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7/29/2019 Hcwm Summary

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HEALTHCARE WASTES MANAGEMENT IN THE PHILIPPINES:Policies, Rules and Regulations and Status of Implementation 1

GERI GERONIMO R. SAEZ2

BASELINE DATA

With a population of approximately more than eighty (80) million and with the rapidindustrialization, incidences of diseases are increasing. These are the health implications ofenvironmental pollution brought about by the changing climate, lifestyles and moderntechnologies and modified consumer products. Thus, establishment of healthcare facilitiesand institutions are at present an imperative to cope up with the demand on healthcareservices.

Based on the 2003 survey and inspection conducted by the Environmental ManagementBureau (EMB)-Regional Offices (ROs) of the Department of Environment and NaturalResources (DENR) and consolidated by the EMB Central Office (CO), there are about one

thousand seven hundred nineteen (1,719) hospitals and medical centers nationwide andmajority of which are located in the National Capital Region (NCR). Of these, only twohundred twenty seven (227) are registered with DENR-EMB as hazardous waste generator(HWG) in compliance with Republic Act (RA) 6969: Toxic Substances and Hazardous andNuclear Waste Control Act of 1990 as shown in Table 1 below.

Table 1. Regional Distribution of Unregistered Hospitals as Hazardous WastesGenerators (As of 2003)

RegisteredHospitals

UnregisteredHospitals

Total Number ofHospitals

Region

No. % No. % Total % of NationalTotal

Region 1 2 1.65 119 98.34 121 7.03Region 2 2 2.43 80 97.56 82 4.77Region 3 3 1.58 187 98.42 190 11.05Region 4A 8 3.58 215 96.41 223 12.97Region 4B 2 3.92 49 96.07 51 2.96Region 5 12 9.91 109 90.08 121 7.03Region 6 13 18.05 59 81.94 72 4.19Region 7 7 6.60 99 93.39 106 6.16Region 8 1 1.31 75 98.68 76 4.42Region 9 1 1.54 64 98.46 65 3.78Region 10 18 18.94 77 81.05 95 5.52

Region 11 35 31.53 76 68.46 111 6.45Region 12 9 9.47 86 90.52 95 5.52Region 13 8 13.33 52 86.66 60 3.49NCR 98 53.55 85 46.44 183 10.64CAR 8 16.00 42 84.00 50 2.90ARMM 0 0 18 100.00 18 1.05National Total 227 13.20 1,492 86.79 1,719 100.00

Source of data: EMB GPOA: 2005-2010.

1Country Report presented during the 1

stThematic Working Group on Solid and Hazardous Waste on

28-29 February 2008 in Singapore2Chief, Hazardous Waste Management Section, Environmental Quality Division, Environmental

Management Bureau, Department of Environment and Natural Resources, PHILIPPINES


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However, the most recent consolidated compliance data (2007) revealed that there arealready one thousand nine hundred fifty two (1,952) healthcare facilities (medical centers,hospitals and clinics) registered as HWGs nationwide which is about 21.21% of the totalregistered hazardous waste generators that include among others major industries andenvironmental laboratories. Table 2 shows the three (3) year consolidated registration dataon HWGs. It is noticeable that as of December 2007, it exceeded the total number ofhealthcare facilities ad hospitals conducted in 2003 that indicates additional facilities eithernewly constructed or come to compliance with environmental regulation.

Table 2. Number of Registered Hazardous and Healthcare Wastes Generators in thePhilippines (2005-2007)

Year 2005 2006 2007 TotalIndustrial 1,250 1,081 1,720 4,050Healthcare 606 514 232 1,352Percentage (%) 32.65 32.23 13.49 25.02Total Generators 1,856 1,595 1,952 5,403

Grand Total (as of..) 5,657 7,252 9,204Source: EMB Regional Offices

According to the website of the Philippines Department of Health (DOH) [www.doh.gov.ph],the following healthcare facilities and services are being regulated by its Bureau of HealthFacilities and Services (BHFS) in coordination with Centers for Health Developments(CHDs): ambulatory surgical clinic, blood bank, clinical laboratory, dental laboratory, dialysisclinic, drug abuse treatment and rehabilitation center, drug testing laboratory, healthmaintenance organization, HIV testing laboratory, hospitals, kidney transplant facility,laboratory for drinking water analysis, medical facility for overseas workers and seafarers,newborn screening center and psychiatric facility. At present, there are about seventy (70)DOH hospitals, medical centers and reference laboratories nationwide and most of which,

twenty one (21), are located in the NCR (Metro Manila). Among the hospitals and medicalcenters located in Metro Manila are: the Philippine Childrens Medical Center (PCMC), theNational Kidney Institute (NKI), the Lung Center of the Philippines (LCP), the PhilippineHeart Center (PHC), the San Lazaro Hospital (SACCL)-HIV Reference Center, the PhilippineOrthopedic Center (POC), the National Center for Mental Health (NCMH), and the ResearchInstitute for Tropical Medicine (RITM).

With regard to the categories, classification, scale and level of services offered by hospitalsand healthcare facilities, the DOH classified them as government or private, general orspecial and according to service capability. Government hospitals or healthcare facilities areoperated and maintained partially or wholly by the national, provincial, city or municipal, orother political unit, or by any department, division, board or agency thereof while the privateis established and operated with funds through donation, principal, investment, or othermeans, by any individual, corporation, association, or organization. General hospitals ormedical centers provide services for all types of deformity, disease, illness or injury whilespecial hospitals and other healthcare facilities are primarily engaged in the provision ofspecific clinical care and management. A primary, secondary and tertiary care hospital ormedical center or infirmary may provide special clinical services.

With regard to the service capability of hospitals, medical centers and other healthcarefacilities, the following are DOH classification and criteria in relation to the categories, scaleand level of services offered:

a. Primary Care Non- departmentalized that provides clinical care and management on theprevalent diseases in the locality;


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Clinical services include general medicine, pediatrics, obstetrics and gynecology,surgery and anesthesia;

Provides appropriate administrative and ancillary services (clinical laboratory,radiology, pharmacy); and

Provides nursing care for patients who require intermediate, moderate and partia

category of supervised care for 24 hours or longer.

b. Secondary Care Departmentalized hospital that provides clinical care and management on the

prevalent diseases in the locality, as well as particular forms of treatment,surgical procedure and intensive care;

Clinical services provided in Primary Care, as well as specialty clinical care; Provides appropriate administrative and ancillary services (clinical laboratory,

radiology, pharmacy) and

Nursing care provided in the Primary Care, as well as total and intensive skilledcare.

c. Tertiary Care Teaching and training hospital that provides clinical care and management on

the prevalent diseases in the locality, as well as specialized and sub-specializedforms of treatment, surgical procedure and intensive care;

Clinical services provided in the Secondary Care, as well as sub-specialty care;

Provides appropriate administrative and ancillary services (clinical laboratory,radiology, pharmacy); and

Nursing care provided in the Secondary Care, as well as continuous and highlyspecialized critical care.

d. Infirmary

A health facility that provides emergency treatment and care to the sick andinjured, as well as clinical care and management to mothers and newborn babies.

e. Birthing Home A health facility that provides medical service on pre-natal and post-natal care,

normal spontaneous delivery, and care of newborn babies.

f. Acute-Chronic Psychiatric Care Facility A health facility that provides medical service, nursing care, pharmacological

treatment and psychosocial intervention for mentally ill patients.

g. Custodial Care Psychiatric Facility A health facility that provides long-term care, including basic human services

such as food and shelter, to chronic mentally ill patients.

On the healthcare waste generation rates, characteristics, composition, collection, storageand transportation system, Table 3 shows the profile of the three (3) year estimated orreported and consolidated data on generated, treated, disposed and stored healthcarewastes in the Philippines. These data are reported by the registered HWGs to the EMB-ROsin compliance with RA 6969 implementing rules and regulations. For the year 2007, theconsolidated data reported are for the first three (3) quarters. The composition andcharacteristics of healthcare wastes are in conformance with the classification of hazardouswastes under Table 1-1: Classification of Hazardous Waste of the DepartmentAdministrative Order (DAO) 2004-36, the Procedural Manual on Title III of DAO 1992-29Hazardous Waste Management. Healthcare wastes are classified under DAO 2004-36 asMiscellaneous Wastes Pathogenic or infectious wastes and Pharmaceuticals and drugs


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with assigned Waste Numbers M501 and M503, respectively. M501 includes pathologicalwastes i.e., tissues, organs, fetuses, bloods and body fluids, infectious wastes and sharpswhile M503 includes expired pharmaceuticals and drugs stocked at producers and retailersfacilities.

Table 3. Approximate Annual Hazardous and Healthcare Wastes Generated, Treated,Disposed and Stored in the Philippines (tons/year) [2005-2007]

Year 2005 2006 2007Hazardous Wastes Generated 1,670,180.02 11,786,052.68 569,015.92Miscellaneous (Healthcare) Waste 798,033.67 912,724.45 1,945.01Healthcare Wastes Treated 797,495.69 906,908.99 1,866.95Healthcare Wastes Disposed 797,565.88 886,571.94 1,119.86Healthcare Wastes Stored 475.21 26,425.24 2,879.24Hazardous Wastes Treated 1,095,339.20 1,473,129.92 241,073.50Hazardous Wastes Disposed 956,749.40 1,051,021.53 618,802.95Hazardous Wastes Stored 660,494.79 2,093,431.31 84,304.42

Source: EMB Regional Offices

Although other hazardous wastes are classified under miscellaneous waste such as M502(Friable Asbestos Waste), M504 (Pesticides), and M505 (POPs-persistent organicpollutants), most and majority of the quantities quarterly reported belongs to M501 and M503.Collection and transportation of these wastes are regulated and requires the necessaryregistration of hazardous waste transporters from the EMB-CO and secure the requiredpermit to transport processed and issued by the EMB-RO including the submission of themanifest of each transport. The required and acceptable type of conveyance for thetransport of healthcare waste is either a refrigerated van or closed van. Permit to transport isonly issued to a registered transporter with a service agreement with a registered TSD withapproved treatment, storage and disposal method.

As of February 2008, there are sixty-one (61) registered hazardous waste transporterscapable of transporting healthcare waste as contained in the Hazardous Wastes TrackingSystem (HWTS) and most of these are operating or servicing the NCR and Region 4A(CALABARZON). The HWTS, database established and being operationalized at the EMB-CO, is updated regularly to further capacitate it in extracting data and information specific tothe waste class of interest, quantities generated, and the treatment and disposal methodemployed. The HWTS also hosts the data and information on the registered hazardouswastes transporters and TSD facilities in the Philippines.

Since the Effectivity of the Philippine Clean Air Act of 1999 (RA 8749) through itsimplementing rules and regulations (DAO 2000-81), only non-burn technologies are allowedto be used in the destruction, treatment and disposal of biomedical (healthcare) andhazardous wastes. Section 20 of RA8749 provides the regulatory Ban on Incineration ofmunicipal, biomedical and hazardous wastes. The allowed non-burn technologies in thedestruction of healthcare wastes must comply with the criteria and emission standards onnon-burn technologies provided in Rule 28 of DAO 2000-81. Non-burn technologies includethermal treatment i.e., pyrolysis, autoclave, hydroclave, microwave and sterilization. TheHWTS registered, as of February 2008, about twenty-four (24) TSD facilities that employs oruses non-burn technologies as well as encapsulation and solidification in the treatment ofhealthcare wastes and expired pharmaceuticals and drugs. Final disposal of the treatedhealthcare wastes and residues are in authorized landfill with specific cell for it.


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INSTITUTIONAL ANALYSIS

The EMB, central and regional offices, is the responsible and primary regulatory agencymandated by law in the Philippines in relation to healthcare waste management i.e.,collection, transport, treatment, storage and disposal. The EMB is tasked to enforce therequirements and procedures including the permitting system on healthcare management.Registration of healthcare facilities as hazardous waste generators are done at the EMB-ROs where the facility is located as well as the processing and approval of permits totransport of such waste. At the EMB CO, it is tasked to evaluate and approved applicationsfor registration as hazardous waste transporter with specific capability (handling) and therequired type of conveyance as well as the registration of TSD facility with specificappropriate technology for the treatment and disposal of healthcare wastes.

Licensing and issuance of permit to operate healthcare facilities such as hospitals, medicalcenters, clinics, etc., is the responsibility and mandate of the Bureau of Health Facilities andServices (BHFS) of the Department of Health (DOH). Its vision is to set regulatory policiesand standards, as mandated of the licensing, accreditation and monitoring of health facilities

and services to ensure quality of health care. The following are its functions: a) setsstandards for regulation of health facilities and services; b) disseminates regulatory policiesand standards for information and compliance; c) issues permits to construct, license tooperate, clearance to operate HMOs and certificate of accreditation; d) ensures sustainabilityof health facilities compliance with regulatory standards; e) provides consultation andadvisory services to stakeholders regarding health facilities regulation; and f) develop andconducts research relative to regulation of health facilities and services. The BHFS has three(3) main divisions, namely: Standards Development Division, Licensing and AccreditationDivision, and Quality Assurance and Monitoring Division.

The Bureau of Health Devices and Technology (BHDT)-DOH, on the other hand, developsplans, policies, national objectives, programs, projects and strategies for regulating health

technologies, medical and health devices and facilities and other health-related devices thatmay pose hazards to human health.

Policies and Legislations

RA 6969: Toxic Substances and Hazardous and Nuclear Waste Control Act of 1990,is at present, the only legislation in the Philippines that regulates healthcare waste. Itsimplementing rules and regulations, most recent is DAO 2004-36, classifies healthcarewaste under Miscellaneous Waste with waste number M501 that includes pathologicalwastes (tissues, organs fetuses, bloods and body fluids), infectious wastes and sharps. Italso classifies expired pharmaceutical and drugs as hazardous waste with waste number

M503.

In an effort to strengthen and streamline policies, rules and regulations on healthcare wastemanagement, the Joint Administrative Order (JAO) No. 02, series of 2005, Policiesand Guidelines on effective and proper handling, collection, transport, treatment,storage and disposal of health care wastes is issued by the DENR and DOH in 24August 2005. The JAO is issued pursuant to the following laws, rules and regulations:

a. Clean Air Act of 1999 (RA 8749)b. Toxic Substances and Hazardous and Nuclear Waste Control Act of 1990 (RA 6969)c. Ecological Solid Waste Management Act of 2000 (RA 9003)d. Refuse Disposal of the Sanitation Code of the Philippines [Chapter XVIII,

Implementing Rules and Regulations, Presidential Decree 856]e. Clean Water Act of 2004 (RA 9275)


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f. Environmental Impact Statement (EIS) System (PD 1586)g. Hospital Licensure Act (RA 4226)

Among the objectives of the JAO 2005-02 is a) to provide guidelines to generators,transporters and owners or operators of treatment, storage, disposal (TSD) facilities ofhealthcare waste on the proper handling, collection, transport, treatment and storagethereof; b) to clarify the jurisdiction, authority and responsibilities of the DENR and DOH withregard to healthcare waste management; and c) to harmonize efforts of the DENR and DOHon proper healthcare waste management.

Under the JAO 2005-02, health care wastes include all wastes generated as a result of thefollowing:

1. Diagnosis, treatment, management and immunization of humans or animals;2. Research pertaining to the above activities;3. Producing or testing of biological products; and4. Waste originating from minor or scattered sources (i.e. dental clinics, alternative

medicine clinics, etc.)

The categories of healthcare wastes are: general waste, infectious wastes, pathologicalwaste, sharps, pharmaceutical wastes, genotoxic wastes, chemical waste, waste with highcontent of heavy metals, pressurized containers, and radioactive waste.

With regard to the responsibilities of implementing and cooperating agencies, the JAO shallbe implemented by the DENR through EMB and its Regional Offices, the National SolidWaste Management Commission (NSWMC) and by the DOH through Center for HealthDevelopment (CHD), BHFS, BHDT, the National Center for Disease Prevention and Control(NCPDC), the National Center for Health Facility Development (NCHFD), and the NationalReference Laboratory (NRL)-East Avenue Medical Center in Quezon City. The following are

some of the main responsibilities enumerated in the JAO, to wit:

DENR-EMB shall:

1. Be the primary agency responsible for implementing pertinent rules and regulationson the management of healthcare waste in the Philippines, particularly concerningthe issuance of necessary permits and clearances for the transport, treatment,storage and disposal of such wastes as governed by RA 6969, RA 8749, RA 9275,RA 9003 and PD 1586.

2. Formulate policies, standards and guidelines on the transport, treatment, storage anddisposal of healthcare wastes.

3. Require TSD facility operators and on-site treaters to present to the DENR copies of

the results of microbiological tests on the healthcare waste treated using autoclave,microwave, hydroclave and other disinfection facilities prior to the renewal of theirPermits under RA 6969.

DOH shall:

1. Regulate all hospitals and other health facilities through licensure and accreditationunder the Hospital Licensure Act (RA 4226).

2. Require all healthcare waste TSD facility operators and healthcare waste generatorswith on-site waste treatment facilities to use DOH-BHDT registered equipment ordevices for the treatment of healthcare wastes.

3. Issue Department Circulars to ensure that all environmental requirements arecomplied with.


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4. Notify DENR on actions taken on cases of non-compliance or notice of violationissued to healthcare facilities, institutions and business establishments.

DOH-Centers for Health Development shall:

1. Advocate healthcare waste management (HCWM) practices to the Local ChiefExecutives, key leaders and stakeholders.

2. Provide technical assistance on HCWM through training, advisory on the preparationof HCWM plans as a requirement for licensing or renewal thereof, dissemination ofpolicies, guidelines and information, ensure compliance by healthcare wastegenerators with all pertinent laws, rules and regulations.

Further, the JAO sets the specific criteria, standards, and guidelines on:

a. Handling, Collection, Storage and Transportb. Treatment (thermal, chemical, irradiation, biological process, encapsulation and

inertization)

c. Final Wastes Disposal Systems and Facilities (Controlled Dump Facility, SanitaryLandfill facility, Safe Burial on Healthcare Facility Premises, Sharps and SyringesDisposal through Concrete Vault)

d. Wastewater Treatment Facility.

INTERNATIONAL AND REGIONAL INITIATIVES

Currently, there are no interventions of multilateral organizations, international collaborativeprograms and local and regional research institutes on healthcare management in thePhilippines. Since the Philippines is a contracting party to the Basel Convention on theTransboundary Movements of Hazardous Wastes and their Disposal and the domestic

legislation in place, RA 6969, there is no documented illegal disposal of healthcare wasteexcept for an incident in 1999. However, international Non-Governmental Organizations(NGOs) like Greenpeace, Healthcare without Harm (HCWH), and Global Alliance on Anti-Incinerators (GAIA) are very vigilant and active in monitoring healthcare wastes treatmentand disposal including the use of treatment technology and disposal methods. They are alsovery active and supportive on some legislative and policy formulation of the government.

AREAS FOR ACTION

In the Philippines, laws, rules and regulations are in place with respect to healthcaremanagement. However, the following are still necessary to further strengthen enforcement of

policies, rules and regulations on healthcare management:

Capacity building for the TSD facility operators on new or best availabletechnology (BAT) for environmentally sound management of healthcare wastes

Implementation of capacity building needs and awareness program amonghealthcare facilities on the importance of pollution prevention through wasteminimization

Harmonization of different agencies policies, rules and regulations pertaining tohealthcare waste management through enactment of a law with specificprovisions on healthcare wastes

Exchange of information and establishment of a regional database on healthcare

waste management technologies and strategies


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RECOMMENDATIONS

Regional exchange of information and experiences on healthcare wastemanagement through the conduct of focus group discussions (FGDs), seminars,workshops, meetings, etc.

Conduct of regional trainings on healthcare waste management with specialattention on best available treatment technologies, packaging and handlingprocedures, best and safe disposal methods.

Involvement of International Funding Institutions for the financial aspects ofhealthcare management.

REFERENCES

1. www.emb.gov.ph2. www.doh.gov.ph

3. DENR Administrative Order 36, Series of 2004: Revising DAO 29, series of 1992, tofurther strengthen the implementation of RA 6969 (Toxic Substances and Hazardousand Nuclear Waste Control Act of 1990) and Prescribing the Use of the ProceduralManual.

4. DENR-DOH Joint Administrative Order No. 02, Series of 2005: Policies andGuidelines on effective and proper handling, collection, transport, treatment, storageand disposal of health care wastes

5. EMB Hazardous Waste Tracking System (HWTS)- database on hazardous wastemanagement

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