final report on finalization of hcwm guiding …

FINAL REPORT ON FINALIZATION OF HCWM GUIDING DOCUMENTS AND

TRAINING OF HEALTH WORKERS ON THE WHO BLUE BOOK AND THE HCWM

INDIVIDUALIZED RAPID ASSESSMENT TOOL (I-RAT)

MARCH 2021

PREPARED BY: MASAHESS P.O. BOX 1922-40100

KISUMU

AUTHORIZED CONTACT PERSON: DR. JOSEPH A. OKWESO

P.O. BOX 1922-40100 KISUMU

SUBMITTED TO THE UPOPs PROJECT MANAGEMENT UNIT (PMU),

MINISTRY OF ENVIRONMENT AND FORESTRY AND MINISTRY OF HEALTH,

NHIF BUILDING, NAIROBI.

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Final Report on Finalization of HCWM Guiding Documents and Training of Health

Workers on the WHO Blue Book and HCWM Individualized Rapid Assessment Tool (I-

RAT)

Introduction

In 2017, with funding from the Global Environment Facility (GEF), the Mainstreaming Sound

Chemicals Management and Unintended Persistent Organic Pollutants (UPOPs) Reduction Project in

Kenya instituted a document review consultancy to establish gaps in national HCWM strategic and

guiding documents.The consultancy was focused at reviewing all the HCWM strategic and guiding

documents, namely; the National Guidelines for Safe Management of Health Care Waste, Injection

Safety and Safe Disposal of Medical Waste National Communication Strategy and Health Care

Waste Management Standard Operating Procedures. The review focused on gaps in guidance

regarding reduction of the release of UPOPs and other substances of concern with the aim of

mitigating health and environmental risks, through the implementation of environmentally sound

management of municipal and healthcare wastes. Processes involved bridging gaps between global

recommendations as summarized in the WHO Blue Book for safe and appropriate management of

health care waste and Kenya’s integrated institutional and regulatory framework covering

management and reporting on POPs.

Background

The main objective of the Mainstreaming Sound Chemicals Management and UPOPs Reduction

Project in Kenya has been to reduce production of POPs through improvement of the

POPsregulatory system, enhancing its enforcement, raising awareness on POPs, and establishing the

capacity for safe handling, transportation, introduction of Best Available technologies (BATs) and

Best Environmental Practices (BEPs),drafting and disseminating the technical guidance on HCWM to

be officially endorsed by the government and improved disposal of POPs-containing or POPs-

generating waste.

As part of this effort, the project supported the Ministry of Health to establish the extent to which

the existing health care waste management guiding documents addressed global environmental and

health concerns. The support was provided in form of consultancy services during which the existing

health care waste management guiding documents were reviewed and benchmarked against global

standards as provided for in the World Health Organization (WHO) blue book, Stockholm

Convention, Basel Convention, Strategic Approach to International Chemicals Management (SAICM)

andthe best available technologies and best environmental practices guidelines.

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The three documents which were specifically reviewed to establish gaps in national guidance

included; the Kenya National Guidelines for Safe Management of Health Care Waste; Injection Safety

and Safe Disposal of Medical Waste National Communication Strategy and the Health Care Waste

Management Standard Operating Procedures (SOPs). In addition, health facility assessments were

conducted in 13 health facilities in Kisumu, Nakuru, Mombasa and Nairobi counties to establish

current health care waste management practices, evaluate functional methods used for managingand

disposing ofHCW and collect financial information related to management of HCW. Findings were

summarized in the 2017 report titled (available in UPOPS website)“Report on the Review of Kenya

National Guidelines for Safe Management of HCW, Injection Safety and Safe Disposal of Medical

Waste National Communication Strategy, and the HCW Management Standard Operating

Procedures (SOPs). Major gaps in each document are summarized in appendix I. The 2017 report

was presented to stakeholders in a workshop held in Naivasha town, Nakuru County, in November,

2017,during which consensus was reached on priority areas and the need to have each document

content updated. It was also agreed that services of a consultancy firm be solicited for to implement

agreed on recommendations. MASA Heath Environment and Safety Systems (MASAHESS), a private

public health consultancy firm, was contracted to achieve this scope of work.

2 Objectives of the Assignment

2.1 General Objective

To finalize the health care waste management strategic and guiding documents and carry out training

of health workers on the WHO Blue Book and I-RAT.

2.2 Specific objectives

To finalize the National Guidelines for Safe Management of Health Care Waste.

To finalize the Health Care Waste Management Standard Operating Procedures( SOPs).

To finalize the Injection Safety and Safe Disposal of Medical Waste National Communication

Strategy.

To conduct a 3-day training on the WHO Blue Book and I-RATfor 65 health workers drawn

from the 13 UPOPs Project health facilities in the Republic of Kenya.

2.3 Scope of Work

The consultants undertook the following:

i. Reviewed findings of the 2017 UNDP/GEF funded gap analysis in HCWM guidance and

generated content to bridge the identified gaps. The team carried out further review and

captured the most recent decisions and relevant resolutions of the most recent conference of

parties in the fields of health and environment.

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ii. Conducted specific field visits to and meetings with the targeted teams and facilities for

stakeholder inputs and reviews as necessary.

iii. Updated the Kenya Injection Safety and Safe Disposal of Medical Waste National

Communication Strategy, the National Guidelines for Safe Management of Health Care Waste

and Health Care Waste ManagementStandard Operating Procedures (SOPs). The updated

documents were validated by stakeholders in a well-organized workshop.

iv. Generated materials that were used in training health workers on the WHO Blue Book and I-

RAT and its application.

v. Trained 50 health workers (mainly public health officers and nurses on the WHO Blue Book and

I-RAT and its application). The Ministry of Health had selected and sent a total of 50 health

workers for the training.

vi. Made recommendations regarding how I-RAT training can be scaled up to expansion areas.

2.4 Deliverables

The following key deliverables for the assignment were successfully completed, approved and

submitted:

i. Finalised copies, both hard and soft, of the Inception Report.

ii. Finalised copies, both hard and soft, of the Kenya National Guidelines for Safe Management

of Health Care Waste,

iii. Finalised copies, both hard and soft, of the Injection Safety and Safe Disposal of Medical

Waste National Communication strategy.

iv. Finalised copies, both hard and soft, of the Health Care Waste Management Standard

Operating Procedures( SOPs).

v. Report on training of health workers on the WHO Blue Book and I-RAT and Training

Materials.

vi. Final Report on the Consultancy with Recommendations.

3 Methodology

The Consultancy firm,using a team of three professionals with a mix of expertise in health care

waste management policy and guidelines review, analysis and development; communication for social

change and environmental preservation and protection,achieved the assigned scope of work in 2

phases. In Phase 1, health care waste management guiding documents were reviewed and updated

while in phase 2, a total of 50 health workers were trained on the WHO Blue Book and I-RAT.

Gaps analysis was done at three levels;

Using recommendations of the 2017 gap analysis reflected in the report titled “Report on the Review of the Kenya National Guidelines for Safe Management of Health Care Waste, Injection

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Safety and Safe Disposal of Medical Waste National Communication Strategy and Health Care Waste Management Standard Operating Procedures (SOPs);

Through analysis of outcomes of focus group discussions held with health workers at selected sites, and;

From recommendations of subject matter experts at the Ministry of Health and Ministry of Environment and Forestry, including NEMA.

3.1 Task 1: Finalization of the Injection Safety and Safe Disposal of Medical Waste

National Communication Strategy

The review earlier done to establish the extent to which the 2010 Injection Safety and Safe Disposal

of Medical Waste National Communication Strategy complied with international and/ or standard

guidance hadidentified several gaps. The gaps are summarized as follows; lack of advocacy for proper

health care waste management planning including providing dedicated budgets to ensure full supply

of injection and health care waste management materials; lack of systems for prevention and

management of exposures to blood and its products; lack of programs that promote use of

appropriate sharps waste disposal containers; low levels of knowledge and awareness among

communities on risks associated with infectious waste, heavy metals, electrical, electronic and

pharmaceutical wastes; handling of highly infectious dead bodies during disease outbreaks by medical

burial teams is not acceptable to communities; lack of knowledge among managers on risks

associated with unsafe treatment of waste such as use of small scale incinerators; etc. The document

was updated as summarized below;

In updating the document, the team reviewed the following documents and/ or technical guidance:

a report entitled - “Report on the Review of the Kenya National Guidelines for Safe

Management of Health Care Waste, Injection Safety and Safe Disposal of Medical Waste

National Communication Strategy and Health Care Waste Management Standard Operating

Procedures (SOPs).

global guidance – from conventions and multilateral agreements on chemicals and HCWM;

Stockholm, Minamata and Basel conventions and the SAICM strategy. The team captured

relevant provisions of the conventions and strategies, confirmed best practices and applied

these in updating the document.

findings of the health facility assessment on HCWM practices to identify gaps and concerns

– in which they conducted consultations withhealth managers and health workers in the 13

health facilities in Kisumu, Nakuru, Mombasa and Nairobi Counties.

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The following changes were made to the document;

Executive summary: added content on pollution, chemicals and emission limits.

Section 1: Background

Reduced on content on injection safety by down-sizing information that was not related to

health care waste management. Introduced subsections on unintended persistent organic

pollutants and chemicals.

• Highlighted burning as a major threat to public health and the environment.

• Included information on current waste management practices; generation, minimization,

segregation, handling, transportation, treatment and disposal, pollution control etc.

• Included illustration of parts of an incinerator

• Provided pictures of ‘what is not an incinerator’.

• Provided key messages at the end of each sub-section.

Section 2: Situation Analysis

• Expounded on the definition of the health care waste management problem-covered under

background to HCWM.

• Provided information on persistent communication challenges that have contributed to

stagnation of health care waste management efforts.

• Provided clarification on the role of NEMA in health care waste management.

• Summarized outcomes of SWOT analysis regarding health care waste management.

• Audience Segmentation – segmented and analyzed target audiences for safe disposal of

health care waste and provided a summary table of outcomes.

• Audience analysis and segmentation were based on the Social ecological model.

• Analyzed priority audiences for priority health care waste management behaviors and

summarized outcomes in a table.

Section 3: Communication Strategy

• Provided information on outcomes to be achieved by the communication strategy.

• Stated strategies through which desired waste management behaviors should be achieved.

• Provided goals and objectives of the health care waste management national communication

strategy. The earlier version lacked objectives for HCWM Social Behavior Change. A total

of 7 targeted objectives were included.

• Provided behavior change models to guide development of the strategy.

New health care waste management objectives that have been included

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• Objective 1: To increase knowledge among health managers on the legal, regulatory and

policy framework for Health Care waste Management.

• Objective 2: To equip health workers with knowledge and skills in safe and appropriate

management of different types of health care waste, including chemical waste.

• Objective 3: To reduce use of waste treatment and disposal methods that pollute the

environment.

• Objective 4: To create awareness among communities on risks associated with health care

waste including risks arising out of use of environmentally polluting waste disposal methods.

• Objective 5: To strengthen collaboration and coordination of partners and stakeholders in

health care waste management. This will be done through building momentum for health

care waste management.

• Objective 6: To increase identification, mobilization, and allocation of resources for proper

management of health care waste.

• Objective 7: To advocate for the development and/or enforcement of standards prohibiting

pollution and illegal traffic of hazardous waste.

For each objective, strategic areas of focus and accompanying priority activities were generated as

detailed in the submitted document.

Messages and channels of communication were derived. Message content has been crafted in such a

way that it produces relevant and take-home messages intended to create awareness, increase

knowledge, change attitudes and practices in relation to HCWM.

Section 4: Strategy Implementation Plan

The implementation plan was adjusted to reflect changes made to the whole document and putting

into consideration reasons why the previous communication strategy was not implemented. One of

the approaches that has been usedinvolves making SMART objectives thereby allowing even small

groups to select what they can do in a measurable way.

Section 5: Monitoring and Evaluation

This section did not have clear indicators for monitoring. The consultants worked in consultation

with the Ministry of Health (MoH) and Ministry of Environment and Forestry waste management

technical teams and communication specialists to generate clear indicators against which

implementation of the communication strategy will be monitored and evaluated.

3.2 Task II Finalization of theNational Guidelines for Safe Management of Health Care

Waste, 2011

The consultants used the following approaches to finalize the National Guidelines for Safe

Management of health care waste;

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Step 1: Reviewed each section of the existing national guidelines for safe management of health care

waste to internalize the content. As part of the review, content that had been overtaken by events

was identified and ear-marked for deletion and/or updating.

Step 2: Reviewed the 2017 report entitled ‘Report on the Review of the Kenya National Guidelines

for Safe Management of Health Care Waste, Injection Safety and Safe Disposal of Medical Waste

National Communication Strategy and the Health Care Waste Management Standard Operating

Procedures (SOPs)’ and captured the gaps and accompanying recommendations.

Step 3: Using a template specifically developed for purposes of this assignment, the consultants

mapped the gaps and recommendations against specific sections/chapters in the National Guidelines

for Safe Management of Health Care Waste that needed to be updated as elaborated on in Annex V.

Step 4:Reviewed the WHO blue book, Stockholm convention and SAICM strategy for achieving

best practices in health care waste management and other relevant source documents such as

reports generated by teams implementing GEF/UPOPs Project on introducing best available

technologies for treating health care waste at selected health facilities in Kenya, Ghana, Madagascar

and Tanzania to help generate content to fill the missing gaps.

Step 5: Conducted key informant interviews with representatives of manufacturers, NEMA, service

providers supplying BATs and BEP services in Kenya and had the information collected used to focus

on specifications for waste treatment technologies used in Kenya.

Step 6:Conducted key informant interviews with hospital managers in Kisumu, Nakuru, Nairobi and

Mombasa counties to get feedback on appropriateness of technical specifications for waste

treatment technologies.

Step 7:For areas where standards had not yet been set, such as minimum health care waste

management training requirements and core competencies by cadre of staff and handling of highly

infectious dead bodies during disease outbreak situations, consultations were made with the Ministry

of Health officials and members of the HCW technical working groups at the Ministry of Health and

NEMA and further reference made to relevant WHO policy and/ or technical documents to get

their views and this helped come up with concrete position regarding what was acceptable.

Step 8: Using information gathered from document reviews and key informant interviews, content

that was used to update the guidelines was generated.

Step 9: Updating of the National Guidelines for Safe Management of Health Care Waste was thus

done.

A summary of what was updated/ Changes made to the document

The following sections were written afresh: Acknowledgement, forward and executive summary.

Environmental aspects were given more visibility in these sections.

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Chapter 1: Was updated to capture/ include content (1.7) that brings out the relationship between

health care waste, environment and ill health.

Chapter 2: Situation analysis had been missed out completely. Content was generated based on

findings of the 2017 health facility assessment.

Chapter 3: had relevant legal framework concerned with chemicals, heavy metals, trans-boundary

movement of hazardous waste including E-waste, laws such as the sustainable solid waste

management bill and related policy that creates a favorable environment for the waste minimization,

reuse and recycling added.

Chapter 4: Characteristics of HCW

• Not much was changed

Chapter 5 (previously 6): Health Care Waste Management Planning

Has been updated as outlined here-below:

• WHO core principles for sustainable health care waste management have been integrated

into the documentas a tool for leveraging partner resources.

• Roles and responsibilities of county and national level staff had not been stated in the

previous version. These roles have now been clarified. In addition, clarity of roles and

responsibilities of facility based teams has been improved on.

• Specifications for waste transport vehicles have been added.

Chapter 6 (previously 7): Waste Minimization, Segregation, Recycling and Reuse

Has had information flow improved, content on waste segregation added and pictorials included to

improve understanding. Information on bills that guide waste minimization efforts has been added.

• Added Figure 1: Samples of reusable bottles.

• Added Figure 2: Receptacles for recyclable plastics.

• Added Table 2: Symbols for different types of recyclable and non-recyclable plastics.

• Added Figures 3: Symbols for paper recycling.

• Added Figure 4: Items for waste segregation.

• Added Figure 5: Segregation of non-infectious, infectious and highly infectious waste

according to color codes.

• Added Figure 6: Waste segregation chart.

Chapter 7 (previously 8): Organization, Collection, Labeling, Handling, Containment,

Transport and Storage

Pictures have been added to communicate safe and secure storage requirements and areas that

should be audited and why have been clarified.

• Added Figure 7: Key messages for ancillary workers in charge of waste collection.

• Added Figure 8: Signage for waste storage area.

• Added Figure 9: Storage area for sharps waste.

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• Added Figure 10: Chemicals stored on a shelf – acids.

• Added Figure 11: Safety cabinet for flammable substances.

• Added Figure 12: Flammable substances inside a safety cabinet.

• Added Figure 13: Liquid chemicals in a chemical-resistant plastic container.

• Added Figure 14: A Sample sketch of a Chemical Storage Area.

• Added Figure 15: Labelling on exterior of storage rooms and facilities for chemicals.

• Added Figure 16: Closed vehicle for transporting waste.

• Added content on Trans-boundary movement and Transfer of Waste.

• Added guidance on Health Care Waste Tracking.

• Added guidance on monitoring waste handling, storage and transportation (Execution of

Legal Notice No. 121; Waste Management Regulations, 2006).

• Added Table 3: Areas for HCWM auditing and parameters to assess.

Chapter 8. Treatment and Disposal of Health Care Waste

This chapter has been updated by adding new content as outlined here-below;

• Added content on best burning techniques.

• Added content on alternative techniques.

• Added content on how to operate an incinerator, autoclave and shredder.

• Inserted an illustration of different parts of an autoclave.

• Added content on steps for selecting the most appropriate technology.

• Inserted content including a table (Table 3) on effective treatment and disposal methods for

chemicals and pharmaceutical waste.

• Inserted content on safe and dignified burial of highly infectious bodies.

Chapter 9: Summary of Recommended Actions for Health Care

Waste Management along the stream


• Added table 9.12 on Electronic and Electrical Wastes (E & E Wastes).

• Added content on Classification of Electronic and Electrical Wastes.

• Added content on hazardous elements found in electricals and electronics.

• Added relevant components of E-waste guidelines for the Department of Environmental

Health and Sanitation in the Ministry of Health (MoH) (Focused on guidelines for Managing

E-waste in the Health Sector).

• Added a section on management of asbestos. Health workers across counties specifically

requested that new guidelines should include guidance on managing asbestos as they tend to

get stuck each time they need to dispose of asbestos.

• Added content on Extended Manufacturer Responsibility – Operations of Producer

Responsibility Organizations.

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Chapter 10: Requirement for Occupational Health and Safety Practices

• Not much was changed.

Chapter 11: Training (previously 10)


• Added content including Table 6 on recommended training programs for different cadres of

staff. Provided guidance on arrangements for keeping knowledge and skills of health

workers up-to-date by sharing minimum training requirements by cadre of staff and assigned

roles.

Chapter 12: Contingency and Emergency Planning

• Not much was changed.

Chapter 13: Environmental Audit Process for Health Care Facilities and Monitoring

• This chapter has been updated by adding content on roles and responsibilities of officers at

national, county, sub-county and health facility levels in monitoring HCWM activities.

Chapter 14 (previously 13): Collection and Disposal of Waste Water from Health Care

Establishments

• Updated as appropriate.

Chapter 15: Emission limits

• This chapter is newly created. It provides emission limits to guide facilities using methods

for disposing of waste. This is aimed at minimizing pollution of the environment.

3.3 Task III Finalization of the HCWM Standard Operating Procedures (SOPs)

The consultants used the following approaches to finalize the HCWM Standard Operating

Procedures(SOPs);

Reviewed the 2017 report entitled “Report on the Review of the Kenya National Guidelines for Safe Management of health Care Waste, Injection Safety and Safe Disposal of Medical Waste National Communication Strategy and Health Care Waste Management Standard Operating Procedures (SOPs).

Reviewed global guidance – including conventions and multilateral agreements on chemicals and HCWM; specifically Stockholm and Minamata conventions and the SAICM strategy. The review captured relevant provisions of the conventions and strategies, confirmed best practices and applied these in updating the guidelines.

Reviewed findings of health facility assessment on HCWM practices to identify gaps and concerns.

Conducted consultative meetings and calls with the MoH officials.

Conducted consultative virtual meetings with operational level staff.

Used flow charts to appreciate the steps captured.

The following SOPs weredeveloped;

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i. SOPs clarifying mandate, roles and responsibilities of national, county and sub-county level staff

in managing health care waste.

ii. SOPs for selecting appropriate waste treatment technologies for use at different health facility

levels.

iii. Generated a table on steps for segregating waste according to color codes.

iv. SOPs for trans-boundary movement of health care waste.

v. SOPs for maintaining functionality of diesel fired incinerators.

vi. SOPs for waste water de-chlorination.

vii. SOPs for training staff in managing chemicals.

viii. SOPs for harmonizing assessment of chemicals for potential risks.

ix. SOPs for managing chemical waste.

x. SOPs for replacing mercury containing devices.

xi. SOPs for mapping sites contaminated with chemical waste.

In addition, all SOPs that favour use of polluting technologies such as those recommending use

of small scale incinerators were eliminated.

3.4 Task IV Training of health workers in application of the I-RATand WHO Blue Book

The Individualized Rapid Assessment Tool (I-RAT) (see annexIII) is a tool used to audit HCW

management systems and practices at health facility level. The tool is individually administered,

allowing for its use both as a Rapid Assessment Tool to benchmark the current/ existing situation

and a quality improvement tool which findings could be used to track progress and institute

corrective action towards improving the situation. The tool assesses several areas.

3.4.1 Preparations for training of health workerson I-RAT

It is a recommended best practice by WHO that health workers selected to be trained on the IRAT

are first exposed to general training in health care waste management to help them appreciate how

I-RAT relates to best practices in managing health care waste. To impart desirable and appropriate

knowledge, skills and attitudes necessary for proper management of HCW to the learners using

standardized training materials and recommended approaches, several steps were undertaken.

Preparationsfor the training: The consultants prepared a lesson plan for each of the topics to be

covered in the training and allocated appropriate time for each topic. Training approaches /methods

for each of the topics to be covered in the training session were outlined. Training materials were

developed using the WHO Blue book as the basis.

3.4.2 Selection of participants

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The responsibility of selecting the participants was given to the Ministry of Health, working closely

with the UPOPs Project Management Unit, as these were the Ministry of Health employees. Priority

was given to the officers working in the public health sector in the four (4) UPOPs Project Counties

of Nairobi, Mombasa, Kisumu and Nakuru. The Ministry of Health, however, extended the target

counties for the training to include Busia and Migori Counties, with a part of the participants being

picked from both the Ministry of Health and Ministry of Environment and Forestry Headquarters.

3.4.3 Training of health workers

A total of 50 health workers, mainly Public Health Officers and Nurses were trained in two separate

three-day workshops.The training was carried out according to the training program attached herein

(seeannex 1). Training methods used included mini-lectures using power point presentations,

brainstorming sessions, question-answer sessions, group reading and practical sessions at selected

practicum sites.

3.4.4 Generating a post training plan for follow-up on tool application related activities

within the respective counties

The purpose of training health workers on I-RAT administration was to enhance their capacity and

ability to carry out audits of health facilities on HCW management using the tool. It is expected that

if this tool is administered properly and successfully at the individual health facilities, thereby

identifying specific aspects/ areas that require improvement, then the health facilities in the four

project counties will in the long run attain high standards of HCW management.

As part of the next steps following the successful training, including practical exposure of the

learners to the application of the I-RAT at the Nakuru Level 5 Hospital, the learners were put into

working groups according to the counties where they work. They were given guidelines on how to

generate an action plan that will guide the roll-out of the implementation of HCWM audits and

assessment of POPs reduction achieved using the I-RAT. The action plan will capture dates for the

visit of the individual health facilities, target health facilities, responsible persons ( to include the

Consultant and the MOH representative ), and activities to be carried out during the performance

monitoring visits, kind of reports to be written and any other relevant/ necessary issues to be

included.

Examples of activities expected to be carried out by the trained health care workers and against

which they will be evaluated may include - ability to ask questions precisely to the respective officers

responsible for various HCWM activities, ability to fill in the tools on receiving the responses from

the interviewees, ability to make proper observations on various current HCWM practices etc.

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3.4.5 Recommendations on how best the training can be scaled up:

According to recommendations of the African Union for achieving sustainable development goals,

scaling up of health interventions is based on five strategic shifts as follows;

i. Prioritizing geographical regions with the highest burden of the problem at hand; for

example in the case of HCWM, regions/ areas with worst HCWM practices will be given

highest priority.

ii. Within each geographical region/ area, health facilities that are worse off in terms of HCWM

practices will have their health workers trained first.

iii. Initially, each county will be requested to come up with its plan for scaling up training and

these options will be evaluated for effectiveness. Interventions with the highest impact in

scaling up training will be adopted and those that have low yields will be dropped.

iv. Counties with other on-going training activities on which I-RAT training can ride will also be

explored for quicker scaling up of the training.

v. Counties that show good post training impact (i.e. are accountable for results) will be given

more support to scale up their training.

Using the above guidance and in consultation with stakeholders, including the Ministry of Health

officials and county-based stakeholders, each county will be expected to develop an initial draft

training scale up plan. The final plan will be developed after the first outcome evaluation exercise

that will be done in the company of the MoH supervisory personnel in each of the counties whose

officers have been trained.

3.4.6 Quality Assurance Measures

To ensure quality assurance, several measures were taken, namely;

i. Generating content from internationally accepted guiding documents(e.g. use of 2016

WHO/UNEP materials, WHO blue book etc).

ii. Engaging stakeholders in validating finished work.

iii. Pretesting developed training materials

iv. Health workers trained on I-RAT were taken out to a nearby health facility ( Level 5

Hospital) for practical application of the skills acquired during lecture sessions.

3.4.7 Logistics and Support Required for the Assignment

The following resources were required for the assignment – transport for the participants during the

I-RAT training and field visits for purposes of collecting relevant information from stakeholders for

the review work; logistics for consultative meetings with hospitals on content of SOPs, guidelines

and communication strategy and on roles and responsibilities of key staff responsible for managing

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waste; subsistence allowance during field work; workshop for the development of training materials;

stationery for development of data collection tools and printing of draft and final documents;

internet services, airtime for coordination purposes, especially during field work which would call for

booking of appointment with the stakeholders and highlighters, among others. In addition,

consultants travelled to a training venue in Nakuru County to train 50 health workers on I-RAT and

its application.

3.4.8 The Client

The direct beneficiaries for this assignment were/are the people and the government of Kenya. The

MoH and MoE&F werejust executing a mandate given by the Government of Kenya while the

indirect Client was the Ministry of Environment and Forestry by virtue of being the Implementing

Agency for the Project. UNDP served as the administrative partner for the beneficiary and GEF

Implementing Agency.

3.4.9 Reporting Obligations

The assignment was jointly supervised by the Ministry of Environment and Forestry ( UPOPs Project

Management Unit), Ministry of Health and UNDP Kenya Country office. Each deliverable was to be

submitted by the MASAHESS Lead Consultant to the UPOPs Project Management Unit, who

received the documents on behalf of the implementing agency and beneficiary. The UPOPs PMU

would thenpass on the documents to the UNDP country office. The MoE & Forestry reviewed

technical aspects related to environment, pollution and management of chemicals and heavy metals

and made necessary comments/recommendations and then passed on the documents to the MoH.

The MoH would then review the entire documents, make comments/recommendations and pass on

the documents to the UNDP who would then pass on the reviewed document to MASAHESS Lead

consultant to address raised issues. Once all issues had been addressed, the documents were

presented to stakeholders for validation. Issues raised during validation were addressed and final

documents submitted to UPOPs Project Management Unit for forwarding to the UNDP country

office. All activities were carried out in compliance with Covid-19 precautionary measures/

requirements and where necessary, alternative virtual means of communication/discussion were

explored.

The activities and progress of this assignment were reported to the Project Management Unit, with

representation from the Ministries of Health and Environment and Forestry, from time to time. The

reporting was done both bi-monthly and monthly.

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3.4.10 Conclusions

Three documents were specifically reviewed to establish gaps in national guidance, namely; the

Kenya National Guidelines for Safe Management of Health Care Waste; Injection Safety and Safe

Disposal of Medical Waste National Communication Strategy and the Health Care Waste

Management Standard Operating Procedures (SOPs). All areas identified for updating were

successfully updated, bringing strategic guidance in the area of health care waste management up-to-

date with global recommendations on this subject using a widely consultative process. All updated

documents were validated at a national stakeholders meeting and finalization done factoring in raised

concerns. The documents are now ready for dissemination. To increase compliance with

recommended standards, a team of Public Health Officers and Nurses was trained to provide

support for continuous quality improvement using the I-RAT tool. Trained personnel should be

supported by the MoH to excel in this assigned role through periodic technical supportive

supervision. There will be need to monitor implementation of the updated communication strategy

as the previous strategy had very low levels of implementation.

3.4.11 Recommendations

i. The new/ revised copies of the National Guidelines for Safe Management of Health Care

Waste, HCWM Standard Operating Procedures (SOPs) and Health Care Waste

Management National Communication Strategy should be uploaded on the web.

ii. The MoH should actively disseminate the new/ revised copies of the National Guidelines for

Safe Management of Health Care Waste, HCWM Standard Operating Procedures (SOPs0

and Health Care Waste Management National Communication Strategy.

iii. The Covid-19 home based care guidelines currently under development should capture

guidelines for managing health care waste in homes.

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Annex 1: Timetable for training health workers on the I-RAT and WHO Blue

Book – 15th March, 2021 to 20th March, 2021; Empolos Hotel, Nakuru Town

Day 1: 15th March, 2021

Time Activity/ Topic Facilitator

8.00 – 8.30 AM Registration MOH/MoE & F

8.30 – 9.00 M Welcome remarks, Objectives MOH/ MoE & F

9.00 – 9.20 AM Pre-test Consultants

9.20 – 9.50 AM Overview of the WHO Blue Book: a WHO publication on Safe Management of Wastes from health care activities, 2nd edition,

2014.

Okweso, J.A.

9.50 – 10.20 AM Health care waste and its concerns Okweso, J.A.

10.20 – 10.50 AM

WHO recommendations for establishing sound health care waste management systems in countries.

Okweso, J.A.

10.50 – 11.50 AM Principles of health care waste management: minimization, recycling and re-use, segregation and color coding, collection and handling, storage, treatment, transportation and disposal

Masembe, V.

11.50 – 11.10 AM Break

11.10 – 12.10 PM Procedures for receiving, tracking and recording waste

Okuku, F.

12.10 – 1.00 PM Organization of a health care waste management system at a health facility (Policy and Planning)

Masembe, V.

1.00 – 2.00 PM Lunch

2.00 PM - 2.45 PM Staff Training Okuku, F.

2.45 PM – 3.45 PM Occupational health and safety: exposure management, use of PPE and vaccination of health workers

Okweso, J.A.

3.45 – 4.45 PM Auditing, Monitoring, Evaluation and taking corrective action

Masembe, V.

17

4.45 – 5.45 Discussions Consultants


8.00 – 8.30 AM Registration MOH/MoE & F

8.30 – 9.00 AM Re-cap Consultants

9.00 – 9.30 AM Introduction to WHO Health Care Waste Management Rapid Assessment Tools (RATs}: objectives and assumptions, description of the tools, who uses the tools, how to use the tools, stakeholder engagement and selection of facilities

Masembe, V.

9.30 – 10.00 AM Preparation for field work and getting started.

Okuku, F.

10.00 – 10.15 AM Break

10.15 – 10.45 AM Tools A, B1, B2, and tool C Masembe, V.

10.45 – 12.00 NOON The Tool D series: D1, D2, D3, D4, D5, and input Quest D; Tool E.

Masembe, V.; Okweso, J.A.

12.00 NOON – 1.00 PM Summarizing results Masembe, V.; Okweso, J.A.

1.00 – 2.00PM Lunch

2.00 – 3.00 PM Practicing filling in of tools in groups Masembe, V. / Okweso, J.A.

3.00 – 4.00 PM Introduction to the I-RAT( overview and step-by-step discussion of the I-RAT)

Okweso, J.A.

4.00 – 5.00 PM

I-RAT - Understanding the Content, Application and Scoring

Masembe, V.

5.00 – 6.00 PM Teaming for field visit Okuku, F.


8.00 – 8.30 AM Registration MOH/MoE&F

8.30 – 9.00 AM Re-cap Consultants

9.00 – 9.30 AM Travel to health facility Okuku, F.

9.30 – 12.30 PM Application of I-RAT tool and giving feedback All Consultants

12.30 – 1.30 PM Travel Back to training venue & lunch All Consultants

1.30 – 3.00 PM Report writing All Consultants

3.00 – 4.30 PM Presentation of reports All Consultants

4.30 – 5.00 PM Post test All Consultants

5.00 – 6.00 PM Way forward. Okweso, J.A.; Masembe, V.

18

Annex 11a):Gap analysis - Summary of Gaps identified from the review of the 2010

Injection Safety and Safe Disposal of Medical Waste National Communication Strategy

Definition of core health issues: the document only covered injection safety issues and left out

broader aspects of health care waste management. Core HCWM communication issues had

therefore not been documented.

Situationanalysis: Although the situation analysis had earlier been done, it needed to be updated

to reflect the HCWM situation at the health facilities in the country.

Identification of necessary change to solve the problem: The document was not

comprehensive in respect to identification of the change that was necessary to solve the problem.

This is because change identification was done by largely focusing on aspects of injection safety and

promotion of use of alternative formulations leaving out important aspects of health care waste

management.

Communication objectives: Objectives generated in the document were not directed at specific

target audiences as should have been the case. Some of the objectives were broad (Not SMART)

and may have been difficult to achieve. The field guide for developing a health communication

strategy (by John Hopkins Bloomberg University) recommends that target objectives are

directed at individual target audiences so that outcomes of interventions are better managed.

Factors predisposing health workers to identified core health care waste management

issues were not well elucidated in the situation analysis leaving out root causes that should have

been captured.

• The document fell short of segmentation of health workers, which if done would improve

targeting. For example, waste handlers would have been targeted to use personal protective

equipment when handling waste while prescribers would be targeted to adhere to treatment

protocol, etc.

19

• Positioning was not done according to provided guidelines. The guidelines require that a

long term image that the program would be remembered for and a promotional image that

stands out from others calling for action - should be selected.

• The document did not clearly spell out key behaviors that must be monitored when

matched against target audience – for example, the need to observe and/or insist that a

waste handler puts on personal protective equipment while handling waste.

• Some of the messages in the document were not comprehensive or were incomplete, lacked

a promise and did not have lasting impressions or call for action.

• The document did not provide for/capture sequencing of activities to indicate when the

expected knowledge, skills, beliefs, attitude change and behavior would be realized.

Immediate, intermediate and long term achievements did not come out clearly.

• In the document linkages of communication activities to services were generally not well

highlighted. It is advisable to tag communication activities to services.

• The document did not have a comprehensive and well developed M & E plan which is critical

in undertaking monitoring and evaluation activities.

Suggestions from the UPOPs Project Management Unit (PMU) review team for

consideration/incorporation

For purposes of updating the document, the team suggested that the consultants do

the following;

• Include in the executive summary content on pollution, chemicals, emission limits and how

these affect the environment and human health.

• Highlight open burning as a serious threat to public health and the environment.

• Bring out mercury containing products as items under control.

• Provide key messages at the end of each section.

• Illustrate critical parts of an incinerator that meet temperature and smoke emission

requirements.

• Add pictures/images to improve understanding.

• Include important laws, regulations and policies so these get to be known.

20

Annex 11b): Gap analysis - Summary of Gaps Identified from the Review of the

HCWM Standard Operating Procedures (SOPs)

Compliance of HCWM SOPs with the BEPs under the Basel Convention

• The SOPs did not cover shipment of hazardous waste e.g. in respect to the need for written

consent from export, transit and import countries.

Compliance of HCWM SOPs with the BATs under the Stockholm convention

• The SOPs still recommended use of small scale incinerators which cannot meet temperature

and smoke emission requirements.

• SOPs did not provide guidance on use of centralized facilities/systems for waste treatment

and/or disposal as is provided for in the global guidance under the Stockholm convention.

• The SOPs did not provide guidance on how to treat highly chlorinated waste water.

• The SOPs did not provide guidance on secondary measures against formation of UPOPS

Compliance of HCWM SOPs with the BEPs under the Minamata convention

• The SOPs did not cover the Minamata convention recommendation on putting a ban on new

mercury mines nor did they point out the role of other relevant government agencies e.g.

the Ministry of Environment and Forestry in this regard.

• Although the SOPs did require Kenyan hospital management to strive to make health

facilities mercury free, the information provided on proper procedures for phasing out

mercury were scanty. Detailed guidance has now been provided.

Compliance of SOPs with BEPs recommended by the WHO bluebook, UNEP and

SAICM regarding management of chemicals

21

• The SOPs did provide information on safeguarding the health of women and children against

chemical exposures before conception, through gestation, infancy, childhood and

adolescence.

• The SOPsrequiredupdating in respect to guidance recommending discharge of chemicals into

a sewer.

• The SOPs had not achieved/complied with recommendations of SAICM, WHO blue book

and BEPs that the country should have a list of prioritized chemicals for assessment. Such a

list has been generated.

• The SOPs did not cover/ reflect contaminated sites and remedial measures put in place as

recommended under BEPs by the WHO blue book, UNEP and the SAICM strategy.

• The SOPs did not provide for putting in place a proper system for monitoring impacts of

chemicals on health and the environment. They lacked guidance on a system for harmonized

risk assessment of chemicals.

• Although some pollution limits had been provided within the SOPs, the guidance was silent

about the national pollutant release and transfer registers as recommended under the BEPs

by the WHO blue book, UNEP and SAICM strategy – for every country.

• The SOPs did not comprehensively cover/outline the provision recommending the existence

of a system for emergency preparedness and response to chemical accidents.

• The SOPs did not cover provision for training of personnel in liability and compensation

schemes in relation to damage to human health and the environment.

• The SOPs did not provide adequate guidance in respect to designing of appropriate storage

areas for chemicals. The SOPs did not comprehensively cover labelling of chemicals and

more needed to be done.

• The SOPs were deficient in respect to provision of guidance on safe use of individual

chemicals.

Suggestions from the UPOPs Project Management Unit(PMU) Review Team for

Consideration/Incorporation

• To include in the executive summary content on pollution, chemicals, emission limits and

how these affect the environment and human health.

• Highlight open burning as a serious threat to public health and the environment.

• Bring out mercury containing products as items under control.

22

• Provide key messages at the end of each section.

• Illustrate critical parts of an incinerator that meet temperature and smoke emission

requirements.

• Add pictures/images to improve understanding.

• Include important laws, regulations and policies so these get to be known.

Annex 11c): Gap analysis - Summary of Gaps Identified from the Review of

theNational Guidelines for Safe Management of Health Care Waste

• Lack of long term waste management strategies (technological, infrastructure, and

human resource development).

• Lack of standardized frequency of conducting needs assessment on various

components of HCWM in order to remain current.

• Roles and responsibilities of officers at national, county and sub-county levels were

not well defined.

• There was scanty/limited guidance on management of electronic and electrical

waste.

• Some relevant pieces of legislation on waste management and/or environmental

conservation had not been captured in the guidelines.

• Some relevant policies on waste management were not captured in the guidelines.

• The guidelines left out certain relevant strategies on waste management and/or

environmental conservation.

• The guidance on planning for monitoring was deficient (not comprehensive) and did

not capture details of parameters to be monitored.

• The content on how to identify recyclable items and proper procedures for

segregating them such as use of symbols for identifying plastic bottles for recycling

was inadequate.

• Information on importance of waste segregation was inadequate. There was

incomplete guidance on training of health workers in waste segregation including

who should be trained as well as on frequency of waste collection from each waste

generation point.

• Guidance to health care workers on how to start waste segregation was lacking.

23

• The provision of illustrative images showing how different categories of waste can be

stored in a storage facility, especially with respect to arrangement for storing

chemicals in a manner that minimizes risk of cross reaction was not comprehensive.

• Guidance on payment for waste collection especially to health facilities that use

external waste collectors was lacking in the guidelines. There was no list of available

licensed HCWM service providers as should be the case.

• Guidance on how to put in place a regular system for monitoring transport and

storage conditions was inadequate.

• There was no guidance on how to select waste treatment technology i.e. that shows

parameters to evaluate while doing so; e.g. characteristics of the waste, availability

and cost of utilities and consumables, initial operational and preventive maintenance

costs, skills among staff etc.

• There was lack of general information on processes for treating health care waste

making it unlikely that managers would be in a position to plan, supervise and

maintain selected equipment efficiently.

• The guidance on suggested options that could be used to treat/dispose of health

care waste under different methods did not provide sufficient step-by-step

information to users of the guidelines.

• The information provided by the guidelines on waste disposal was not

comprehensive enough and lacked details on processes for completing waste

disposal tasks.

• In respect to management of waste water and acceptable limits of emission of

atmospheric pollutants, limits of emission of atmospheric pollutants had not been

provided.

• The guidelines lacked specific guidance on financial investment and operational

resources dedicated to HCWM. The chapter on planning did not provide guidance

on clear delineation of responsibilities of funding that takes place at the planning

stage across levels of care (national, county, sub-county levels).

• The guidance provided on capacity building was limited. There was no indication for

standardized HCWM courses for different cadres of staff involved in managing

health care waste.

• Guidance on management of asbestos waste was missing.

Suggestions from the UPOPs project Management Unit(PMU) review team for

consideration/incorporation

• Inclusion of effects of HCW on human health and the environment.

24

• Additional relevant laws, policies, regulations and strategies on HCWM.

• Additional relevant content from Stockholm, Basel and Minamata conventions and the

SAICM strategy.

• Inclusion of specifications for approved HCW transport vehicles.

• Frequency of training for facility health care waste management committee.

• Inclusion of guidance on what is recyclable.

• Inclusion of best available techniques for combustion.

• Inclusion of air pollution compliance requirements.

• Considerations when selecting a non-incineration technology for waste treatment.

• Inclusion of a picture of an autoclave.

• Addition of insurance issues under contingency planning section.

Annex 111: Individualized Rapid Assessment Tool (I-RAT)

Individualized Rapid Assessment Tool • Healthcare Waste Management

Put yes/no responses in the yellow spaces in column C; use "y" for yes and "n" for no. Put text or numerical responses in the yellow spaces in column F. Numerical answers should be in the units specified and should not

include any text. The final score is shown at the bottom.

C F Name of the person collecting the data Date of assessment

PART I. INITIAL INTERVIEW

BASIC DATA Name of the healthcare facility: Address Telephone/Fax: Description of healthcare facility: Number of beds: Average occupancy rate (in percent): Average number of outpatients per day: Names of persons interviewed: Lengths of service of persons interviewed in healthcare

facility:

#

"y" or "n" WeightValue Score Text or Numerical Input

25

ORGANIZATION 1 Is there a person in charge of healthcare waste

management? 5 0

If yes, write the name of the person in charge: 2 Is there a permanent committee that deals with healthcare

waste management and meets on a regular basis? 1.5 0

3 Are the roles and responsibilities regarding healthcare

waste management made clear to the staff? 1.5 0

POLICY AND PLANNING

4a Does the healthcare facility have written policies dealing with healthcare waste management?

2 0

4b Does the healthcare facility have written plans, manuals, or

written procedures dealing with healthcare waste management?

2

5 Are the policies, plans, manuals, and/or written procedures

consistent with national laws, regulations, and any permits? 3.5 0

6 Does the healthcare facility have a plan for recycling or

waste minimization? 1.5 0

7 Does the healthcare facility policy explicitly mention a

commitment to protect the environment? 0.5 0

8 Is the healthcare facility mercury-free? OR Does the

healthcare facility have a policy or plan to phase out mercury?

1.5 0

TRAINING 9 Does the facility have a training program on healthcare

waste management for managers, health professionals, waste workers, and auxiliary staff?

5 0

10 Does the training program include relevant national laws

and regulations? 1 0

11 Does the training program include the following:

segregation, collection and handling of sharps waste, use of proper containers and bags for infectious waste, color coding, 3/4th fill rule, use of personal protection equipment by waste workers, transport, storage, and treatment?

2 0

12 Are the staff trained, including new staff when they begin

their employment? 3 0

13 Is there refresher training at least once a year? 1 0 OCCUPATIONAL HEALTH AND SAFETY

14 Do the policies and plans related to healthcare waste management include occupational health and safety (including policies for needle-stick injuries or exposure to blood splatter)? OR Does the facility have separate occupational health and safety policies that include needle-sticks and exposure to blood?

3 0

15 Are the workers who collect, transport and treat waste

provided with the proper personal protection equipment (gloves, shoes or boots, and aprons)?

2 0

16 Are the health workers and workers handling waste given

hepatitis and tetanus vaccinations? 2 0

MONITORING, EVALUATION AND CORRECTIVE

ACTION

26

17 Is there a system of internal monitoring or inspection to determine compliance with healthcare waste management requirements?

1 0

18 Is there a system of taking corrective action when

practices or technologies related to healthcare waste management do not meet the requirements?

1 0

19 Are policies and/or plans reviewed or updated at least

once a year? 0.5 0

FINANCING

20 Does the facility have an annual allocation in its budget for healthcare waste management?

4 0

21 Is the current budget sufficient for healthcare waste

management? 2 0

Budget for healthcare waste management (in the local

currency):

22 Does the facility have a long-term financing plan or

mechanism to cover the costs for sustainable healthcare waste management?

0.5 0

PART II: POST-INSPECTION TOUR INTERVIEW CLASSIFICATION AND SEGREGATION List the types of waste produced in the facility:

23 Are the wastes properly segregated at the source according to different categories?

5 0

24 Are the health workers familiar with the classification and

segregation requirements? 2 0

WASTE GENERATION DATA

25 Have the amounts of total waste and infectious waste produced per day been measured? If yes, put the figures below; if no, provide the best estimate below.

1 0

Total waste (infectious and non-infectious) generated on

average (in kilograms per day):

Total waste minus recycled or reused waste (in kilograms

per day):

Infectious waste generated on average (in kilograms per

day):

percentage of infectious waste relative to total waste: 0.5 0 kilograms infectious waste per bed per day: kilograms unrecycled waste per bed per day: 0.5 0.5 COLLECTION AND HANDLING Describe the types of containers used for each separated

category:

26 Are used syringe needles collected WITHOUT recapping? 2 0 27 Is sharps waste collected in sharps containers or

destroyed using needle destroyers? 5 0

28 Are the sharps containers puncture-resistant and leak-

proof? OR Are the needle destroyers approved under existing regulations or standards?

2 0

29 Are the sharps containers filled only 3/4th full? OR Are the

needle-destroyers well maintained? 2.5 0

27

30 Are the sharps containers or needle-destroyers always available?

1 0

31 Are the sharps containers or needle-destroyers properly

placed such that they are easily accessible to personnel and located as close as possible to the immediate area where the sharps are used?

1.5 0

32 Do the health workers know what to do in the event of a

needle-stick injury? OR Are the health workers familiar with the policy on needle-stick injuries?

1 0

33 Are the plastic bags used for non-sharps infectious waste

of good quality? OR Do you use specialized containers that are disinfected, cleaned and reused and do not require a plastic bags?

1 0

34 Are plastic bags always available? OR are the specialized

containers described in #33 always available? 1 0

35 Are the bag holders or hard containers holding the plastic

bags of good quality? OR Do you use specialized containers that are disinfected, cleaned and reused and do not require a plastic bags?

0.5 0

36 Are the infectious wastes removed at least once a day? 1 0 37 Do the waste workers know what to do if sharps or

infectious waste is accidentally spilled? OR Are the waste workers familiar with the spill clean-up plans?

0.5 0

COLOR CODING AND LABELING

38 Does the healthcare facility use a system of color coding for different types of wastes?

3 0

39 Are the colors of the waste containers consistent with the

color coding? 2 0

40 Are the infectious waste bags colored or labelled in

accordance with the policies or regulations? 1 0

POSTERS OR SIGNAGE

41 Are there posters or signs showing proper segregation of healthcare waste?

0.5 0

TRANSPORTATION INSIDE HEALTH ESTABLISHMENT

42 Is the waste transported away from patient areas and other clean areas?

0.5 0

43 Is the waste transported in a closed (covered), wheeled

transport cart? 1 0

44 Is the transport cart cleaned at least once a day? 0.5 0 STORAGE

45 Does the storage area meet the proper requirements? 1 0 46 Is the storage area kept clean? 0.5 0 47 Are the wastes removed before the maximum allowable

storage time is exceeded? 1 0

HAZARDOUS CHEMICAL, PHARMACEUTICAL AND

RADIOACTIVE WASTE

28

48 Are hazardous chemical, pharmaceutical, and radioactive wastes segregated from infectious and general non-risk wastes? (Put Y in column C if the facilities does not generate these categories of waste.)

4 0

49 Does the healthcare facility have a plan for the treatment

and disposal of hazardous chemical, pharmaceutical, and radioactive wastes? (Put Y in column C if the facilities does not generate these categories of waste.)

1 0

TREATMENT AND DISPOSAL

50 Does the healthcare facility treat its infectious waste (either on-site or at an off-site treatment facility) before final disposal? If infectious waste is not treated before disposal, put N in column C of QUESTION #53b and skip to QUESTION #69.

25 0

51 Are laboratory cultures and stocks of infectious agents

treated within the healthcare facility before being taken away from the facility?

2 0

52 Is there a contingency plan for the treatment of infectious

waste in the event that the treatment technology is shut down for repair?

1 0

53a >> Does the healthcare facility treat its waste on-site? If yes, put Y in column C, make sure column C of QUESTION #53b is left blank, and go to QUESTIONS #54-61. If the healthcare facility treats its waste off-site, put N in column C, make sure column C of QUESTION #53b is left blank, and go to QUESTIONS #63-68. However, if the healthcare facility treats its waste BOTH on-site and off-site, put Y in column C and Y in column C of QUESTION #53b.

53b >> Does the healthcare facility treat its waste both on-site

and using an off-site treatment center? If yes, put Y in column C and answer QUESTIONS #54-68.If the healthcare facility does not treat its waste before disposal, put N in column C of QUESTION #50 and go to QUESTION #69.

For facilities with on-site treatment: Describe the method of treatment used:

54 Is the waste transported safely to the treatment area? 0.5 0 55 Is the treatment area located in a place that is easily

accessible to the waste worker but not accessible to the general public?

0.5 0

56 Does the healthcare facility have a program of regular

inspection and periodic maintenance of the treatment technology?

3 0

57 Is the treatment system clean, operating properly, and well

maintained? 3 0

58 Does the treatment system destroy or mutilate sharps

waste in order to prevent reuse? 1 0

59 Does the healthcare facility use an approved non-

incineration treatment technology such as an autoclave-shredder, integrated steam treatment system, or microwave unit? If yes, put Y in column C and skip to QUESTION # 60.

6 0

29

60 If the facility uses an incinerator: Does the incinerator meet international standards?

3 0

61 If the facility uses an incinerator: Are PVC plastics kept out

of the waste that is burned? 0.5 0

62 Is the waste that is treated in an alternative technology

disposed of in a sanitary landfill? OR Is the incinerator ash buried in a hazardous waste landfill?

1 0

>> If the answer to QUESTION #53a is yes, go to

QUESTION #69. If the answer to QUESTION #53b is yes, answer QUESTIONS #63-68.

For facilities that use centralized off-site treatment: Name of the company that transports the infectious waste: Name and location of the off-site treatment center:

63 Does the transport vehicle meet the regulations or international standards?

2 0

64 Does the healthcare facility keep copies of manifests or

shipment records? 2 0

65 Has a representative of the healthcare facility inspected

the off-site treatment center? 2 0

Describe the method of treatment used at the off-site

treatment center:

66 Does the off-site treatment center use an approved non-

incineration treatment technology such as an autoclave-shredder, integrated steam treatment system, or microwave unit? If yes, put Y in column C and skip to QUESTION #68.

7 0

67 If the answer to QUESTION #66 is no, does the off-site

treatment center use an incinerator that meets international standards?

4.5 0

68 Does the healthcare facility know where the treated waste

or incinerator ash is dumped? 2 0

If yes, described the final disposal of the treated waste or

ash:

WASTEWATER

69 Does the healthcare facility treat its wastewaste (liquid waste) before being released? OR Is the healthcare facility connected to a sanitary sewer that is linked to a wastewater treatment plant?

3 0

70 Does the treated wastewater from the healthcare facility

meet national or international standards? 1 0

TOTAL SCORE = 0