Kenya - Additional Financing for the Health Sector Support Project : environmental assessment

 E2900 Republic of Kenya MINISTRY OF HEALTH The National Health Care Waste Management Plan 2008-2012 KENYA. CHAPTER ONE 1.1 INTRODUCTION: In Kenya and the world over, health-care services in rural or urban settings inevitably generate wastes that may be hazardous to health or have harmful environmental effects. Potentially infectious waste such as; sharps, cultures from medical laboratories or infected blood, carry a higher risk for infection and injury than any other type of waste. Other wastes of significant importance include; body fluids, all body parts, human tissues, placenta and radioactive waste among others. The absence of proper management measures to prevent exposure to hazardous health-care waste (HCW) results in important health risks to the general public, in- and out-patients as well as the medical and the supportive staff. Improper disposal of health care waste may result in syringes and needles being scavenged and reused thus leading to significant numbers of hepatitis B, hepatitis C, and HIV infections among others. Even after the formulation of policies and laws on health care waste management, many health care establishments in Kenya still lack enforcement of legislation for handling, and disposal of health care waste. Furthermore, improper treatment or disposal of HCW such as open-air burning can constitute a significant source of pollution to the environment through the release of substances such as dioxins, furans or mercury. Safe management of HCW is key in controlling and reducing nosocomial infections inside a hospital and ensure that the environment outside is well protected. Studies conducted earlier in Kenya by Japan International Cooperation Agency (JICA) and the Kenya Expanded Programme on Immunization (KEPI) in conjunction with WHO reveal that the health care waste management (HCWM) practices encountered in most of the health care facilities do not comply with the international requirements to guarantee a safe and environmentally sound management of HCW. The full spectrum of HCWM practices are found in the health-care facilities (HCFs), from the most hazardous ones where no segregation system is applied and the waste is simply dumped in the backyard of hospitals, to safer procedures where the waste is segregated and the part considered to be hazardous is incinerated separately. In order to reach to the current situation where the profile of waste management in Kenya has been elevated, the government of Kenya, together with its development partners has made significant attempts in addressing the HCWM problems. The introduction of the following health care waste management initiatives and concepts are listed below although some initiatives found to be harmful have since changed; 1. The concept of removing needles from syringes and placing the needles into five litre jerry cans was an attempt to reduce the harmful nature of waste generated from health care facilities but turned out to be needle- stick-prone. 2. The adoption of the WHO recommended use of safety boxes for the containment of all sharps waste generated in health care settings. The initiative was first used in Kenya by the expanded immunization programme. 3. The construction of De Montfort incinerators by the Ministry of Health (MoH) countrywide through the assistance of United Nations Children’s 1  Fund (UNICEF). Medicines San Frontiers (MSF), JHPIEGO and Family Health International (FHI) are also some of the organizations that have supported the construction of De Montfort incinerators in some of their programme supported HCFs in the country. 4. The concept of waste segregation resulted in some institutions following colour coding practices in waste handling using varying bin colours. 5. The comprehensive approach of Injection Safety and Health Care Waste Management (HCWM) which was piloted in 2004 and is being scaled up by the MoH and JSI-MMIS. Other attempts made include putting in place various legislative and regulatory mechanisms for the purpose of strengthening enforcement and compliance on waste generation and handling. It is important to mention that for most HCFs, lack of resources tends to affect negatively the way HCW is managed. Furthermore, the situation differs significantly from the public sector to the private sector. Under adverse circumstances where resources (financial, human and material) are limited, planning becomes a problem since the definition of strategy will require taking into account the given constraints and opportunities, clear formulation of objectives, appropriate allocation of resources, and listing practical indicators of achievement. Following consultative meetings in 2005/2006 between the National AIDS Control Council (NACC), the Ministry of Health and its development partners mainly the World Bank (WB), Ministry of Health found it necessary to develop a national plan on health care waste management. The plan spelt out medium-term and long-term goals for safe management of HCW. The Global Alliance for Vaccines and Immunization (GAVI) through the World Health Organization (WHO) supported the development of this plan to complement the initiative and take HCWM in Kenya to next level. The preparation of this plan therefore was preceded by an assessment that was conducted in four of the eight provinces in Kenya. The results obtained were then analyzed and shared with the National Working Group on Health Care Waste Management (NWGHCWM). From the results, a number of recommendations were arrived which have helped in providing a framework for this action plan. This plan attempts to comprehensively address the problem of planning, resource allocation and implementation of HCWM programme in Kenya. 1.2 BACKGROUND The National Health Sector Strategic Plan I (NHSSP I) running between 1999- 2004 re-stated the Kenya Health Policy Framework (KHPF) strategic imperatives and articulated a large number of strategies and activities including how to address the deteriorating environmental health status as one of the factors responsible for increasing health problems in the country. The goals of the national environmental sanitation and hygiene policy among other things underscores the need to have clean human dwelling that is free from waste and unpleasant odours. For a long time, Kenya has lacked a comprehensive management plan for handling and disposing domestic, agricultural, industrial, 2 and health care waste. The government of Kenya in taking cognizance of the risks of mismanagement of health care waste or use of inadequate or harmful treatment technologies has set forth a framework of activities aimed at jumpstarting better health care waste management practices in Kenya. This makes it necessary that HCWM should be given priority in order to reduce if not eliminate its adverse environmental effects on human health. Kenya has been grappling with the problem of poor and ineffective management of HCW from HCFs in the country. While the rest of the waste is handled on an ad hoc basis by both the local authorities and the private sector, HCW poses a serious challenge in both public and private sector since no serious planning arrangements have so far been put in place. Because of the immense challenges experienced in the area of health care waste management, the World Health Organization (WHO) selected Kenya with other 36 countries for support in the development of its national plans under Global Alliance for Vaccine and Immunization (GAVI) initiative. 1.3 ORGANISATION OF HEALTH SERVICES The Ministry of Health has made shifts towards decentralization of health services as part of the broad policy framework in the recent past. In 1984, the country was transformed through the District Focus for Rural Development, (DFRD) programme, which decentralized most government services including health systems management to the district level through District Health Management Boards (DHMB). District health management boards were created in 1992 so that it could represent community interests in health planning, coordination and the implantation of projects in public facilities at the district level. In order to make health management boards and health facility committees active, the Exchequer and Audit (Cap. 412) was amended to provide for the creation of health care service fund where 75% of the revenue generation are utilized by the collecting facility and 25% directed to the source districts to support primary health care activities at community level. In Kenya, the hospital system with a total of 306 hospitals and 191 Nursing homes (public hospitals and sub district hospitals - 158, FBO/ NGO - 74 and Private - 74), MoH, 2006, is the backbone of health care provision. The health sector has facilities ranging from the national referral and provincial, district and sub district hospitals that provide integrated curative, rehabilitative care and supportive activities for peripheral facilities. The facilities offering healthcare services in Kenya are inclusive of government managed facilities through the Ministry of Medical Services and Ministry of Local Government, mission or Faith Based Organizations (FBOs) and those that are privately-managed. The vision of the Ministry of Public Health and Sanitation and the Ministry of Medical Services is to create an enabling environment for the provision of sustainable quality of health care that is acceptable, affordable, and accessible for all Kenyans. The government is a major player in health services provision where it owns slightly more than half of health facilities while the rest belongs to private organizations which are classified as; for profit and not-for profit. 3 The overall mandate for the health services promotion in Kenya is vested with the Ministry of Health under the public health Act, Cap 242 of the Laws of Kenya. This mandate is also placed under various subsidiary legislations dealing with specific areas by various boards and councils, which regulate the performance of services and institutions and of health workers themselves in general. Kenya’s second National Health Sector Strategic Plan (NHSSP II 2005-2010) defines a new approach in the way the sector will deliver health care services to Kenyans. The NHSSP II aims to improve the health and well being of all Kenyans, based on a lifecycle approach for ensuring that each age cohort receives health services according to its needs. The plan expects to achieve that goal through selective, highly cost-effective service package interventions for each age cohort that is likely to result in health improvement in the overall population. The proposed structure of the health services delivery system is hierarchical in nature and can therefore be discussed under life cycle cohorts and six health delivery levels. 1.3.1 Level One Services. The Kenya Essential Package for Health (KEPH) is designed as an integrated collection of cost-effective interventions that address common diseases, injuries and risk factors, including diagnostic and health care services, to satisfy the demand for prevention and treatment of these conditions. Strategy for the delivery of Level One Services, intends to make KEPH a reality through empowering Kenyan households and communities to take charge of improving their own health. This new approach clearly defines the type of services to be provided, the type of human resources required to deliver and support this level of care, the minimum commodity kits required, and the management arrangements to be used in implementation. The strategy sets out an ambitious target of reaching 16 million Kenyans (3.2 million households) in the next four years (2007-2010). It envisages building the capacity of households not only to demand services from all providers, but to know and progressively realize their rights to equitable, good quality health care. This strategy introduces innovative approaches for accomplishing these challenging but realizable targets. The approaches include; • Establishing a level 1 care unit to serve a local population of 5,000 people. • Instituting a cadre of well trained community-owned resource persons (CORPs) who will each provide level 1 services to 20 households. • Supporting every 25 CORPs with a Community Health Extension Worker (CHEW). • Ensuring that the recruitment and management of CORPS is carried out by village and facility health committees. The levels of action to support level 1 services at; Household, Village, School, or Congregation includes; organizational, coordination structures, entry steps to roll out the strategy, planning and management of operations, and linkages with facility based health systems. 4 The activities at this level entails to; • Plan, implement, monitor, evaluate and provide feedback on activities. • Mobilize and manage resources. • Undertake health promotion, hygiene, lifestyle and care seeking initiatives. 1.3.2 Level Two Services (Sub location, parish, and dispensary). Dispensaries provide the bulk of services and form the first level contact with the community. This level should have dispensary committees with representation from locational and sub locational levels. This level forms the main linkage between the community and the health system and they report to the location /sub locational development committee on matters of health. The technical resource persons here include the CHEW who are trained to train and coached to support CORPs. The committee in addition to the formal roles assigned to it through the various guidelines should; • Plan, implement, monitor, evaluate and provide feedback on level 1 services. • Mobilize resources for development of the health facility as well as supporting out reach and referral activities. • Facilitate regular dialogue between the community and health service providers based on available information. • Promote inter-sector collaboration. • Organize the community for health action. • Strengthen community involvement in decision making process. • Facilitate planning, budgeting, budget controls and accountability, to ensure availability of all the resources needed for level one services. • Establish linkage between the health system and the community by helping to market the health facility to enhance its credibility based on quality of care and thus promote a culture of good health promotion at the community level • Use the services as the place of first when in need of care. • Listen to and address complaints of clients. • Coordinate the recruitment of CORPs and CHEWs. • Convene monthly community health days for joint health action. 1.3.3 Level Three Services (Division, health centre). A district health committee will be established to be responsible for health services in the whole division. The health centres committees shall be responsible for facilitating level one services by reporting to the health centre committees, and providing day to day support of CORPs in their service delivery. At this level also is where the CHEWs: • Plan, implement, monitor, evaluate and provide feedback on activities for continuous improvement. • Provide training and supportive supervision. • Coordinate, collaborate, network, exchange ideas and pool resources. 5 1.3.4 Level Four Services (District, Diocese Hospital). The district hospitals and other diocese hospitals provide both referral and out patient services in addition to the requisite technical support and responsibility to the health care facilities at the periphery. The DHMB and District Health Management Team (DHMT) provide governance and technical support respectively to the level three facilities which include planning, implementation, monitoring and supervision. Other responsibilities mandated to the district level includes to; • Carry out comprehensive district planning, implementation, monitoring, evaluation and feedback, budgeting, and supervision. • Identify and increase the utilization of existing community organizations and structures and sensitize them on rights for health. • Strengthen health boards. • Build capacity of villages on safe water supply, sanitation facilities. • Train extension staff and leaders on level one services and ensure that resources reach level one to implement their village health plans. • Facilitate community capacity for providing technical and material support. • Coordinate input of development partners/NGOs/CBOs through the district health stakeholders forum. This package has to be incorporated into comprehensive district health plans organized by cohorts to enable districts to properly utilize available scarce resources. Similarly, the filtered health service delivery packages targeted at community level should be incorporated into the community-based health plans in which HCWM is among them. 1.3.5 Level Five Services (Province). The Provincial Health Management Team (PHMT) is responsible for integrating health services into normal health care system in Kenya through provincial or regional coordination. Apart from the provision of support in capacity building and quality assurance by the provincial team, the Provincial hospitals perform the role of referral to the district hospitals in the province. It is also at this level that feedback of projects and programmes run from the district level is transmitted to the national level. The provincial team gives supervisory support to district teams by; • Building capacity of districts for implementation of level one services and assure quality, including rights. • Provide technical and material support on planning, implementation, monitoring, evaluation and feedback. 1.3.6 Level Six (National). At the national level is where policies, regulations and national guidelines are formulated and reviewed in relation to the national health policy. The national level is responsible for; 6  • Developing strategic plans and implementation plans for lower level action. • Ensuring multi-sector and donor coordination in health and resource allocation. • Ensuring equity of health services, quality assurance, and technical support. • Building the capacity of districts in planning and action process. • Ensuring health information is passed to the Kenyan populace. Kenyatta National Hospital is at the apex; with Moi Teaching and Referral Hospital following it at a distance in service provision. The two national referral hospitals have the referral duties to perform both to the provincial general hospitals and district hospitals. 1.3.7 Private Health Services The Ministry of Medical Services is the main provider of health services in Kenya but Kenya’s strategy of pluralism in health care provision has nevertheless facilitated the growth of diverse non government health sector which is well developed. An elaborate network of non-governmental or private health providers (both for profit and not-for profit) supplements the public health system. The private sector health services are mainly concentrated in the urban areas essentially providing curative services. Despite its importance, the private sector, safe for few occasions, hasn’t been involved in the national health policy formulation. Since there has been little cooperation and coordination of planning regarding the delivery of health services between public and private actors, it is incumbent upon the Ministry of Health and its stakeholders to open up this avenue for successful implementation of programmes. 1.3.8 Faith Based and Community Based Organizations. Faith based organizations are coordinated by religious groups which run health services and they include; Christian Health Association of Kenya (CHAK), the Catholic Health Secretariat, the Supreme Council of Kenya Muslims, and other religious organizations. In particular, the experiences of Faith Based Organizations, Non Governmental Organizations (NGOs) and Community Based Organizations (CBOs) in working with community are an asset for the implementation of health programmes at grassroots level. NHSSP II sets out the approach to be taken to ensure that Kenyan Communities have the capacity and motivation to take up essential roles in health care delivery. Through Civil Society Organizations (CSOs), these community based groups offer not-for-profit health services. They often consist of local initiatives such as women groups that respond to felt needs, e.g. building a small maternity or dispensary. Their source of income most often comes from local contributions among those interested or money from cost sharing. The quality of services provided by these organizations attracts many people thus translating into service provision to an important segment of the Kenya population. 7 1.3.9 Home Based Health Care Services. Home Based Care (HBC) health services in Kenya have been practiced through the Primary Health Care /Community Based Health Care (PHC/CBHC) since the Alma-Ata Declaration of 1978. The treatment for HIV/AIDS patients have been complicated by stigma and discrimination attached to the disease and the fact that HIV mode of transmission is surrounded with a lot of myths. Prolonged hospital care for patients with HIV/AIDS puts too much constraints in the hospital budgets and compromises the resources that should be utilized on emergency cases. Patients put on Anti Retro-Viral (ARV) drugs are not mostly admitted to hospitals but take drugs home and therefore require adherence follow-up, nutritional support, spiritual support, social support among other things. Effective home based care will help to decongest hospitals, where currently 65% of hospitals bed occupants suffer from AIDS related illnesses. However, the community systems are faced with the challenge of coping with growing demand for care, in the face of deepening poverty and dwindling resources. In the new approach, the DHMT will advocate for support by religious, government and political leaders, other influential people, and NGOs and CBOs for resource mobilization and allocation for level one services at community level. Social mobilization through sensitizing and motivating social partners to work together in raising awareness and pooling resources, targeted interested organizations, individuals and health related sectors, along with CBOs, NGOs, professional associations and the private sector. A clear organizational structure with well defined roles and responsibilities of all sectors at all levels is necessary to ensure the success of level one services. 1.3.10 Monitoring and Evaluation. Monitoring is the process of regularly reviewing achievements towards the goal. In order to carry out monitoring and evaluation activities, critical issues are; the goals, objectives, targets, inputs, outputs and indicators must be clearly defined. An effective monitoring and evaluation system needs monitoring structures with appropriate staff, a good information network system, and appropriate reporting formats/ registers and procedures. The work performance expected to be delivered at the various levels of services provision provide the bench marks of expected out puts. Likewise HCWM needs to be bench marked. Fundamentally, monitoring should be established from the beginning as part of the planned activities. The purpose is to ensure that KEPH activities are implemented according to the set plan, that lessons are derived from the way the programme is implemented, and health extension programmes are effectively implemented. Monitoring involves comparing what is actually happening with what was planned. On the other hand, evaluation asks whether we succeeded or failed to meet stated goals, whether we used resources appropriately, and whether our actions will have long-term results. In this context, therefore, there have to be specific tasks identified for implementation with targeted expected outputs at the community level based on invested required inputs. The aspects to be monitored and evaluated on health care waste management should be identified based on the 8 injection safety and medical waste management policy guidelines and the National Environment Management Authority (NEMA) standards. 1.3.11 Conclusion. All efforts to improve health sector performance, irrespective of which approved provider runs it, are ultimately geared towards improving people’s health. Stakeholders in the health sector are many and they range from other government ministries, the private sector institutions including non-governmental organizations, professional associations, and development partners. The re- organization of health services through the NHSSP II aims at improving service efficiency and effectiveness at level one in the community. Management of HCW is an integral part of hospital hygiene and infection control. Infectious HCW contributes to the risk of nosocomial infections, putting the health of medical workers and the community at risk. Proper HCW practices should be strictly followed as part of a comprehensive and systematic approach to hospital hygiene and infection control. Harmonization of health systems especially on health care waste management can be an asset if it is enforced in all health care providing institutions. Efforts by government institutions and development partners namely; the World Bank, WHO, JSI-MMIS among others are so far commendable. This partnership has provided the required financial support to HCWM assessments and plan of action development, an area that for a long time has been neglected. The development of the plan reflects the integral effort that is necessary to set up a safe and environmentally sound HCWM practices acceptable by the national environmental legislations. 9 CHAPTER TWO. 2.0 SITUATION ANALYSIS. A national assessment was done in October 2007 and was aimed at exposing legislative, institutional and infrastructural problems touching on health care waste management in the country. The assessment done in a desk review and a rapid assessment are detailed in the sections that follow: 2.1 SECTION A: LEGAL AND REGULATORY FRAMEWORK. In the desk review, the current legal provisions for HCWM in Kenya as well as the current rules that are applied within the health sector were explored. This was to bring out the inter-linkages and synergies aimed at improving the management of HCW. The documents used for this purpose were; i) The Public Health Act, Cap 242. ii) EMCA No. 8. 1999, Waste Management Regulations, 2006. iii) National policy on injection safety and medical waste management. iv) Kenya National Guidelines on Safe Disposal of Pharmaceutical Waste. v) National Environmental Sanitation and Hygiene Policy. vi) The National HCWM plan of 2006-2015. In reviewing the legislative provisions and other related documents, it was imperative to consider their significant roles in the management of HCW. 2.1.1 The Public Health Act, Cap 242, Laws of Kenya, on Waste Management: The Public Health Act Cap 242, part IX deals with sanitation and housing. The Act imposes responsibility on local authorities to take measures and maintain their areas in clean and sanitary condition. It also prevents the occurrence of nuisances and aspires to remedy nuisances or other conditions liable to be injurious or dangerous to health. Section 118 defines nuisances and includes any accumulation or deposit of refuse which is offensive or which is injurious or dangerous to health. Where the Medical Officer of Health of a local authority is satisfied that a nuisance exists he shall serve a nuisance abatement notice to the owner or occupier. This notice can be enforced by taking criminal proceedings against the owner, occupier or the person responsible for the nuisance. It is instructive that the provisions in Public Health Act are not really designed to deal specifically with health care waste. However, these provisions address the conditions which render premises dangerous to health. There can be circumstances in which the danger to health arises from the handling of infectious health care waste, in which case the provisions of the Public Health Act can be used. 10 2.1.2 The Environmental Management and Coordination Act, 1999. The National Environmental Management Authority (NEMA) Regulations made under the EMCA 1999, imposes duty of care on the occupier of premises where health care waste are handled to take measures to ensure that such waste is handled without adverse effects on human health and to the environment and natural resources. A waste generator is expected to minimize the waste generated by adopting cleaner production methods that focuses on; reclamation and recycling and elimination of use of toxic raw materials, and reducing toxic emissions and wastes among others. These provisions also impose segregation as a means of waste minimization in order to make the choice of waste treatment easy. In hospital settings, Persistent Organic Pollutants (POPs) will be produced if the health care waste to be incinerated contains any chlorinated products such as blood bags, catheters, IV bags, tubing, and some surgical gloves. Worldwide, it is estimated that 10% of dioxins pollution occurs after the incineration of medical waste containing chlorinated substances. It is therefore important for health care institutions to segregate and carefully separate chlorinated waste from waste earmarked for incineration. The NEMA Regulations on waste management permit emission of dioxins and furans that do not exceed 80ng/m3. This however does not mean that the Authority allows air pollution but the emissions should be within allowable limits. The regulation imposes standards for treatment and disposal of biomedical waste, including standards of air emissions from incineration and other related activities. The NEMA regulations also deals with the transport of waste and prohibits the transport of waste without license issued by NEMA, or transporting waste to a disposal site which is not licensed by NEMA. Further, the section prohibits the operation of a site or plant without being licensed by NEMA. It further directs that no person shall be granted a license under the Act to transport waste, operate a waste disposal site or plant unless such a person complies with all conditions that apply to waste transport vehicles and waste disposal sites. NEMA has also operationalized part VI of EMCA which deals with environmental impact assessment licensing. This section requires that project proponents apply for and obtain an Environmental Impact Assessment (E.I.A.) license from NEMA, before commencing, carrying out or proceeding with a project that is generally considered to be hazardous. The EMCA, 1999 provides that NEMA may appoint inspectors who may enter any premises to determine compliance with environmental management requirements and demand for an Environmental Audit (EA) of a premises, plant or project. 2.1.3 Kenya National Guidelines on Safe Disposal of Pharmaceutical Waste, 2001. The provisions of these guidelines describe a series of steps that need to be followed in order to dispose unwanted pharmaceuticals. The steps required include; identification of pharmaceutical waste, sorting of pharmaceutical waste by category, filling the relevant forms to seek authority from the DHMT and the 11 Chief Pharmacist among other persons to dispose such waste. Upon obtaining all the relevant approvals, the disposal of the pharmaceutical waste shall be effected under the supervision of the local pharmaceutical waste disposal team or the Waste Management Team (WMT). The recommended methods for disposing of unwanted pharmaceuticals include; • The use of either medium temperatures incineration at a minimum of 850°C or high temperature incineration exceeding 1200°C with two chamber incinerator for solids, semi- solids and powders for controlled substances e.g. antineoplastics. • Engineered sanitary landfill to be used for disposal of expired or unwanted pharmaceuticals. • Sewer disposal for diluted liquids, syrups, intravenous fluids, small quantities of diluted disinfectants and antiseptics. 2.1.4 National Policy on Injection Safety and Medical Waste Management. The mission statement of this policy is to ensure safety of health workers, patients, and the community and to maintain a safe environment through the promotion of safe injection practices and proper management of related medical waste. This is the first document of the Ministry of Public Health and Sanitation that is explicit on the need to address health waste management problems. The policy objectives spell out the need to advocate for support and implementation of proper management of medical waste among others. Some of the guiding principles for the implementation of this policy include; • Establishment of organizational structures at all levels for all the implementation of injection safety and related medical waste. • The policy also addresses the need for environmental protection through appropriate waste disposal methods. • Minimization of risks to patients, health workers, communities and the environment through application of safer injection devices and sharps waste disposal methods. • Advocating for the strengthening of the necessary human resource capacity through training and sensitization for safe waste disposal. One of the key policy strategies indicated in this policy is the need for appropriate financial mobilization and allocation of the components of injection safety and medical waste management for effective policy implementation. The provision of sustained supplies and equipment for waste management through strengthened logistics system addresses the need for commensurate investment in waste handling requirements. A unique strategy recommended also is the advocacy of best waste management practices through behaviour change communication as a key element in the strategy. 2.1.5 Radiation Protection Act, Cap 243. The Radiation Protection Act, Chapter 243, aims to control the; import, export, possession and use of radioactive substances and irradiating apparatus. Under this Act in section 9, a license is required to handle any radioactive substances or 12 irradiating apparatus from the National Radiation Protection Board. Handling here includes the method of disposing of radioactive waste products, transportation of radioactive materials, storage, use and maximum working hours that employees are expected to work with radioactive materials. Under this Act also, institutions generating this category of waste shall be expected to apply for a license from the same board. 2.1.6 International Conventions The documents reviewed did not mention the existence of Stockholm Convention which is explicit on protecting human health and the environment from Persistent Organic Pollutants (POPs) specifically dioxins and furans. The Kenyan Government ratified this convention and the main objective of this convention is to reduce/eliminate POPs. POPs is generated by various health care institutions whose activities may directly or indirectly produce these harmful substances during the incineration by oxidation of chlorinated waste products. The Basel Convention (Trans-boundary movement of hazardous waste convention) to which Kenya is a signatory was given mention in the waste management regulations where the waste imported or exported is expected to meet the ambient soil or water standards as shall be determined by the lead agency. The standards issue here is vaguely handled and should be clear on permissible levels. 2.2.0 SECTION B: ASSESSMENT OF HCWM PRACTICES. This section presents the findings of the rapid assessment which was conducted in four provinces in Kenya, namely Nairobi, Central, Rift Valley and Western. 24 hospitals were selected from four of the eight provinces in Kenya. • Six hospitals from each province were randomly selected each from a stratified sample based on ownership of the hospital. o Public hospitals at provincial and district hospitals were included. o Faith Based hospitals and private (private-for-profit) hospitals were also included. • Questionnaires were administered to the Medical Superintendents or Hospital Matron of the visited hospitals. • Observational Checklists were administered by the assessment team leader who assessed the health care waste management facilities/ tools and practices in the hospitals. • The weighing of the various categories of health care waste generated in the selected hospitals was done. The assessment was aimed at bringing out the issues which were seen to be part of the problems afflicting health care waste management practices in Kenyan hospitals. 2.2.1 HCW Production and Containment. Generally speaking, health care waste in most hospitals in Kenya is separated into three main categories. The commonest practice is the use of three bins system to accommodate waste as follows; 13  1. Infectious or hazardous health. 2. General waste or non-infectious waste 3. Sharps in puncture proof safety boxes. Appropriate handling, treatment, and disposal of waste by type can help to reduce costs and does much to protect public health. However, the assessment revealed the findings discussed under the following themes; i) Waste Generation. The measurement of waste was conducted in 23 hospitals by field officers who were each given a spring dial weighing machine. Weighing of wastes was done for a continuous seven days so as to obtain the weeks’ trend of waste generation. The results obtained from the targeted facilities were very much varying in their weight range from one hospital to another. ii) Waste Minimization; Health care waste minimization is considered one of the possible strategies of managing health care waste in a sound manner. However, most health facilities did not practice any form of waste minimization or show any efforts geared towards waste minimization. iii) Waste receptacles: The assessment showed that sharps waste was well contained in (95%) of the hospitals visited therefore implying that special attention was being given to sharps waste management both in government facilities and in faith based hospitals. Most areas generating sharps in the private hospitals (private-for-profit) were using 5 litre sharps boxes and in some cases 2 litre plastic sharps containers. For non-sharps waste, the 10 litre and 30 litre bins were the commonest bins provided in most clinical areas. However, improvisation of carton boxes, and buckets to take the place of waste bins was observed in some hospitals. The use of bins without liners was also evident. 2.2.2 Waste Handling Practices. i) The Practice of Waste Segregation: Segregation of HCW was done according to the following categories; infectious or clinical waste (hazardous waste), Non-infectious or general waste, highly infectious waste, and sharps waste. In few hospitals, glass waste was placed in its own category. Use of colour codes for waste containers was low. The following colour codes for HCW are recommended by NEMA: • yellow for infectious and sharps waste; • black for non infectious. Further, WHO recommends red for pathological and/or highly infectious waste. The use of colour coding system is to enhance segregation practices. Careful segregation of waste into different categories helps to minimize the quantities of hazardous waste. ii) Packaging of HCW: The exercise of packaging was seen in few health care facilities that were using an off-site waste treatment facility to dispose their waste. The packaging involved putting waste in larger bags, some of 14  which had not been sealed. Most of the waste for on-site treatment was simply loaded on waste transport utilities without sealing. Few waste bags were tied up before as they awaited transportation. iii) Labelling: Even though labeling of waste receptacles is a recommended practice to ensure each waste category is easily identified, it was observed that only few hospitals labelled their waste. 2.2.3 Waste Storage and Transportation. i) Waste Transportation: Most hospitals were using wheelbarrows for the transportation of waste within the compound, while only a few of the facilities were using trolleys. The use of wheelbarrows should be discouraged since it leads to spillage of waste. It was noted that more than half of the hospitals had noticeable waste spillage within. The recommended practice for waste transportation within hospitals should be dedicated trolleys with separate ones for infectious waste. The frequency of collection of waste in most hospitals was once daily. Few hospitals had identified some areas with high waste generation for two or three collections daily. ii) Storage of Waste: 47% of hospitals visited were found to have refuse storage areas/rooms. In some of these hospitals, disused rooms, some with leaking roofs were used to store waste. Of the waste storage areas provided however, 61% of them were fenced or had restricted entry. 2.2.4 Waste Treatment and Disposal. i) Treatment of Health Care Waste on-site. Most of the hospitals visited were treating their waste onsite. The commonest method of waste treatment was incineration at 62% using functional incinerators. Most of the wastes taken from hospitals for treatment off-site were glass waste and domestic waste while open burning, open dumping was still being practiced along with incineration. Of those taking their waste off-site, it was found out that most facilities never kept records of the waste they contract for off-site disposal. For the incinerators observed in hospitals, majority of them were in functional status while a quarter were dysfunctional; either undergoing repair or in a non-working status. Other waste treatment facilities available in these hospitals included; compost pits for non hazardous biodegradable waste, and shredders which were found in only Kenyatta National Hospital, Mater Mission Hospital and Nairobi Hospital. Most of the hospitals did not have an alternative waste treatment option apart from incineration. ii) Final Waste Disposal. Almost half of the hospitals visited had well kept compounds around the final waste disposal areas in the hospitals, while less than half did not maintain cleanliness around their waste disposal areas. 64% of the hospitals had done good siting of their waste disposal areas while 12% of the facilities had tried to site the disposal area or 15  facility fairly well. 24% however did not do good siting of their waste disposal areas. Good siting of waste disposal sites or facilities entails locating them where they do no cause pollution or injury to the occupants of adjacent dwellings. Most rural hospitals were doing onsite disposal of waste in pits or open dump sites which in some cases were fenced off. Most hospitals dumped their anatomical waste in placenta pits. Pumwani Maternity hospital was using a contracted company to dispose off maternity waste off site. 2.2.5 Occupational Health & Safety. Personal Protective Equipment. All the waste operators said they had gumboots for protection of their feet, and most of them had them on. They also had the possession of heavy duty gloves for hand protection. The provision of respirators or face masks, overalls, helmets, and plastic goggles for eyes protection was poor on an overall average of 37%. In most waste treatment sites where waste operators had possession of respirators or goggles, most of those found handling waste did not have them on but wore them on noticing visitors. 2.2.6 Institutional Capacity. i) Training and awareness: Best practices in health care waste management require that all staff receive induction and repeated training on health care waste management. However, 61% of technical staff had received training on how to management health care waste. About a similar percentage (65%) of the waste operators had been trained on incinerator operation. The deployed members of staff for waste management duties was expressed as adequate in 57% of the hospitals visited, while the rest of the staff complained of lack of enough staff for waste management. Most staff members deployed to handle waste were engaged in doing other chores apart from waste management. ii) Development of Waste Management Plans: On the development of Annual Operational Plans (AOPs) from the facility level, the assessment revealed that only 16.7% of hospitals visited had health care waste management plans, verified with copies seen. iii) Finance and Resources: Most health managers did not know the costs involved in managing health care waste in their hospitals. In some cases the difficulty of separating cost of managing waste was expressed since the costs had been lumped up with other operational costs. Obtaining resources to purchase bins, bin-liners and maintenance of incinerators was difficult in most facilities. 2.3 SECTION C: ESTIMATION OF QUANTITIES OF WASTE GENERATED. Understanding the quantities or volumes of waste generated in a HCF is very crucial to health managers and planners. Measurements of waste generated in the selected HCFs were considered necessary for informed decision making to those 16 in charge of planning and financing of health care services. The quantities of HCW generated can guide decisions on what disposal method(s) is required for a particular HCF. This assessment was aimed at determining the average daily quantity of waste in each category generated by each hospital. The types of waste targeted were mainly of three categories; Infectious waste or hazardous waste (soft waste), Sharps waste which is also infectious and the Non- Infectious waste or general waste. Other categories anticipated included; highly infectious waste, glass waste, food waste and other special waste from major hospitals. 2.3.1 Estimation Methodology. The measurements of waste were done in 23 hospitals for one week (7 days) in order to obtain the desired waste generation trends in a week. Public Health Officers were involved in supervising the measurements which was handled by the waste operators in those institutions. The hospital administration was informed about the exercise and their support sought. An induction was conducted by the principal assessor to ensure that the waste operator and their supervisors understood the tasks well. Staff members in the various departments were likewise informed of the exercise. Waste operators identified for measuring the waste were inducted to understand what types of waste was targeted and how the data entries were to be done. The weights were obtained using appropriate spring dial weighing scales and were tabulated on a recording tool provided. The total weight of the various waste categories in the seven days was used to calculate the daily average from each facility. The data obtained was then divided by the total number of both in- and out-patients in order to achieve quantities of particular category of waste per patient per day. The weights of waste were obtained under the assumption that whatever was placed in yellow bags meant for infectious waste was accepted as such and were not adjusted. The limitation of the study however, was the small sample and the few days for weight measurements. Some facilities lacked waste bin liner bags and some also lacked waste categorization in their practice. 2.3.2 Quantities of Waste Generated. From the data of the 23 facilities whose waste was weighed and analyzed; 39% of the waste was infectious, while 61% were non-infectious. The varying levels of waste segregation practices observed in the sampled hospitals brought out the difference which doesn’t agree with the WHO health care waste proportions where 80% of the waste is considered non-infectious while 20% is infectious. 17 Table 1: Estimated health care waste production in Kenyan Hospitals. The data below are average values obtained from 23 hospitals of different levels over a period of one week in October 2007. ____________________________________________________________________ Overall Average waste per patient Material per day (Kg/day) _____________________________________________________________________ Sharps 0.031 Infectious waste 0.175 Non infectious waste 0.135 Food waste 0.184 Total waste produced 0.525 Per person per day The categories of facilities selected here encompasses Government hospitals (National, provincial, and District), private and mission or faith based organization hospital. Table 2: Results of waste generation in Kgs. from selected hospitals in Kenya. Eldoret Bungoma Nazareth Nyeri Kenyatta Private District Mission Provincial National Hospital Hospital Hospital G. Hospital Hospital No of all Patients (in- 97 625 318 1000 2936 and out patients) Bed capacity of 141 167 216 38 1845 Hospital (official) Sharps waste 1.8 22.8 8 19.4 45.7 Infectious waste 7.4 54.4 69.6 188 1212.4 Non-Infectious 3.6 27.3 22.2 172.5 579.2 waste Food Waste 3.6 62.7 47.2 216.8 963 Total Waste in 16.4 165.2 147 596.7 2800.3 Kgs. In table 2 above, the selected results presented just reinforces the disparity observed from the measurements from the WHO expected standard practice on HCWM. 2.4. DISCUSSION OF THE FINDINGS. 2.4.1 Capacity and Resource Availability for Handling HCW. The handling of waste requires both technical and financial resources for effective management of waste emanating from health care services. This issue is not properly addressed in the documents under review. Most of the documents are not clear on waste management responsibilities but in EMCA 1999, a provision is made for a waste transporter to transport waste by obtaining waste transportation license. The national policy on injection safety and medical waste by Ministry of Health only mentions appropriate financial mobilization and allocation by health 18 care institution and more so relies on development partners, NGOs, faith based organizations and the community as potential sources of funds to handle waste. This does not provide clarity on how to generate sustainable funding to effectively handle HCW through government’s national budgets. The inadequate health care waste receptacles discussed in health care waste management plan have not been adequately addressed in the policy document and only safety box has been mentioned under logistics as covered by national injection safety and related medical waste management policy. Documents reviewed have not shown interest in knowing the volumes of the waste generated and what scales of measurement to apply although the injection safety policy has indicated the need to come up with standards at some stage. 2.4.2 Roles of Different Sectors towards HCWM. The national injection safety and medical waste policy recognizes the roles played by the division of nursing and division of environmental health. Management of HCW needs well-coordinated approach in ensuring effective handling of the waste in order to reduce its adverse effects. Except the EMCA Act, the other documents under review did not mention private sector health care providers in waste management and as such more relationship needs to be built between public and private sectors. EMCA, 1999 is clear on enforcement and the need for EIA, prior to the siting and approval of disposal areas or the disposal of hazardous waste. The policy on injection safety and related medical waste management is clear on the need for stakeholders to provide logistics to support HCWM in institutions, including support for operational research. Most of the documents under review did not provide defined roles of the wider community when it comes to the management of HCW. The national policy on injection safety and medical waste management has some mention on community roles, although their real participation in terms of increasing information sharing and communication on HCW was not addressed. However, in the Waste Management Regulations 2006, assignment of responsibility to all players in HCWM has been spelt out and this document therefore reinforces specification of roles and responsibilities for all, including funding and training needs. 2.4.3 Point of Linkages. The management of HCW is a crucial issue that requires synergistic approach where all relevant sectors and sub sectors agree on what constitutes hazardous waste, with special preference given to waste generated from health care institutions. In the National Environmental Sanitation and Hygiene Policy, the protection of the environment from pollution and its negative effects has been mentioned, and the government’s commitment to protecting its citizens from adverse environmental consequences. 19 The NEMA Waste Management Regulations 2006, in the ninth schedule refers to the Kenya National Guidelines on Safe Disposal of Pharmaceutical Waste for direction in as far as pharmaceutical waste management is concerned. The Kenya National Guidelines on Safe Disposal of Pharmaceutical Waste provides a schedule on how unwanted pharmaceutical waste is disposed. The document also makes reference to the Radiation Protection Act, Cap 243, for directions on radioactive waste management. The Medical Practitioners and Dentist Board Act, which regulates the licensing of private health care establishments within the country has addressed dental units as generators of dental health care waste which has not been given mention in other documents. Whereas NEMA has talked on the need for zoning HCWM facilities with relevant lead agency, there is section 36 of the Physical Planning Act, Chapter 286 Laws of Kenya which gives power to local authorities to call for an EIA study with respect to application for planning permission for among other development, waste disposal sites. 2.4.4 Sharps waste Management The practice of proper segregation of sharps materials in rigid, puncture proof containers was the commonest practice in the assessment conducted. It is noteworthy that only 10% or less portion of the waste stream that is potentially infectious, is the most immediate threat to human health (patients, workers, public) if indiscriminate disposal of sharps (needles, syringes, lancets, and other invasive tools) is allowed. However, beside the effort that has been shown by the Kenyan government in the provision of sharps boxes for use in most public and faith based facilities (95%), it is apparent that if proper sharps waste management were instituted in all health care facilities, most of the risk of disease transmission from health care waste would be reduced markedly. 2.4.5 Segregation Practices. It is possible that segregation can be achieved through training, and designing of clear standards to be followed by all players in waste generation in hospitals. Segregation consists of separating the different waste streams based on the hazardous properties of the waste, the type of treatment, and disposal methods that are applied to each. The current waste management practices observed was fair segregation posted from some hospitals (55%) who were observing good segregation practices in some departments and in some cases waste mixing was observed in some waste receptacles within the same hospitals and this needs to be captured as an attempt towards best practice. Poor segregation, and poor choice of technology for treatment and disposal of waste are two problems identified that are due in part to inadequate management practices or simply because of absence of adequate provision of waste receptacles. The results analyzed showed that Kenya was still way below the WHO recommended standards, where 80% of waste should be non-infectious and can be recommended to join the municipal waste stream, while 20% is the infectious wastes that require special waste treatment methods. In best practices, segregation is expected to be systematically maintained all along the waste stream for easy and cheaper treatment and final disposal. 20 2.4.6 Benefits of Good Segregation Practices. The benefits of waste segregation can be realized when secure internal and external transport system for waste is provided and the segregation practice is appreciated by the technical staff and waste collectors. Evidence shows that in hospitals such as; Nairobi hospital and Gertrude Children’s Hospital, HCWM practices are institutionalized through continuing training programmes coupled with provision of the necessary resources. In these hospitals therefore, it is noteworthy that great levels of segregation and general hospital cleanliness have been achieved. However, if waste is segregated at the points of generation only to be mixed together by labourers as they collect it, or to have waste collection company workers mix it together upon a single collection, then the ultimate value of segregation is lost. In some hospitals, there is still evident failure to establish and follow segregation protocols and put in place the required infrastructure for handling waste. It is best practice in HCWM that items that could potentially be used illegitimately must be either rendered unusable after their use or secured for legitimate recycling by vendors or systems that can be monitored for compliance. A recommended way of identifying HCW categories is by sorting the waste into colour-coded, well packed and labelled containers. It is cardinal that segregation must always be applied at source. 2.4.7 Waste Treatment Practices. Most of the visited hospitals treated their waste using incineration processes. Whereas medical waste incinerators are effective in volume reduction of waste to a small quantity of ash, the incinerator at the same time also releases into the air a wide variety of pollutants including dioxins and furans, metals (such as lead, mercury, and cadmium), particulate matter, acid gases (hydrogen chloride and sulfur dioxide), carbon monoxide, and nitrogen oxides. These emissions have serious consequences on worker safety, pubic health and the environment. The concern of NEMA has been to raise the incineration temperatures to over 800°C and the stack height to over 10 metres so as to enhance the dissipation of the emissions and subsequently lower its adverse effects. 2.4.8 Technology Choice. Choices of treatment technologies should be made in line with particular waste stream to be managed and the goal to be achieved through treatment. If the technology for use is environmentally sound, the waste stream should be able to be treated without creating other hazardous by-products. Because of the challenges touching on incineration technology on HCW, it is necessary to explore other environmentally friendly technologies as HCWM solutions for the future. The technology for adoption should fix the situation and work in the management system to achieve the final goal as part of the overall system, not as a replacement for the system. The current practices in Kenya are not giving clarity in technology choices for use. This therefore brings to the fore the need to identify 21 better operational conditions for small scale incinerators to operate under, as they meet stipulated NEMA requirements. 2.4.9 Risks Associated With the Current HCWM Practices. A policy for the management of health care waste cannot be effective unless it is applied carefully, consistently and nationally. Improper disposal of health care wastes, especially; syringes, needles and other materials that are scavenged and later reused, may lead to significant numbers of hepatitis B, hepatitis C, HIV/AIDS and other infections among ignorant persons. It was clear that infectious waste generated in Kenyan hospitals were usually all items contaminated, or suspected of being contaminated with body fluids such as bandages and gauze, swabs, intravenous fluid lines, maternity and incontinence pads and disposable spatulas, bowls and caps. The assessment revealed that good segregation practice was at only 27%, with most hospital departments mixing their waste. The wanting segregation practices coupled with lack of colour coded bags, poor labeling practices and inadequately provided bins for waste containment encouraged the mixing of waste. Poor transport facilities (mainly wheelbarrows) used also encouraged the spillage (in 63% of hospitals visited) of waste and only helped to make the situation deplorable and an obvious potential for injury and infection. It was clear that most waste disposal and storage areas were not secured from unauthorized entry. This means that risks exist especially to people (“Chokora groups