RECOMMENDATIONS, AND CONCLUSION

CHAPTER- 7

RECOMMENDATIONS AND CONCLUSION

7.0.0.0. Introduction

As a normal citizen of Nasik, it was quite an experience to go into research on this

topic. As a citizen, this researcher always waited for Ghantagadi to come to his

residence and collect house hold garbage. Slowly, out of curiosity the researcher

dwelved into hospital waste disposal. It is only after such extensive research, and

interaction with different stake holders that the magnitude and seriousness of this

subject is appreciated, first by the researcher himself.

It is said that it is very easy to suggest from out side of any establishment. We do not

understand problems of any system, yet suggest. The statutes are common for every

state and hospital to follow but we find all at different pedestal. It depends on

awareness levels of citizens in general and interest of particular hospital authorities.

States of Tamilnadu, Kerala, Andhra Pradesh, and Gujrat are much ahead of others in

India. Within backward states also few hospitals take more interest. It is pertinent to

mention about King George’s Hospital, Lucknow, UP which in two years time has

done turn around in this field. It has recently, in March 2013 been awarded by UNDP

in this regards.

At the outset it can be said that no one is to be blamed for present status of hospital

waste Management in Nasik. It actually gets back seat in comparative priorities. In

Nasik, as much in Maharashtra, as anywhere else in India the importance is driven by

techno-economic considerations. At all levels we all tend to ponder “can we dowithout it for the time being. Not withstanding the above, following issues as

discussed subsequently are discussed;-

7.1.0.0 Suggestions for Improvement of Medical Waste Management System in

Nasik. The present practice of BMW Management involves key stakeholders such as

;-

(a) Regulators (including ULB/NMC, MPCB, CPCB and MoEF)

(b) Administrators of Health Care Establishments (HCEs) (bedded, non-

bedded and others)

(c) Contractor of CBMWTFs at Tapovan, Nasik

(d) Community, including users of HCEs.

(e) Social monitors- Press, media, NGOs, researchers

The effectiveness of BMW management rests on the dynamics of their interactions

and linkages between policy/regulations; technology options; data harmonization;

economics (charging policy) and awareness; Recommendations regarding each of

these elements in the perspective of key stakeholders are presented below.

7.1.1.0. Role of MPCB. It is the single largest factor responsible for present status

of Hospital Waste Management. In Nasik, the Regional and sub-regional offices of

MPCB are lodged in same building. While this arrangement suits and provides

complacency to staffs of both organizations, but from monitoring point of view it is

not good. Some important issues are;-

(a) Website. Independent websites of sub-regional and regional offices

must be hosted. All data must be made available in public domain for

information and transparency. It is also mandatory from RTI regulations point

of view. Updating must be monthly at sub-regional level and quarterly at

regional level. In present study, only MPCB website could be accessed. It

hosted annual report of 2011 only. The researcher realized that it is extremely

difficult to get even simple details from these offices, and had to resort to RTI

to access basic information. In this regards mention must be made of Gujrat

which has made wonderful website XGN(Xtended Green Node ).

Improve Data Flow to establish a Common Central Database: Data flow

between the HCEs, MPCB and CBMWTDFs is shown in Figure 16. The

actual data on BMW generation (that flows from HCEs to CBMWTDFs) is not

shared with MPCB. This may be done to allow MPCB to validate the

estimates of authorization and actual BMW generation. This will also help in

establishment of realistic BMW generation factors that could be used for

authorization and verification.

(b) From response of various stake holders, it is obvious that visits by

senior officers of MPCB to hospitals, and central facility are very rare.

Interaction with NMC health officer is also rare.

© It is stated that last training was conducted in 2009.In last 4 years no

integrated training was held. The researcher felt its dire need and proposed an

integrated training schedule through an article in a reputed magazine. It has

already been published.

(d) New draft MSW(M&H) Rules 2011 are already suggested by Ministry

of Environment. Even present rules of 1998 are not fully in place. MPCB have

no game plan to execute new rules.

(e) Co-ordination between Bombay Shop Act and M& H Rules-1998.

The role of Urban Local Bodies (ULBs) in the BMW management is not well

defined under the BMW Rules. ULBs are responsible for providing license to

smaller HCEs including clinics, nursing homes etc. under the Shops and

Establishment Act. In many cases,as also in case of Nasik, the CBWTDFs are

contracted by ULBs, with premises/land leased. Some ULBs take royalty or

levy fees from the operators of CBWTDFs. Unfortunately, there is poor

coordination between ULBs and MPCB. If requirements (under the Shops and

Establishment Act, and BMW Rules) could be integrated with BMW

authorization then this will ensure that more HCEs (which are not authorized

and /or not members of CBMWTDFs) will be brought under compliance net.

(f) Develop BMW Generation Factors: After implementation of a

central database for BMW, MPCB should undertake development of BMW

generation factors (which may include BMW generated/bed/d/ and /or BMW

generated/clinic/month). HCEs should be encouraged to use these generation

factors while filling up BMW authorization application form for the first time.

Such criteria need to be category specific and typical for a type of HCE. The

above results clearly show that there is no consistency followed while granting

authorization and estimates provided by HCEs are taken for granted. Hence,

creation of central database with development of rational BMW generation

factors will greatly help towards improving consistency as well as better

estimation of BMW. Once the central database is created and actual generation

data is available, then MPCB may even provide incentive in case there is

lesser BMW generated than calculated.

(g) Rationalize fee structure for Authorization: The charge for BMW

authorization is based on number of beds for bedded HCEs and on a lump sum

or normative basis for non-bedded HCEs. The authorization fees payable to

MPCB are depicted below in Table 7.1.

Table 7.1-Present and Recommended annual fee for BMW Authorization

Serial Bed Capacity/Other

Details

Present

Rates

Charged

Recommended Rates(Rs)

1 Between 01-05 No Fees Nil

2 Between 06-25 Rs. 1,250/- Rs 25/bed

3 Between 26-50 Rs. 2,500/- Rs 30/bed

4 Between 50-200 Rs. 5,000/- Rs 35/bed

5 Between 201-500 Rs. 10,000/- Rs 40/bed

6 Above 501 Rs. 15,000/- Rs 45/bed

7 Treatment Facility

provider for bio-medical

waste

Rs.10,000/-

yearly

5 blocks(Serial2-6) of

Rs7000,7500,8000,9000,10000

8 Transporter of Bio-

Medical Wastes

Rs.7,500/-

yearly

5 blocks(Serial2-6) of

Rs3000,4000,5000,6000,7500

9 All other bio-medical

waste generating, and

handling agencies.

(Except 8,9)

Rs.2,500/-

per year

No change

In the present charging system, there is no discrimination between 50 and 200

beds, and 201 and 500 beds. So, if a 50 bedded hospital is authorized for say

10 kg/day (based on 0.2 kg/per bed/day) and a 200 bedded hospital that may

generate 40 kg/day, the fees for authorization remain the same. This may lead

to a tendency to "overestimate" BMW waste generation and a 50 bedded

hospital may well seek an authorization of 30 kg/day instead of 10 kg/day.

MPCB may therefore link the authorization fee directly to the number of beds

instead of "block based" approach.

Table 7.1 shows bed based ranges of authorization fees for various bed

capacities. It may be observed that the existing fee structure for authorization

favors HCEs with higher number of beds. This can well be a barrier to HCEs

with smaller bed capacities.

Thus, larger bedded hospitals will pay higher authorization fee as compared to

the smaller HCEs. The fee will be bed based and hence rational avoiding

thereby tendency to seek higher authorization.

(h) Disseminate Technology Information and set Technology

Performance Standards (TPS). Technology Providers (TP) should be

encouraged to provide replicable, feasible, and environment friendly solutions

for BMW management. MPCB along with CBMWTDFs and Indian Medical

Association (IMA) could arrange for :

− Annual exhibition of suppliers in partnership with IMA and CBMWTDF at

Nasik for Nasik Region/State level

− Development of Technology Performance Standards (TPS) for a specific

type and generation of equipment, including Testing and Monitoring methods

− The TPS should be made aware of the importance of energy audits. Energy

audits should be made mandatory for renewal of Consent to Operate.

7.1.2.0 Role of Administrators

Since medical is most booming business, administrators will not like to waste money

on issues like this of waste management. They think that once they paid registration

charges to MPCB, they are not to be monitored for next 5years.It is suggested that as

rain water harvesting/recycling is mandatory for residential premise. In the same

manner exclusive places must be made mandatory to earmark separate space for

storage of hospital waste for segregation before transportation. The administrators of

the hospitals who are responsible for managing the biomedical waste disposal in the

hospital gave this researcher the following suggestions :

Regular lifting of bio-medical waste by NMC Contractor

Regular organization of proper training programs for nurses and

sweepers. They all liked idea propagated by this researcher for

integrated training where all stake holders work together and not in

water tight containers.

Proper formulation of waste management committees

Regular supply of materials required for proper management of

biomedical waste.

Maintenance of proper waste records

Increase in the number of nurses and sweepers.

Provision of incentives to motivate the healthcare personnel to manage

hospital waste effectively and efficiently.

1. Revisit Categorization and Color Coding: HCEs, while filling in their

authorization and / or filing Form II (annual report) have to submit details pertaining

to waste categories and waste generated. The Biomedical Waste (Management and

Handling) Rules, 1998, as amended in 2003 have classified BMW in 10 categories.

However, in practice, it is practically difficult for the HCEs to monitor the waste

generated under different categories. Only nos. of colored bags and total weight of

bags are recorded, and reported in the registers. Instead of 10 category data, data on

colored bags is only used in transactions (viz. between the HCEs and CBMWTF

transporters/operators or CBMWTDF operators and MPCB). Further more there is no

‘one to one’ mapping between color codes and categories, i.e. Category 1 may be putin either color code ‘b’ or ‘c’. This can lead to difficulties in exact mapping between

data from authorization and data generated through weighing of color coded bags. It

may be worth therefore to revisit categorization and color codes to achieve simplicity

as well as mapping in data recording and management.

7.1.3.0. Role of Contractor/CBMWTF Administrator

(a) Standardization of Incinerator Operating Hours: CBMWTDs

should not operate their incinerators as low as 0.45 and 1.6 hrs. /day. An

incinerator takes considerable time (which may be close to 1.5 hrs. depending

on model and age) to reach the desired temperature (850+ 50ºC in primary and

1050+ 50ºC in secondary chamber). Thus, running the incinerator for this short

period may result into loss of heat and fuel in addition to increased risks of

non-compliance. While issuing Consent to Operate to CBMWTDFs therefore

MPCB may put in a condition that average incinerator runtimes should not be

less than 4 hrs /day. Also, larger incinerators (say, beyond 200 kg/hr) could

have a direct online interface into MPCB’s central BMW database transmitting

details like kg of BMW fed, temperatures of primary and secondary chambers

and run hours/day. This will also result into better performance from

CBMWTDFs and lesser efforts on field based manual sampling.

(b) Mandate Management Systems for CBMWTDFs: CBMWTDFs

should be mandated for ISO 14001: 2004 and OHSAS 18001:2007

certification. As an incentive, the CBMWTDF may be provided a one timely

ex gratia grant in the form of reduced Consent to Operate renewal fees. This

could be ensured if this condition and timeline is included in the Consent to

Operate conditions. This will ensure that (a) increase in credibility of

CBMWTDF, (b) better Health, Safety and Environment (HSEs) compliance

from CBMWTDFs side, (c) increased safety of CBMWTDF’s employees.

Special incentive may be provided to those who are also ISO 9001: 2008

certified

7.1.4.0. Role of Community, including users of HCEs.

Out of all stake holders role of community including users of medical services are the

most powerful and effective. Why Tamilnadu, and Kerala are leading states in all such

ventures because the population is educated and aware towards ills of hazards of

mismanagement of BMW services. They force their governments to ensure policies

completely. Latest example in this case is strike in Kerala against corruption in Solar

energy establishment in Kerala State. On 9 July 2013 state level bunds are called

seeking resignation of CM Oomen Chandi.

Similarly, the users of private hospitals must ensure to fill the suggestion registers at

the time of final payments. In that they must mention their experiences of Hospital

waste management in the hospital where their patient was admitted. They must

interact wih registrars and Management committee for waste management and discuss

issues of mutual interest.

Not to incite, but this researcher also opines that the CBMWTF at Tapovan must be

shifted to Tapovan and technologically more sophisticated machines must be installed.

This must complete before Kumbh Mela of 2014.

7.1.5.0. Role of Social monitors- Press, media, NGOs, and researchers. Almost

all newspapers today have a set pattern of social accountability. Each has earmarked

space in their paper for once a week reporting on such matters. The correspondent is

not qualified to report but yes, same reporter handles same topic each week. We there

fore find interviews under “Men Who Run Nasik”. In this the medical officer of

NMC, Regional Officer MPCB have both been interviewed. Their interviews are

appended at Appendices J, K respectively. It can be read that, questionnaire framed by

correspondents are not very direct.

Similarly, it is suggested to make small documentaries shot at Khat Prakalp, and

CBMWTF Tapovan. These must be shown in Marathi cable net work at least once a

month. Much more effort is required in this direction from NMC/MPCB Regional

offices.

All India Medical Waste Association, Dwarka, New Delhi is Nodal Agency in this

field. It has about 400 life members till date ; but surprisingly not a single

doctor/NGO/ HCE is the member of this association from Nasik. Nor to the best of

belief of this researcher any waste management Consortium has been held in Nasik

Region ever. As if this were not enough, even Maharashtra University of Health

Sciences (MUHS) does not conduct any capsule for such thing. The researcher very

sanguinely wishes there was sincere efforts in this regards.

7.2.0.0. Alternate means for Waste Management;-The researcher therefore,

recommends that as no single medical waste treating technology can take care of all

the ten categories of biomedical waste, a judicious package has to be evolved for

disinfection of all the biomedical waste. The incinerator should be used for disposal

of only anatomical waste, discarded medicines, cytotoxic drugs and other non burn

technologies should be used for all the other infectious medical waste at common

treating site.

Developments in alternative medical waste treatment technologies have been on going

at rapid pace over the last few years and alternatives to incineration are being looked

at. Dr Bhawalkar S Sujala Biosanitizer – an effective alternative medical waste

disposal technique is one of such new developments in the field of waste disposal

technologies.

Dr Nirmala Ganla with other experts from Department of Microbiology, BJ Medical

College, Pune conducted a study to analyse the suitability of this alternative method

for dealing with hospital waste by using Sujala Biosanitizer an enzyme for

bioconversion. Over a three-year period, medical waste from a 12 bedded maternity

hospital was treated with this Sujala Biosanitizer It resulted in a 99 percent reduction

in volume with no aesthetic nuisance. The end product was also monitored

microbiologically for its safety. It was similar in its microbial content to soil and no

pathogens were detected. It thus seems to be a promising cost effective alternative

technique for handling infectious medical waste in small healthcare establishments.

7.3.0.0; Conduct awareness and training programmes on a campaign basis:

Arrangements should be made for periodic awareness programs to raise awareness

amongst MPCB, HCEs, CBMWTDF operators and transporters as well as common

public understand the risk associated with BMW management. MPCB has already

carried out various awareness programs for this purpose in scattered manner. A need

is felt to consolidate these. The following steps should be adopted by MPCB:

o Conduct surveys to understand the gaps in

(a) Understanding of BMW Management rules,

(b) Practical problems at ground level etc.

o Design awareness programs to answer these specific queries. Such

programs should be timely, focused and flexible.

o Make easily accessible materials like e-resource (manual) on BMW

management to all parties.

o Parameters related to awareness should be selected and monitored

before and after training to evaluate the change imparted by training.

7.4.0.0; Addressing In-House Issues First. Problems enunciated in Chapter 4,

given in official brochure of Khat Prakalp, Nasik must be resolved earliest by

NMC/MPCB Regional office. Similarly, proposals forwarded by their staff, as given

in Chapter 4 must be addressed. The official brochure of Khat Prakalp has

suggested Rs 60 crore investment on this scheme. The researcher suggests that NMC/

Commissioner must specify and make public the investment planned under JNNURM,

and make it public under provisions of RTI Act 2005. The staff has also suggested

‘invessal Composting’. Its financial viability must be assessed and if suitable must beco-opted. The researcher feels his will yield good dividends to all stake holders. Some

details of this system are given in this Figure-7.1 below;-

7.5.0.0 Immediate Application of Suggestions of Ministry of Environment and

Forests (MoEF) as Elucidated in “Report to Evolve Road Map on Management

of Waste in India”. Very comprehensive and all inclusive suggestions are given by

MoEF for application by State Governments. These are once again enunciated below;-

A national data bank must be made in respect of all BMW generators

private/state and HCFs falling under purview of DG AFMS.

More stringent action be initiated under defaulters. The revised Statutes Sep

2011 also suggest the same.

‘Jimmewari’ must be fixed in respect of Central Treatment Facilitycontractors.

Pollution control Committees to monitor more often and more strictly.

Within MoEF, “BMW Management Cell” is suggested to be created soon. The

authorisation and other finances could self sustain it; or additional grants could

be given from MoEF.

Costly machines from abroad could be purchased by states/ centre to ensure

high end technology.

Surprise checks on ground against that reported in annual reports.

More research in specialisation in BMW field. Greater interface of UNDP

GEF and such agencies at State/District level so as to spread awareness.

Coordination of land for central treatment facilities, landfill sites, composting

sites must be resorted after mutual interaction of Districts and States.

Extended Recycling Procedure (ERP) must be encouraged while finalising

contractors. In such cases the supplier is responsible for collection and

recycling the product after first use by client.

Have qualified/trained persons on roster to ensure BMW management.

Number of laboratories must be increased to be available at Sub- regional

levels.

Segregation must be simplified to 5 categories from present 10. The same has

been included in Sep 2011 revised statutes.

Photo 7.1; Invessal Composting (source; epd.gov.hk)

7.5.0.0. Suggestions Given by Scholar in Article on Minimisation.

Minimisation is the most important issue as per this researcher. Therefore, there are

many suggestions in this regards. First, the suggestions which Comptroller and

Auditor General (CAG)of India have been giving at higher levels to Ministry of

Environment and Forests (MoEF). Some of these are;-

(a) Coordination with other ministries for introducing ‘3 R’s’strategies(Reduce, recycle, and reuse).

(b) Ministry of Finance (MoF) could be approached for promoting the

procurement of recycled products by the government.

© Ministry of Commerce (MoC) could be approached for providing

incentives for the reuse of products in manufacturing.

(d) Department of Industries could be approached for promoting the use of

recycled products and encourage industries to use cleaner technology, to

undertake product stewardship and other such waste reduction, reuse, and

recycling strategies.

Extended Producer Responsibility (ERP) is the most important aspect. As

prevalent in some foreign nations, the government must insist on suppliers to

recover the product after use and recycle it. This will ensure better packaging

norms.

Less packaged products must be purchased. Reward points must be instituted

for reduction at initial stages to encourage nurses and ward boys/sweepers.

Community/press/NGOs must be more aggressive towards better prioritisation

of BMW issues. They must force administrators to abide by govt statutes.

To increase awareness ‘Nukkad Nataks” or street plays at Prabhag levels mustbe organised by wings of Pollution Control Boards (PCB).

Right from primary school level these issue must form part of essential

education. Presently it has remained up to yearly poster competitions. Forests

related entries are invariably received in such poster competitions. No one

talks about hospital and all other types of Waste Management.

Another important suggestion is to have compulsory ECOMARK on all

packaging. Like ISI marking, this will ensure correct packaging and reduction

will take place at initial stages.

It is also recommended to encourage ISO; 9001;2008 certifications for HCEs.

This certification is under revision at International level as 5 years have

completed since inception. So, we must propagate this.

In case government hospitals do not have sufficient staff for minimisation, the

Municipality/PCB can consider outsourcing the minimisation efforts to

technically competent groups.

Qualified technocrats must head the minimisation management teams in

HCEs. These must have clear goals to conserve water, energy, material and

reduce/recycle/recover maximum possible stores. This team must be allocated

dedicated funds.

Brainstorming sessions must be organised by administrators in attendance of

this team.

Sufficient posters must be displayed for every one to be aware of such issues.

Feed back registers at receptions of HCEs must be filled by relatives of

patients/guests to assess own efforts in this direction.

7.5.0.0 Conclusion

To conclude we can thus say that though biomedical waste (management and

handling) Rules 1998, have been passed, hospitals are still not implementing them and

therefore lots of efforts are required for management of biomedical waste in Nasik

hospitals.

As biomedical waste management is a management problem MPCB, NMC, hospital

health care personnel, patients and citizens of city should join hands with each other to

manage biomedical waste safely and efficiently then only we can solve the burning

problem of BMW disposal in nasik.

7.6.0.0 Suggestions for Further Research :

The present research has tried to find out strengths and shortcomings of the practices

adopted for disposal of bio-medical waste in the general hospitals of Nasik so that the

hospital administrations can utilize the study research findings for planning an

efficient hospital waste management system. This study has also tried to assess the

economic, technological, social and environmental effectiveness of the technologies

presently used in Nasik for disinfecting bio-medical waste generated in healthcare

establishments which will help the policy makers and hospital administration to select

an appropriate bio-medical waste treatment technology for treatment and disposal of

their medical waste. The present study has also made an effort to highlight the

adverse hazardous impact of improper bio-medical waste disposal on the health of the

workers engaged in management of healthcare waste, community and the environment

by giving many examples and case studies.

Based on the findings the researcher observed that some of very important aspects of

hospital waste disposal need special attention to sustain safe environment for the

community and the environment. It is thus hoped that the present study will

encourage, stimulate and provoke further studies in the field of bio-medical waste

management.

Besides these suggestions, the researcher observed that very few data are available on

the health impacts of exposure to healthcare waste, particularly in the case of

developing countries like India. Better assessment of both risks and effects of

exposure would permit improvements in the management of healthcare waste and in

the planning of adequate protective measures. The great diversity of hazardous waste

and the circumstances of exposure is a problematic feature of all such assessments.

This prevents development of a unified analytical approach to the assessment of

exposure and health outcome as well as generalization of any statistical inferences

drawn about a specific waste exposed population. Therefore, suspected cases of

adverse health effects of healthcare waste should be adequately documented with

precise description of exposure, exposed individuals or population and outcome and

needs research efforts in this direction.

Within healthcare establishments, the surveillance of infection and record keeping are

important tools than can provide indication of inadequate efforts put in the

management of biomedical waste as well as contamination of the immediate

environment. Surveillance allows an out break of infection to be recognized and

invested. This provides basis for introducing control measures, for assessing the

efficacy of those measure and of the routine preventive measures taken by the

establishments. It helps in reducing the level of infection. It will also ensure that the

control measures have maximum effect and are cost effective. Therefore, there is need for

series of research studies in this direction.

A few suggestions for further researchers in the field of hospital waste management are

thus listed below :

Ways and means of minimizing the healthcare waste.

Cost effective measures for occupational and safety of the healthcare

personnel.

Preparation of training modules for healthcare workers at all levels-

Researcher has already suggested integrated training module.

Economics of biomedical waste management inside the hospital

Formulation of cost effective system for management of sharps waste

Development of appropriate system for bio-medical waste

documentation

Economic benefits of outsourcing of hospital waste management.

Development of cost effective medical waste treating technologies for

small generators etc