment of biomedical wastes. Chemicals are put in the waste to destroy or inactivate the pathogens. This treatment usually is more efficient as in disinfection than in sterilization. Chemical disinfection is most suitable for treating liquid waste such as blood, urine, stools or hospital sewage. Solid (and even highly hazardous) biomedical wastes, including microbiological cultures, sharps, etc., may also be disinfected chemically. Chemical products such as hypo chlorine and other acids are used to destroy pathogen, before wastes are thrown or burned in disposal sites. The most frequent chemical disinfecting are : - chlorine which is a universal disinfecting, very active against micro-organisms. In case of possible HIV/AIDS infectious, concentration of 5 g/liter (5000ppm) of chlorine are recommended; - formaldehyde which is an active gas against all micro-organisms except at low temperature (<200C); the relative humidity must be near 7 %. It is also sold in the form of gas dissolute into water at concentrations of 370 g / liters. This disinfecting product is recommended for Hepatitis and Ebola virus (but not for HIV/AIDS). A part from this, the formaldehyde can cause cancer. - The drawback of this system is that the disinfected wastes are still there and other methods of final elimination must be devised. This method gives highly efficient disinfection in good operating conditions, and some chemical disinfectant are relatively inexpensive. But it requires highly qualified technicians for operating the process. v) Burial in municipal landfills This practice consists in putting the HCW directly at municipal disposals. In fact, it is not a treatment system: the wastes are stored with household littering. This system requires very low investments, but it presents huge health and environmental risks, if we consider the undesirable scavenging practices at public landfills. However, landfilling is better than leaving hazardous wastes accumulated at hospitals or other publicly accessible places. More suitable treatment methods should immediately be envisaged. vi) Burial inside health facilities The burial at the very place of HCW production, is another form of elimination mainly used in health facilities where there is no treatment system or means of waste transportation to public landfills. The risk in this case is that the destruction of infected wastes is not sure according to the burial place. Also, there is always the risk of digging out wastes, most of all, the sharp objects. vii) Open air burning When done at open air, the burning of HCW constitutes a factor of pollution and harm to the environment. Since it is generally burned in a hole, the destruction is never complete: often quantity of unburned constitutes 70 % of wastes. This encourages children and scavengers to look for toys and reusable objects. viii) Encapsulation This method consists to dispose wastes to land, by filling metal or plastic container to 3/4 with waste and fill up with plastic foam, bituminous sand, cement mortar or clay material. The process is cheap, safe and very appropriate for health centres that cannot envisage other methods to treat sharps, chemical and pharmaceutical waste. Encapsulation is not recommended for non-sharps infectious waste. The main advantage is to prevent even more effectively the risk of scavengers getting access to landfills and to reduce mobilization of toxic substances. 37 c. Comparative analysis of solid HCW treatment systems The following boards will determine the advantages and drawbacks of each treatment system, along with their fitness in the economic and socio-cultural context of Mozambique. Table 10 Comparative analysis of solid HCW treatment systems Technical investments Operating Easiness/ Availability Environmental Social feasibility Cost Cost simplicity of exchange viability acceptability parts Autoclave Very efficient Fairly high Average Very Not obvious Ecological, but very good but cannot be qualified generates used for all staff contaminates type of waste wastewater Microwave Very efficient Very high Very high Very Not obvious Very ecological very good irradiation qualified staff Pyrolyse Very efficient Very high Average Qualified Possible Very ecological very good staff Pyrolitic Very efficient Fairly high Average little Possible Little pollution very good incinerator qualified (modern staff incinerator) Local material Fairly Weak Weak Little Available Polluting Very good incinerator efficient qualified staff Chemical Fairly Weak Weak Qualified Available Polluting Fairly good disinfection efficient staff Burial in Little efficient Weak Weak Qualified Available Very polluting Bad municipal public staff and risky landfills Burial inside Little efficient Weak Weak Little Available Polluting and Bad health facilities qualified risky staff Incineration at Little efficient Weak Weak Little Available Polluting and Very bad open air qualified risky staff Encapsulation Very efficient Weak Weak Little available Non polluting good for sharps, qualified chemical staff wastes, drug ,but not recommended for non-sharps infectious d. Recommendations The comparative analysis, based on the above mentioned economic and technical criteria, allows the recommendation of: - modern incinerators in Central, general and provincial hospital, because of its fairly low cost; 38 incinerators built with local material, in rural hospital, health centres and health posts, because of its very low cost and small quantities of HCW produced in these facilities. However, inadequate incineration, or incineration of non-incinerable (halogenated plastic, radioactive waste, reactive chemical waste, silver salts or radiographic waste, mercury or cadmium, heavy metals, etc.) waste can release pollutants into the air. The incineration of materials containing chlorine can generate dioxins and furans, which are classified as possible human carcinogens and can have other adverse effects. Incineration of heavy metals or materials with high metal contents (in particular: lead, mercury and cadmium) can increase the spread of heavy metals in the environment. Dioxins, furans and metals are persistent and remain in the environment. Materials containing chlorine or metal should therefore not be incinerated. That is why waste incineration is fundamentally based on a strategy of segregation at source, to reduce maximally the infectious wastes and prevent the contamination of other wastes (papers, plastic objects, etc.). All types of wastes must not be incinerated, mainly the non-incinerable ones above mentioned. So, the waste segregation will allow the non-contaminated, non-infectious and non-incinerable wastes disposal at municipal landfills. Only the contaminated wastes (needles, sharp objects, blood stained cottons, etc.) are reserved for incineration. The latters don't produce (or produce a little) toxic elements. In addition, this system of treatment allows a complete melting of needles, which are the main vectors of accidental transmission of HIV/AIDS. Modern incinerators, with special emission-treating equipment, are able to work at 800-1000 oC, and can ensure that no dioxins and furans, or only insignificant quantities are produced. Smaller models, built with local materials and able to operate at these high temperatures are currently being field-tested and implemented in some countries. In the health centres, the quantities of HCW produced are insignificant. If the segregation is really performed, the quantities to be incinerated will be more reduced and the negative impacts on environment insignificant. In addition, the promotion of the use of non-chlorine plastic containers can reduce pollutant products in solid waste incineration. Even if incineration is more and more criticized, it is difficult to choose another system for developing countries such as Mozambique, given the economic and technical conditions. It is necessary to precise that we should not incinerate all solid urban waste (household littering, industrial wastes, etc.), but only the selected contaminated health care wastes. In addition, this technology is not totally disapproved by the WHO. In fact, during vaccination campaigns against tuberculosis in Togo and Benin (West African countries), the WHO has implementing, since 2001, craft incinerators (made of local materials, cement with clay), in order to destroy the syringes' needles. Beforehand, the WHO had organized a specific workshop in Bamako in 2001, to train some African technicians in the building of these types of incinerators. These models can reach very high temperatures (800 oC) able to get the needles and sharp objects melted (the model is shown in the annex of the report). Presently, there are not in fact any environmentally sound options at low-cost for safe disposal of infectious wastes. Incineration of wastes has been widely practiced, but alternatives, which may be preferable under certain circumstances, are becoming available, such as autoclaving, chemical treatment and microwaving. Landfilling, when safely practiced, may also be a viable solution for part of the already segregated wastes. Autoclave, microwaves systems are surely more efficient and environmentally sound, but more difficult to realize too; they are very expensive and require qualified staff for operating. They cannot be used for all types of waste and generate contaminated wastewater. Chemical disinfection requires 39 chemical products permanently and qualified staff for operating; the so disinfected wastes should be sent to landfill disposals or other systems of disposal. The Maputo CHU has got two modem incinerators which are not yet installed because of environmental preoccupations about this system ; the result is that a large area of the hospital yard has become a wild landfill; because of dangers related to infectious wastes, the collection by municipal services is not regular; so, it is a source of harms for the hospital staff, the patients and visitors. This kind of situation is worst than the impacts of incineration. It is therefore important that where incineration is recommended, it should be accompanied by: (i) appropriate skills training of those who will operate the incinerators; (ii) appropriate and continuous monitoring of level of inflammability and type of waste incinerated. Whenever incinerators become an increasingly difficult option to use, the following treatment systems should be proposed: Chemical disinfection: - This method gives a highly efficient disinfection, and some chemical disinfectants are not expensive. As for drawbacks, the method requires highly qualified technicians for operating and it is inadequate for pharmaceutical, chemical and some types of infectious waste. In central, general and provincial hospitals, which produce rather important quantities of HCW, the latters should be disinfected with chemical products, then evacuated to the public landfills where specific areas have been prepared before hand. Disposal at municipal landfills: - In case hazardous health-care waste cannot be treated or disposed elsewhere, direct burying in the municipal landfill should be recommended. To prevent the important disease burden currently created by these wastes, it is necessary : to prepare specific areas for that, to limit access to this place (wire fencing and lock) and to bury the waste quickly to avoid a contact with people or animals. It is a temporary solution before more suitable treatment methods are found. Burying inside hospital premises: - In health centres where the HCW production is rather little, a ditch should be dug. Its bottom and walls must be cemented (or stabilized) to ovoid the water napkin contamination and prevent the walls from collapsing. The HCW thrown in the ditch must be covered with sand. The same procedure is repeated every time a new quantity of HCW is disposed, until the hole is full; in such a case, another hole is dug nearby. The hole must be protected to avoid access and accidents. The main drawback is that burial places are not always available inside the health centres. Anyway, in all cases, the principle of waste segregation at their sources of production must be seriously respected, to minimize the contamination of general wastes by the infectious ones. The other systems (autoclave, microwaves, etc.) are too expensive and need highly qualified staff to handle them, though they are more secure for the environment. In case of malfunction, the exchange parts are not always available locally. So, these types of technologies should not be recommended in Mozambique, given the present economic situation. 40 e. Sharps and needle treatment Probably the most frequent risk is created by sharps (needles, scalpel blades, bloods vials, glassware, etc.) in contact with infectious germs. In the health facilities, needles and sharps should be collected in non-reusable containers, such as puncture-proof "sharps boxes", specific cardboard, metal or plastic boxes, or in empty rigid plastic bottles (with a tight fitting lid), if financial resources are not available). One must not put sharp objects in any container to be recycled or returned to a store. Table 11 Comparative analysis of needles and sharps treatment systems Criteria Technical Cost of Cost of Easiness Availability Environment Social feasibility investments operating and of exchange al viability acceptability simplicity parts Technology Autoclave Very efficient Very high Average Needs very Not obvious Non very good Microwave qualified polluting, but irradiation staff requires to dispose the remnants Melting in Very efficient Medium for Low Little Possible non polluting good incinerator modern qualified (or needle incinerator) staff incinerator) and low (for craft ones) Chemical Efficient Low Low Qualified - Polluting and Fairly good disinfecting staff requires to dispose the remnants Storage in Fairly Very low Low Non - non polluting, Fairly good specific efficient qualified but risks of containers staff digging out then landfill sharps burial Burial in the Little Very low Very low Non - risks of Bad site of health efficient qualified digging out centre staff sharps Mechanical Very efficient High Low Little Not obvious Non Good grinding qualified polluting, but staff ground sharps must be I disposed Encapsulation Efficient Low Low Simple, non Safe and non good qualified polluting staff The melting of sharps in incinerators is very efficient. Whenever incinerators become an increasingly difficult option to use, encapsulation (filling metallic or plastic containers up to % with wastes then filling up with cement, bituminous sand, etc.), chemical disinfecting, storage in specific containers (then landfill burial), should be recommended because of their very low cost. Autoclaving is a very efficient system, but it is very expensive. 41 f. Liquid wastes collection and treatment As for the liquid wastes, there are many treatment systems among which: (i) physic and chemical treatment; (ii) intensive biological systems (activated mud system; biological disk; bacterial field, etc.); (iii) septic pits; (iv) disinfection; (v) decanting and digesting basin; lagooning, etc. Table 12 Comparative analysis of the different technologies (liquid wastes) System of Operating Technical Cost (investment Recommendation for treatment Efficiency and bearing) Mozambique Decanting and - Mud draining medium Fairly important can be recommended in digesting basin - very weak area (buried) central and provincial hospitals Lagooning system - cleaning of shores high weak Not recommended - very important area Septic pits - Mud draining medium Very weak can be recommended in - very weak area (buried) health centres Activated mud - sifting Very high Very high not recommended system - mud draining (very expensive) - ventilation - fairly important area Biological disk, - sifting High Very high not recommended bacterial field - mud draining (very expensive) - fairly important area Physic and - sifting Very High Very high not recommended chemical treatment - chemical products (very expensive) for - fairly important area health centres, but can be proposed for central or general hospital Chemical - use of chemical products only high Medium Recommended for disinfection - little area is necessary Mozambique - No investments in infrastructures . Disinfection is clearly the most efficient way to deal with liquid infectious wastes. That is why this option should be favored among the other interventions, because the HCWM plan is focused especially on HIV/AIDS related waste management. Consequently, a combined system (disinfection then storage in septic pits) is recommended for the provincial hospitals, district hospitals and health centres, which don't produce much liquid waste. For the central and general hospitals, a physic and chemical treatment, comprising a disinfection system, is recommended. The implementation of this option requires a feasibility study. g. Choice of landfills sites- In Maputo, the incineration remnants, which are considered as household littering, can be disposed in the public municipal landfill, if specific burial areas are prepared, mainly to receive sharp objects not melted during the process. These types of waste hurt scavengers and street children even though they are sterilized during incineration. At provincial and level, the remaining wastes after burning can be buried inside health centres. 42 7. PARTNERSHIP FRAMEWORK AND FUNDING a. Involved actors' potential field of intervention The national strategy of struggle against HIV/AIDS relies on the involvement of all-public and private sectors, NGOs, Associations and civil society. So it necessary to establish a partnership framework to determine the roles and responsibilities of each category of actors. Table 13 Potential field of intervention Actors Potential field of intervention The technical services - inform the local and national authorities of the State - facilitate the co-ordination of the project's activities (MOH/MOE) - supply technical expertise - execute control and monitoring activities - train the health staff - supervise the training process, monitoring and evaluation The Municipalities - participate at the mobilization of populations - participate in the HCWM in their landfill - participate in training, monitoring and evaluation The public health - participate at the training activities facilities - put their staff aware and supply them security equipment - elaborate internal plans and guidelines about HCWM - forecast financial resources allotted to HCWM - ensure their HCW management Private health facilities - participate at the training activities - put their staff aware and supply them security equipment - elaborate internal plans and guidelines about MHCW - ensure collection and treatment of their HCW Private collection - participate at the training activities operators - put their staff aware and supply them security equipment - ensure HCW collection in private cabinets The NGOs acting in - inform, educate and put population aware health and - participate at the training activities environment The community based - serve as "go-betweens" among the populations, the project and others actors organizations and - participate in information and populations awareness other environmental - help in the mobilization of populations associative movements - participate in training activities b. Involvement of private societies in HCWM The HCW collection is a major preoccupation for all the public and private health facilities. According to the regulations about environment, the health facilities must ensure a sustainable management of their wastes. In Mozambique, the Health facilities have very limited financial resources. No public health establishment has a paid collection service of wastes. But in Maputo, certain private clinics have such type of service. For the health facilities having got incinerators, the collection does not matter. For the private cabinets, the major constraints are the absence of alternative solution for their present practices consisting in: HCW mingling with general wastes; anarchical disposal. Most of them can't afford appropriate equipment for treatment. They all manifest their will and availability to participate to an institutional arrangement, in order to treat their HCW, i a system where the costs are shared in 43 common agreement. In this line, a system of public-private partnership can be devised on the basis of following principles: - supply of incinerators to publics health facilities, in order to polarize a referential area; - obligation of health centres equipped with incinerators, to polarize private cabinets located in their area and to receive their HCW, in a system where the costs are shared in common agreement; - obligation of the private health cabinets, so polarized, to contract a paid collection service. To better ensure the privates' involvement in the process of HCW collection, it is necessary to get incitement measures ready, mainly reinforcement of their capacities in HCWM. It is also necessary to improve financial resources allotted to HCWM in the health facilities. 8. ENVIRONMENTAL AND SOCIAL MEASURES a. Measures for reduction of incinerators and landfills negative impacts The operating of incinerators has negative impacts on environment and health. Anyway, when we consider the very reduced quantities of HICW to be incinerated daily by every establishment, it is obvious that the environmental and health impacts are not significant and the harm caused will not be big. Nevertheless, the following measures should be taken: for the installation, it is better to choose, inside the health facilities, places distant from the admission rooms and health care rooms; concerning the noise and harms in operation, it is better to start incineration by night, to reduce harm caused by smokes. Moreover, the promotion of the use of non-chlorine plastic containers is a recognized means of reducing the pollutant products from solid wastes incineration. In this way, they should be recommended as dustbins for waste collection. As for the large central disposal sites, wire fencing and lock could be realized to reinforce security and to minimize the access of scavengers and children. These protection measures will allow (i) to control and regulate the access to the landfill, (ii) to identify the scavengers and (iii) to put the users aware. b. Social measures The execution of the HCWM Plan might have negative social impacts on scavengers earning their daily living at landfills. Their income may decrease with a well-organized management of HCW, mainly when segregation is done at the source. It is possible, through partnership with health centres, to give non-infectious reusable objects (such as empty bottles) directly to scavengers, or at least authorize them to come and collect them according to well-defined modalities. For the populations neighboring the landfills, the risks of being driven away and resettled in other areas are minor. Generally, these populations did not come to settle around the landfills : instead, the disposals sites have been created inside these districts. There are cultural issues relating to disposal of anatomical wastes (amputated body parts, placenta, etc.), about which communities may be strongly sensitive. These cultural aspects should be taken into account in the action plan, to better ensure the populations involvement in the implementation. For example : the placenta could be buried or put in septic pits, as it is the case presently in some health facilities; generally, anatomical wastes such as the body parts are buried inside the hospital; they can also be given to the patients or their family if they claims for it; liquid wastes from washing of the dead are generally evacuated in septic pits. Generally, people don't find any harm in these methods. 44 9. THE MONITORING PLAN a. Principles To measure the efficiency of the HCWM Plan, as far as the reduction of infections is concerned, mainly in the health centres, the mentioned activities should be monitored and evaluated, in collaboration with of the institutions concerned : MOH, MOE, municipalities, NGOs, etc. b. Methodology The HCWM Plan will be executed in 5 years and the implementation monitoring will be the following: Object Timing/Periodicity Responsible National Launching Seminary At the beginning of the program DEH/(Ministry of Public Health) of HCWM Plan Planning activities At the beginning of the program National and international Consultants Execution of HCWM Plan's Yearly, according to the time- DEH activities table established Control and follow up of the Daily Health facilities execution of HCWM Plan Monthly Health Directions in the Provinces and activities Districts (Ministry of Public Health) Yearly DEH (Ministry of Public Health) Training - two first years - DEH (Ministry of Public Health) and National Consultants Awareness - yearly - DPE (Ministry of Public Health) and Egos, CBOs HCWM Plan Appraisal Half-way (at the end of the 2nd National and international Consultants year) At the end of the 5 years International Consultants Supervision yearly Ministry of Health Ministry of Environment Municipalities 45 c. Responsibilities in the implementation The following table shows the responsibilities in the implementation of the HCWM Plan. Tableau 1 Responsibilities in the implementation Components and Activities Execution Control Supervision Improvement Regulate the management of HCW at Consultants DEH/MOH MOE of HCWM the level of health facilities organizational Set up procedures of control in the Heads of Health PHD and DEH/MOH and and technical management of HCW centres DHD MOE framework Elaborate training programs and train Consultants PID and DEH and Training trainers DHD TD/MOH Train all the health acting in HCW Supervising staff Heads of DHD and DHD still trained Health centres Evaluate the training program Heads of Health PHD and DEH implementation centres DHD Public Televised messages National Television DPE DEH/MOH awareness Messages radio local Radios DPE DID and DHD Posters in Health centres Printers societies DPE DHD and DHD Health centres Public animation sessions NGO and CBO DPE DHD and DHD Support the Validate the HCWM Plan Actors involved DEH MOH execution of Plan activities National PHD and DEH/MOH HCWM Plan Consultants DHD Monitor the execution (national and PHD and DHD DEH DEH (national local level) level) Evaluation of the HCWMP (halfway International PHD and DEH/MOH and and final) Consultants DHD MOE d. Institutional arrangements for the implementation The execution of the HCWM Plan components means to clearly define the institutional arrangement for the implementation. In fact, the training and capacity reinforcement needs should be defined on the ground of the actors' responsibilities. In addition to this, we should verify if the required human and institutional capacities are available or not. So, the following institutional arrangements are proposed: i) Improvement of regulation in HCWM In this component, the technical guidelines about HCWM should be improved in the health facilities. National consultants having acquired a large experience in HCWM, under the control and supervision of DEH must realize this task. ii) Training The training activities should be led by the Training Department of the MOH, but this structure hasn't the require competence in HCWM and will be obliged every time to rely on the DEH. So, the training activities may be co-piloted by these two institutions: the DEH ensuring technical expertise and the Training Department ensuring that activities are in conformity with the training strategy of the MOH. 46 At regional and local levels, control of training activities should be assigned to the Provincial and District Directions. The specific training activities will be done in the first two years of the program. National Consultants will train trainers in health facilities, but also in the other institutions (municipalities, private societies, etc.). Then, the so trained key staff should train their employees. The DEH and the Provincial and District Directions haven't got enough human resources to prepare and diffuse the training courses about HCWM. The DEH could prepare the TOR, and do the control and supervision at national level while Provincial and District Directions would assure the monitoring at local level. So, the following is proposed: - The DEH prepares the Terms of References of training programs,(with the support of The Training Department of MOH), and does the control and supervision at national level; - National Consultants having acquired a large experience in HCWM will prepare the training courses; - In each province, a training trainers workshop will be held and will be animated by national consultants having acquired a large experience in HCWM, under the supervision of Provincial Directions. The latter's must prepare periodical reports to be sent at the central level (DEH/MOH); - In each health facility, the supervising staff trained in the provincial workshops will ensure the training of medical and paramedical staff, cleaners, etc. The heads of the health establishments must supervise this work and prepare periodical evaluation reports. iii) Population awareness rising The Department of Public Education of the MOH will lead the activities intended to make the populations aware about the HCW. At local level, Provincial and District Directions will do the supervision. These activities will cover the 5 years of the program, through district animations, radio and television messages, posters, etc., and will be done as follows: - The Department of Public Education of the MOH will elaborate, with the help of the DEH, the content of these messages, of posters and district animation; - The televised messages will be diffused by the National Station; - The radio messages will be diffused by the local radio stations, in Portuguese and local languages, under the supervision of Provincial and District Directions; - Private societies (printing enterprises) will make posters to be dealt in the health centres; - Public animation sessions will be led by NGOs acting in the health and the environmental field, under the supervision of Provincial and District Directions. iv) Strategy for privates involvement and partnership The elaboration of motivating measures for private societies acting in waste management, and the mechanisms intended to get them involved in HCWM, will be coordinated by the MOH, in concordance with the other ministries. v) National workshop for launching the HCWM Plan The National workshop for launching the HCWM Plan will be organized by the DEH/MOH. It will be an occasion of realizing a national consensus around the Plan. vi) The starting evaluation and planning of activities National consultants, controlled by Provincial Directions under the supervision of DEH, will realize the starting evaluation, which must be done at the beginning of the project. During this step, the 47 consultants will indicate the situation prevailing presently in the health facilities, elaborate evaluation criteria, and prepare the execution plan. vii) Control and monitoring of the execution of HCWM plan At provincial level, it is recommended that the control should be done by Provincial and District Directions which will ensure the monthly monitoring, while the yearly follow up will be realized by DEH. viii) Evaluation of the HCWM Plan It is recommended to assign this evaluation to international consultants, to ensure its neutrality. This evaluation must be done halfway over (at the end of the 2nd year) and at the end of the project. e. Timetable The following timetable indicates the implementation schedule of HCWM Plan. Tableau 2 Implementation Timetable HCWM Plan Activities Yearl 2 3 4 5 Regulation of HCW management Procedures of control in the management of HCW Public awareness Elaboration of training programs and training trainers - Training for all the health staff acting in HICW Support the private initiatives and partnership in HCWM Bettering the HCWM in the health establishments National workshop for approval of the HCWM Pan Planning of initial activities - Monitoring and evaluation of the HCWM plan Before such an elaborate plan is implemented, certain activities can be started immediately, and the others realized in medium/long term. The following actions could be realized immediately: - elaboration and dissemination of technical basic guidelines in HCWM - elaboration of in HCWM training program - elaboration of public awareness rising modules and supports - planning of starting activities - set up HCWM procedures in health facilities, including health staff responsibilities In short term: - training trainers - training all the stakeholders involved in the HCWM - diffusing of public awareness rising modules - assessment of training program implementation - halfway appraisal In medium/longer term: - bettering the HCWM in the health facilities - Support the private initiatives and partnership in HCWM - Monitoring and evaluation of the HCWM plan 48 10. THE HCWM PLAN COSTS The Management Plan is meant to initiate a process of proper handling, disposal and management of medical waste, and as.such, one should not expect that an HIV/AIDS project will totally assume the responsibility of baring all the cost involved. Instead, the project should embark on the following aspects: (i) Training of hospital workers, waste handlers, municipal waste collectors, dump site managers, pickers and other ; (ii) Awareness building programs of the general public and government officials; (iii) Consultation with the relevant Government authorities to initiate policy formulation and formulation of rules and regulations which are enforceable; and (iv) Help initiate private /public/ civil society partnerships for waste collection and management. Under this view, the proposed plan is oriented only towards the HIV/AIDS related waste management within the health sector (and not towards the whole health sector). It is structured in the way where the project will be assigned specific functions. So, the HCWM Plan focuses institutional and legal framework, training and public awareness, at a cost of$1.177 million and it should be totally financed by HIV/AIDS program. Table 3 Implementing costs of the HCWM Plan Activities Unit Quantity Unitary cost Total cost Us$ US$ Improve the Elaboration of technical U 15 000 5 75 000 organizational and guidelines about HCWM for technical health facilities framework in Sub-total 75 000 HCWM Training programs Training trainers Man/day 3000 40 120 000 Training of medical and Man/day 21000 20 420 000 paramedical staff Training of cleaners, helpers Man/day 6000 20 120 000 Sub-total 660 000 Public awareness Televised messages U 60 300 18 000 Messages radio U 240 150 36 000 Posters in Health centres U 30 000 1 30 000 Public animation sessions U 2000 100 200 000 Sub-total 284 000 Support the Starting evaluation and planning Man/day 90 400 36 000 execution of starting activities HCWM Plan Monitoring at national and local Man/day 500 100 50 000 level Halfway evaluation Man/day 90 400 36 000 Final evaluation Man/day 90 400 36 000 Sub-total support 158 000 TOTAL 1177 000 USD 49 11. COSTS OF HCWM PLAN COMPLEMNTARY MEASURES Other aspects such as HCWM improvement in health centres should be left to central Government (MOH and MOE). It is up to them to take these aspects into account, in the framework of a health project or a waste management project. These complementary measures for HCWM plan, which cost $1.260 millions, are necessary in the process of bettering HCWM in health facilities (provision of incinerators or other treatment systems, dustbins, security equipments, etc.). They constitute a framework of potential intervention for the governmental institutions (MOH, MOE) which could realize these activities according to their priorities and their financial resources. These long-term aspects should be left to governmental institutions. Table 14 Costs of the complementary measures These measures concern the activities for bettering the HCWM in all the health facilities. Activities Unit Quantity Unitary cost Total cost USD USD Bettering the Supply the health services with adequate HCWM in the HCW collection equipment health facilities - baskets for syringes U 1600 10 160000 - Dustbins in health care rooms U 1600 10 16 000 - Boots for cleaners U 2 000 15 30 000 - Masks for cleaners U 10000 1 10000 - Glovers for cleaners U 2 000 5 10 000 Acquire modern incinerators for central, U 12 20 000 240 000 general and provincial hospitals Build local material incinerators in rural U 1000 800 800 000 hospitals, health centres and health posts TOTAL 11 266 000 USD 50 I. ANNEXES 1. LIST OF ACRONYMS DHA Departanento die Higiene Ambiental PHD Provincial Health Direction DHD District Health Direction DPE Department of Public Education/MOH DT Department of Training/MOH DN S Direction Nacional de la Sajide EA Environmental Assessment DEH Department of Environment Health /MOH HCW Health Care Wastes HIV Human Immunodeficiency Virus HCWM Health Care Wastes Management HCWMP Health Care Wastes Management Plan MOE Ministry of Environment MOH Ministry of Health MISAU Ministrio da Saiide MICOA Ministerio para a Cooenai'o da Acq6o Ambiental MWM Medical Waste Management NGO Non-Goveernmental Organisation RESP Reparqo de Educacion da Sadde Publica/MISAU USD United-States Dollar WHO World Health Organization WB World Bank 51 2. PERSONS INTERVIEWED No Institution Surname - Name Function City/Phone Central Level at Maputo Dr.Humberto Cossa DirecqAo Nacional de PlanificaqAo Maputo Ministry of Health e CooperaqAo (Ministdrio da Saude) Alexandre Manguele DirecqAo Nacional de Sa6de Maputo Dr. Avertino Barreto Adjoint/DNS Maputo MArio J. Robeiro de Coordenator de Projectos de Maputo Almeida Investment (GACOP) 258 1 42 63 75 Rosa Marlene MISAU/Project HIV/AIDS Maputo Dr. Marcellino Lucas Head of Environment Health Maputo Department (DHA) 258 1 31 02 81 Jordao Amatimula Biologist/ Environment Health Maputo Department DHA 258 1 31 0281 Dr. Anabella DHA Maputo/ 31 02 81 Lagaima Mausse Head of Training Department Maputo/42 21 59 Ferrucuo Vio Training Department Maputo/ 31 29 70 Silvano Lenchisso RESP/MISAU Maputo Francisco Mandlate Ali Hamido Ministdrio para a CoordenaAo da Hafido Abassamo Bioquimico/Direcqao Nacional de Maputo AcqAo Ambiental (MICOA) Avliaqao do Impacto Ambiental 258 1 46 68 63 Hospital Central de Maputo Alfredo J. J. Chichava Director Administrativo Maputo Mr. Consolo Engineer of maintenance 42 56 97 Dr. Rui Bostas Commission of HIV/SIDA Dr. Selma Valgy Sub-commission of biosecurity Dr. Eduondo Mijon Hopital General Jose Macamo Momade Bay Usta Director Maputo Mr. Teixeira Head of Waste Management and Cleaning Services Benjamin Viandro Nurse-Chief Centro de Saude de Xipamanine Dr. Maria B. Matsinh Director of health center Maputo Clinica "Cruz Azul" Louisa Margarida Medical waste manager Maputo Clinica "Sommerschield" Pino Moreira Nurse chief Maputo Conselho Municipal de Maputo Jeremias Mabuyna DirecqAo Dos Servicos Maputo Municipales De Salubridade e Cimeterios SOLUA (Private waste collection) Fernando Silva Director Maputo/ 30 57 57 Impacto (Privated Consulting firm) Uke Overvest Environmental Scientist Maputo/ 49 96 36/7 WHO Emmanuel A*d6 Focal Point of HIV/AIDS Maputo Pierre Kahozi Program officer Provincial level Hospital Provincial de Gaza Juan Mata Administrator of hospital Xai-Xai Joseepha Chambisso Chief nurse Hospital Rural de Chicumbane CristovAo Pedro Tovela Director of District Chicumbane Rodriguez Roberto Chief Nurse 022 25 467 Zulmeira Carlos , Technician of Laboratory Centro de Sa6de de Macia Veronica Mario Tembe Medical Assistant Macia Rosta Pedro Centro de Sa6de de Manhiqa Armando Manuel Timane Director of Health Center Manhiga Centro de Sa6de de Marracuene Lucia Tembe Doctor Marracuene Lisette DIASE Chief nurse Alexandrina Chalua Secretary 52 3. BIBLIOGRAPHY Title Author/Organism Year Projecto SIDA Departemento da Formação 2002 Componente Formaçào e Recursos Humanos MISAU Improving Health for the Poor in Mozambique Worldbank-Africa region Human 2002 The Fight Continues Development Projecto de decreto o Regulamento sobre a Gestão de Lixos Republica de Moçambique 2002 Biomédicos (Draft) Medical Waste Management Regulation (Draft) Ministry of Health 2001 Medical Waste Management Audit MS/MICOA 2001 Strategic Plan for the Health sector (PESS) 2001-2005-2010 Ministry of Health 2001 Directiva Geral Para Estudos Do Impacto Ambiental Direcçào Nacional de Avaliaçào 2000 do Impacto Ambiental /MICOA Environmental law in Mozambique : Law N° / 97 of July 30 The Republic of Mozambique 1997 (AR-IV/044/30/07/97) The Assembly of the Republic Lei n°20/97 de 01 de Outubro (definição das bases legais para uma The Republic of Mozambique 1997 utilizaçào e gestào correctas do ambiente e sus componentes) Decreto n° 22/99 Aprova o Regulamento do sistema do Registro Conselho de Ministros 1999 do Medicamento Boletim da Republica Decreto n° 21/99 Aprova o Regulamento do Excercicio da Conselho de Ministros 1999 Profissão Farmacêutica Boletim da Republica Lei n°4/98 Aprova a Lei do Medicamento e cria o Conselho do Conselho de Ministros 1998 Medicamento Boletim da Republica Management of wastes from health facilities (WHO) A. Pruss; W.K. Townend 1998 Inquéritto Demogràfico e de Saúde Instituto national de Estatistica 1997 Ministério da Saúde Macro International Inc. -DHS Demographic and Health survey Instituto national de Estatistica 1997 Ministério da Saúde Macro International Inc. -DHS Decreto n°9/92 de 26 de Maio approva Regulamento de Presstaçào Conselho de Ministros 1992 de Cuidados de Saúde por Entidades Privadas Boletim da Republica Lei n° 26/91 Autoriza a prestação de cuidados de saúde, por Assembleia de Republica 1991 pessoas singulares ou colectivas de direito privado com caracter Boletim da Republica lucrativo ou no Lei n° 25/91 Cria o serviço Nacional de Saúde - SNS Assembleia de Republica 1991 Boletim da Republica 53 4. HCWM IN HEALTH FACILITIES Box 1 Central Hospital of Maputo Characteristics The Central Hospital of Maputo is the biggest one in Mozambique and is at the first level in the national health system. The number of beds is 1 500. The staff is composed of about 2 600 agents, among them 229 doctors. How the wastes are managed - In general, in each health care room, there is plastic bag put in dustbins or any other recipient which can receive wastes; - There is no separation between general waste and health care wastes and between needles and others health care wastes (cotton, etc.); - Plastics bags and others dustbins for health care wastes are collected by cleaners, and all these wastes are discharged in an area located in the center of the hospital, where they are collected irregularly by the municipality; during our visit, there was a big heap of solid wastes, which made the neighbour feel unease very much; - The Hospital has received from ABD two new incinerators which are not working now, because the place reserved for incineration is not appropriate, according to the hospital Direction - There is a commission of bio-security in the hospital, which follows up some aspects of HCWM. Constraints - no sufficient wastes collection equipments; - no separation of wastes; - no system of treatment: health care wastes are discharged in the public landfill of Maputo, with the general wastes non contaminated; - generally, the staff is not trained in wastes management Needs - training programs for all the staff - wastes collection materials - security equipments for the cleaners - installation and operation of the new incinerators 54 Box 2 General Hospital Jose Macamo-Maputo Characteristics The General Hospital Jose Macamo is at level 1 in the health system. The number of beds is 350, with occupancy rate of 100%. The staff is composed of about 170 agents, among them 25 doctors, 81 paramedical staff and 61 cleaners and others servants. How the wastes are managed - The production of solid wastes is about 75 kg daily - In general, there are plastic dustbins in each health care room - There is no separation between general waste and health care wastes, but needles are separated from other health care wastes (cotton, etc.) and are put in metallic boxes; - Dustbins for health care wastes and metallic boxes for needles are collected by cleaners and all these wastes are discharged in the hospital, in a large hole behind the buildings where they are burned incompletely (particularly the metallic boxes of needles); according to the responsible of the hospital, when the hole is full, another is dug nearby; - There is an old incinerator, which is not working now. Constraints - no sufficient collection equipments - no system of treatment: the hole presently used looks like a wild landfill, wastes are incompletely burned in open air and the smoke makes the neighbour feel unease; - generally, the staff is not trained in wastes management Needs - training programs for all the staff - wastes collection materials - security equipments for the cleaners - incinerator for wastes treatment 55 Box 3 Xipamanine Health Center - Maputo Characteristics The Health Center of Xipamanine in Maputo is at level 3 in the national health system. The staff is composed of about 42 agents, among them I doctor and 10 nurses. How the wastes are managed - In general, there are plastic dustbins in each health care room - There is no separation between general waste and health care wastes and between needles and other health care wastes (cotton, etc.); - Dustbins for health care wastes are collected by cleaners and all these wastes are discharged in the hospital, in a large hole behind the buildings, (in a cassava field), near the houses, where they are burned incompletely; according to the responsible of the health center, when the hole is full, another is dug nearby; Constraints - no sufficient collection equipments - no system of treatment: the hole presently used looks like a wild landfill, wastes are incompletely burned in open air and the smoke makes the neighbour feel unease; - in general the staff is not trained in wastes management Needs - training programs for all the staff - wastes collection materials - security equipments for the cleaners - incinerator for wastes treatment Box 4 Private Clinic "Clinica Da Sommerschield "- Maputo Characteristics The Private Clinic "Clinica Da Sommerschield "in Maputo has a staff composed of about 120. There are 23 beds with occupancy rate of 80%. How the wastes are managed - There are enough plastic dustbins in each health care room - There is no separation between general waste and health care wastes, even if needles are separated from other health care wastes (cotton, etc.); - Dustbins for health care wastes are collected every morning by a private company (Emolympa) which probably discharge them in the public landfill of Maputo; Constraints - The responsible of the clinic don't know exactly where the collected wastes are really discharged; Needs - training programs for all the staff - incinerator for wastes treatment 56 Box 5 Private Clinic "Clinica Cruz Azur "- Maputo Characteristics "Clinica Cruz Azur" is one of the oldest private clinics in Maputo. How the wastes are managed - The wastes are put in plastic bags and then in dustbins - There are enough plastic dustbins in each health care room - There is separation between general waste and health care wastes, and between needles and others health care wastes (cotton, etc.); - Dustbins for health care wastes are collected every morning by a private company (Solua) which discharge them in the public landfill of Maputo; Constraints - The health care wastes are discharged with other non contaminated wastes, in the public landfill of Maputo; - The staff is not trained in health care waste management Needs - training programs for all the staff - Incinerator for wastes treatment (but the clinic can't receive an incinerator, because there is no place to install it and the clinic is located in the town center of Maputo). Box 6 Provincial Hospital of Gaza - Xai Xai Characteristics The Hospital of Gaza, in Xai Xai city, is at provincial level in the national health system. The number of beds is 220, with occupancy rate of 115% (sometimes, two sick persons share one bed). The staff is composed of 167 agents, among those 9 doctors. How the wastes are managed - In general, there are plastic or metallic dustbins in each health care room - There is no separation between general waste and health care wastes, but needles are separated from others health care wastes (cotton, etc.) and are put in cardboard boxes; - Dustbins for health care wastes and cardboard boxes for needles are collected by cleaners and all these wastes are discharged in the hospital, in a big hole, behind the buildings and nearer the houses; even if needles are sometimes separated, they are found in the hole, with others HCW; - There is an old incinerator, which is not working now; - Liquid wastes are collected in septic pits. Constraints - no sufficient collection equipments - no system of treatment: the hole presently used looks like a wild landfill; - the staff is not trained in wastes management Needs - training programs for all the staff - more collection materials for the wastes - security equipment's for the cleaners - new incinerator (or repair the old one) for wastes treatment 57 Box 7 Rural Hospital of Chicumbane Characteristics The Rural Hospital of Chicumbane, located in the province of Gaza, is at district level in the health system. The number of beds is 93, with occupancy rate of 100%. The staff is composed of about 45 agents, among them I doctor, 26 paramedical staff and 18 cleaners and other servants. How the wastes are managed - Plastic dustbins are put in each health care room - There is no separation between general waste and health care wastes, but needles are separated from other health care wastes (cotton, etc.) and are put in boxes; - Dustbins for health care wastes are collected by cleaners, twice a day, and all these wastes are discharged in the hospital, in an area behind the buildings where they are burned incompletely; - Needles boxes are buried when they are full - There is an old local incinerator, very degraded, which doesn't work well; - Only one person is responsible for burning the wastes - The chief nurse supervises every day the management of wastes in the hospital Constraints - no sufficient collection equipments - no system of treatment: the area presently used looks like a wild landfill, wastes are incompletely burned in open air and the smoke makes the neighbour feel unease; - generally, the staff is not trained in wastes management Needs - training programs for all the staff - more wastes collection materials - security equipment for the cleaners - efficient incinerator for the treatment of wastes 58 Box 8 Health Center of Macia Characteristics The Health Center of Macia, located in Macia city (province of Gaza), is at district level in the health system. The staff is composed of about 79 agents: there is no doctor; there are 21 cleaners and other servants. How the wastes are managed - Metallic dustbins (with pedals) are put in each health care room - There is no separation between general wastes and health care wastes and between needles and other health care wastes (cotton, etc.); - Cleaners collect dustbins of health care wastes, which are discharged in the hospital, in a hole dug behind the buildings and nearer the houses. When it is full, another hole is dug nearby. The old pits have not been closed very well: we can see needles on the ground. Constraints - no equipments for the pre collection of needles - no system of treatment: the hole presently used looks like a wild landfill; - no equipments of security for the cleaners - generally, the staff is not trained in wastes management Needs - training programs for all the staff - more wastes collection materials - security equipments for the cleaners - efficient incinerator for wastes treatment Box 9 Health Center of ManhiVa Characteristics The Health Center of Manhiga, located in Manhiga city (province of Maputo), is at district level in the health system. The number of beds is 122, with occupancy rate of 150%. The staff is composed of about 67 agents, among them I doctor. How the wastes are managed - plastic dustbins are put in each health care room - There is separation of general waste from health care wastes; - But needles are not always separated from others health care wastes (cotton, etc.); - Dustbins for health care wastes are collected by cleaners; - HCW are burnt in a craft incinerator (very degraded) located in the hospital - In another hole, there was plastic needles boxes - The others wastes are incompletely burnt in a hole near the incinerator, - There are septic pits for liquid wastes and placentas - Sometimes, training sessions are organized for the staff on biosecurity, sterilization, etc. Constraints - no sufficient collection equipments - the incinerator is not working well and the system which consists in digging pits in the health center is not ecological; - generally, the staff is not enough trained in wastes management Needs - training programs for all the staff - more wastes collection materials - security equipments for the cleaners - efficient incinerator for the treatment of the wastes 5)9 Box 10 Health Center of Marracuene Characteristics The Health Center of Marracuene, located in Marracuene city (province of Maputo), is at district level in the health system. The number of beds is 42 and the staff is composed of about 55 agents, among them I doctor. How the wastes are managed - dustbins are put in each health care room - There is no separation of general waste from health care wastes, or needles from other health care wastes (cotton, etc.); - Dustbins for health care wastes are collected by cleaners and wastes are discharged outside the hospital, in a small hole, near the road; Constraints - no sufficient collection equipments - no system of treatment: the hole presently used is located by the road side. During our visit, we have seen children (school boys) playing near the hole; - generally, the staff is not trained in wastes management Needs - training programs for all the staff - more wastes collection materials - security equipments for the cleaners - incinerator for the treatment of the wastes ou 5. SUMMARY OF THE PROPOSED LAW ABOUT MWM The key provisions of the proposed law are summarized as follows: The law comprises 32 articles divided into 6 chapters. The Chapter I is about General dispositions: definitions (health care facility, medical waste, risk management, medical waste officer, infectious waste, sharps, anatomical waste, general waste, other waste, pharmaceutical waste, hazardous substance, radio-active waste, cytotoxic drug waste); objective; principles of implementation; definition of the competencies in the medical waste management (between the MOH and the MOE); The chapter 11 is about Medical Waste Management (MWM): obligation for all the health centres to elaborate a MWM Plan ; principles and obligation of management (waste minimization and segregation, employees protection, containment of hazardous and infectious waste, staff training in health, etc.) The chapter III is about waste storage identification of waste containers : norms of storage and identification of medical waste; segregation of medical wastes (infectious wastes, anatomic wastes, etc.; identification and storage of infectious wastes; identification of sharps wastes containers; identification of anatomic waste containers; identification of generic waste containers; pharmaceutical wastes; hazardous wastes; radioactive wastes; article 16: cytotoxic drug wastes); The chapter IV deals with medical waste disposal: methods of medical waste disposal; infectious waste disposal; sharp waste disposal; anatomic waste disposal; general waste and other wastes with specific risks, disposal; pharmaceutical waste disposal; hazardous wastes disposal; radioactive waste disposal; cytotoxic drug wastes disposal; The chapter V deals with the transportation of medical wastes : medical waste storage in the health facilities; transportation of medical waste inside the health facilities; transportation of medical wastes out of the health facilities; criteria of authorization for medical wastes transportation vehicles; The chapter VI deal with final dispositions (article 30: infringements; article 31: fining; article 32: destination of funds from fines The text ends with explanatory notes about infectious, sharp, anatomic, generic and other types of wastes. 61 6. MODEL OF CRAFT INCINERATOR Some technical characteristics :Efficient model of craft incinerator (WHO-Togo) - Materials : red sand (laterite), clay, white cement - Bricks of cooked sand - Galvanized metal sheet Chimney Structure: - 0.6m x Imx 1.5m - Height of chimney : 5 to 6m - Opening << A > for lighting and ashes recuperation 40cmx30cm - metallic gate (Galvanized metal sheet galvanized) for opening (( A > - metallic grate for burning the waste - opening << B )) for the introduction of waste: 40 cm x30cm - mobile lid for shutting opening << B n Concrete paving stone (2m x 2m) a- Face view Profile view Chimney Chimney Opening <B Opening << B > Structure Structure Opening (( A > Grille Pavin Z I 7= 62 7. TERMS OF REFERENCE Background and Introduction The Mozambique HIV/AIDS Response project will support the goal of the national HIV/AIDS strategy of the Government of Mozambique, which is to reduce the spread of HIV infection in the country. As a means of achieving this goal, the project will also support the following areas: a) mitigation of the health and socio-economic impact of HIV/AIDS at individual, household and community levels thus sustaining an economically productive population and; b) build strong and sustainable national capacity to respond to the epidemic. The handling, collection, disposal and management of HIV/AIDS infected materials are the most significant environmental issue in this project. A Medical Waste Management Plan which will be appropriately costed with clear institutional arrangements for its execution will be prepared during project preparation. Inappropriate handling of HIV/AIDS infected materials constitute a risk not only for the staff in hospitals and other health care centers, but also for families and street children who scavenge on dump sites. Some aspects of project implementation, for example the establishment of HIV/AIDS voluntary counseling and testing clinics, the purchase of equipment by communities for home care of people living with HIV/AIDS, and the promotion of the use of condoms etc. could potentially constitute an increase in the environmental and health risk associated with handling of HIV/AIDS infected waste. Project Justification The HIV/AIDS epidemic now poses the paramount threat to development in Sub-Saharan Africa. Responding to this development crisis, the Africa Region of the World Bank adopted a new strategy, Intensifying Action Against HIV/AIDS in Sub-Saharan Africa. In order to outpace the epidemic and to avert its potential consequences, the Africa Region has designed the Multi-Country HIV/AIDS Program for Africa (MAP), of which the Mozambique HIV/AIDS Response project is a component. scales up successful interventions to comprehensive national programs encompassing multiple sectors and implementers, thus elevating HIV/AIDS beyond the health sector to a fundamental development issue. The consistent and streamlined approach in the MAP framework throughout the region would enhance the effectiveness and efficiency of Bank interventions in contributing to nationbuilding efforts in Sub- Saharan Africa in general and Mozambique in particular. Project supported activities will complement the activities of existing programs financed by various donors and NGOs which are already engaged in the fight against HIV/AIDS in Mozambique. The project will channel resources through both the public sector (line ministries and municipalities) and the private sector ( both for-profit and not-for-profit). Detailed Project Description The project will have the following components: 1) Capacity Building; 2) Public Sector Initiatives with the two sub-components of a) National Initiatives and b) Municipality Initiatives; 3) Civil Society and Private Sector Initiatives; and 4) Project Coordination. The Capacity building component will support capacity building for both the public sector and the civil society/private sector initiatives. The public sector initiatives component will support the HIV/AIDS activities of line ministries and municipalities while the civil society /private sector initiatives component will support the activities of civil society organizations and the private sector. The project coordination component will support the functions of the National Committee to combat AIDS (CCS-SIDA) and its Secretariat, including the Project Coordination Unit (PCU). Study Objective The objective of the study is to identify the level of Health Care Waste Management that will be relevant to help implement and enforce proper health and environmentally sound, technically feasible, economically viable, and socially acceptable systems for management of health care waste in Mozambique. The examination of the of the current practices with regard to the handling of hospital waste will verify both the management of waste within the hospitals, clinics and other health care centers as well as the management by local authorities once the waste has left the source. It will also look into the level of knowledge among health care staff and local authorities about safe disposal practices to be adopted for medical waste and into the availability of capacity to deal with this type of waste. Scope of the Study Task I Assess the Policy, Legal and Administrative Framework as well as the Regulatory Framework on health care waste management and treatment /destruction facility in the country including air emission standards which are currently required by law and which would likely be required in the next say ten years. * Identify permit requirements, including environmental building, and other permits and procedures that health care waste treatment/destruction facilities would need to address. * Outline any public participation or public hearing requirements and procedures. For each requirement, list the lead agency to be contacted. Assess the typical time demands for proposed facilities to obtain permits and address environmental impact requirements and public participation requirements. Identify all healthcare facilities in the country and include basic information for each facility, such as number of beds, bed occupancy rate, specialization, divided into categories such as: National Hospitals, Regional Hospitals, etc. Assess the health care waste generation at (i) the two national hospitals in Mozambique; (ii) one other general hospital (e.g. Sal) and; (iv) one private clinic. The details should include the minimum weight of total waste generated at each health care facility per week. Composition of the waste should be determined through segregation at the waste end point and extrapolation of the results to cover the entire country. Assess the level of scavenging, if any, or recycling taking place inside health care facilities, along transportation routes, and at final disposal sites. Determine social issues in relation to scavenging taking place. Review and analyze existing health care waste storage, collection and disposal systems with due regard for level of separation, the frequency of collection; and environmental and health impacts for existing treatment. Task II Determination of Technology and Siting Facility: Determination of Technology For the types and quantities of health care waste generated in the study area, assess alternative technologies and facility sizes for treatment and destruction. The assessment shall compare the alternatives on the basis of capital cost, operating cost, ease of operation, local availability of spare parts, local availability of operational skills, demonstrated reliability, durability, and environmental impact. The technologies to be considered include: safe land filling, incineration, sterilization (Autoclave and Microwave ) and Chemical disinfection. On the basis of this assessment, recommend a process flow for economic and environmentally sound treatment and final disposal of health care waste leading to selection of appropriate technology. The final decision on choice should be made by the Government and /or facility. Determination of Disposal Sites If site for disposal exists, collect all existing plans of suitable sites to be considered for the locations of the treatment facility(ies) and review general transport and traffic systems relative to appropriate sites. Consider (a) accessibility to the site; (b) distance from health care facilities to the site; (c) distance to sensitive areas; (d) future development plans of the area; (e) possibility to acquire the area; (f) cultural and historical sites; (g) public opinion; (h) noise and dust impact to nearby areas. Public consultation /hearing must be held as part of the final assessment for siting of the treatment facility. Analysis of site Analyze the above information to determine whether there is sufficient appropriate material on site for daily and final cover, whether the site soil, hydrological and geo-hydrological conditions would ensure adequate protection of any ground and surface water used for drinking and/or irrigation. If the sites prove to be unsuitable, inform the client stating the reasons. Financing The National Government or local government, potentially in conjunction with other municipal solid waste treatment and disposal activities, may finance a regional facility. An alternative approach is for the private sector to provide the health care waste treatment and disposal activities or waste transport for the entire region/island. Assess private sector participation as service provider. * Assess public-private partnerships and cost recovery at the national, island or municipal level, based on the polluter pays principle, where each health care facility contributes according to the volume of waste generated. Task Ill Review existing training and public awareness programs on health care waste management at hospitals and other health care establishments and prepare training needs assessment. Working in conjunction with the relevant government institutions and Municipalities, prepare a costed training program and a well targeted Awareness Building Campaign Program including the general public, and more specifically health care workers, municipality workers, dump site managers, nurses, scavengers/pickers, families and street children. The design of the material required for the awareness building programs should be discussed with the relevant authorities and the general public to ensure that their concerns that are deemed appropriate are incorporated in the design of the program, siting layouts, mitigation measures and community communication programs. The Training and Awareness Building Program and the Management Program shall be appropriately costed and the Plan shall be presented in a National Workshop. Output and Reporting Present and discuss a full draft report with the project authorities and the Task Team Leader and focus on the significant environmental health issues in a format similar to the following: Executive Summary Policy, Legal and Administrative Framework Project Description Baseline Data Assessment of Healthcare waste Healthcare waste Training Needs Assessment Determination of Technology Determination of Disposal Sites Management and Training for Institutions and Agencies Monitoring Plan Appendices List people consulted References Record of Inter-agency / forum/ consultation meetings Task IV Final Report U.) Revise the draft report in accordance with the comments of the World Bank, the Government and other interested parties and submit the Final Report incorporating all changes and modifications required to the Project Task Team. Study Supervision and Time Schedule The work of the consultant would be supervised by the relevant government institution(s) responsible for the project. The institution will coordinate with all other government agencies, and other donors working in the sector. The Consultant (s) shall begin work no later than 30 days after the date of the effectiveness of the contract. It is anticipated that the Consultant would complete the outputs of the work over a maximum duration of 6 weeks with four weeks in the field for data collection and collation and two weeks of report writing and finalization of the document after the review has been carried out by ASPEN and the Task Team Leader. The consultant should propose a clear schedule with critical milestones, and make all possible efforts to complete the work at the appointed time. The consultant should have technical competence in environmental health and/or sanitary engineering. He/She may also have experience in private sector participation, and/or in training and institutional strengthening. The Consultant is expected to provide 6-8 well bound reports with pictures and maps where necessary to the Government of Mozambique and the World Bank.