No.

Japan International Cooperation Agency (JICA)

Ayuntamiento del Distrito Nacional (ADN)

THE STUDY ON INTEGRATED SOLID WASTE MANAGEMENT PLAN IN SANTO DOMINGO DE GUZMAN NATIONAL DISTRICT DOMINICAN REPUBLIC

Kokusai Kogyo Co., Ltd.

March 2007

GEJR

06-065

Final Report Volume IV MAIN REPORT (Healthcare Waste)

PREFACE

In response to a request from the Government of Dominican Republic, the Government of Japan decided to conduct “The Study on Integrated Solid Waste Management in Santo Domingo de Guzman, National District” and entrusted to the study to the Japan International Cooperation Agency (JICA).

JICA selected and dispatched a study team headed by Mr. Ikuo Mori of

KOKUSAI KOGYO Co., LTD. between July 2005 and October 2006. In addition, JICA set up an advisory committee headed by Dr. Hidetoshi Kitawaki, Professor, Toyo University, which examined the study from specialist and technical points of view.

The team held discussions with the officials concerned of the Government of

Dominican Republic and conducted field surveys at the study area. Upon returning to Japan, the team conducted further studies and prepared this final report.

I hope that this report will contribute to the promotion of this project and to the

enhancement of friendly relationship between our two countries. Finally, I wish to express my sincere appreciation to the officials concerned of the

Government of Dominican Republic for their close cooperation extended to the study.

March 2007

Ariyuki Matsumoto Vice President

Japan International Cooperation Agency

March 2007

Mr. Ariyuki MATSUMOTO Vice President Japan International Cooperation Agency

Letter of Transmittal

Dear Sir,

We are pleased to submit the report of The Study on Integrated Solid Waste Management Plan in Santo Domingo de Guzman, National District, Dominican Republic.

This report consists of two fields, i.e., Municipal Solid Waste Management and Healthcare Waste Management. The former introduces the result of current status diagnosis, the result of Pilot Projects, Master Plan and Action Programs. The latter shows the result of current status diagnosis, the result of Pilot Project and Action Plan.

Santo Domingo Municipality’s vision regarding Municipal Solid Waste Management (MSWM) is “Clean City.” The Master Plan is to contribute its fulfillment, which advocates “the municipality, the citizens and the private sector shall collaborate with each other in order to establish high quality and sustainable solid waste service,” and has the following goals: 1) 100% collection rate, 2) establishment of sanitary final disposal, 3) 15% waste minimization, and 4) 30 – 50 % dependency rate on the municipal general finances, by 2015. These challenging goals were set by the municipality itself.

Implementation of the Master Plan has begun. The Municipal Regulation on Non-hazardous Waste Management, which is a legal infrastructure for all individuals and organizations concerning MSWM, was promulgated and enforced during the period of the Study. The Pilot Project of Integrated Improvement of Collection Service has been expanding with participation of the private sector.

Meanwhile, in the field of Healthcare Waste Management, the Action Plan aims at “proper management of healthcare waste in order to reduce health risks of cleaning workers in healthcare centers, patients, waste collection workers and citizens.” The goal is that healthcare waste is to be properly managed in all healthcare centers in Santo Domingo by 2015.”

On the basis of the success of the Pilot Project carried out in Ciudad Sanitaria, Dr. Luis E. Aybar, the Secretary of State for Public Health and Social Assistance and the Secretary of State for Environment and Natural Resources, witnessed by the Mayor of Santo Domingo, declared the expansion of the proper Healthcare Waste Management to other hospitals. Some hospitals have already commenced the proper management.

We would like to take this opportunity to express our sincere gratitude to your Agency, the Advisory Committee for the Study, the Ministry of Foreign Affairs and the Ministry of Environment of Japan. We would also like to extend our deep appreciation to the Government of Dominican Republic, the Embassy of Japan and the JICA office in the Dominican Republic for their vital cooperation during the implementation of the Study.

Last but not least, we hope that the output of the Study presented here will contribute to the improvement of Solid Waste Management and citizens’ welfare in Santo Domingo de Guzman, National District.

Respectfully,

Ikuo MORI Team Leader The Study on Integrated Solid Waste Management Plan in Santo Domingo de Guzman, National District, Dominican Republic

The Study on Integrated Solid Waste Management Plan in Santo Domingo de Guzman, National District Dominican Republic List of Volumes Volume I Summary (English, Spanish, Japanese)

This Volume is consisted of two parts, Municipal Solid Waste Management and Healthcare Waste Management. The former part is a summary of the Volume II, Main Report, Municipal Solid Waste. The later part is a summary of the Volume IV, Main Report, Healthcare Waste.

Volume II Main Report; Municipal Solid Waste (English, Spanish)

This Volume contains the whole items conducted and planed during the Study on the aspect of the Municipal Solid Waste Management.

Volume III Annex; Municipal Solid Waste (English, Spanish)

This Volume contains detailed results of site surveys conducted and products such as manuals prepared during the Study.

Volume IV Main Report; Healthcare Waste (English, Spanish)

This Volume is consisted of two parts, Main Report and Annex. The former contains the whole items conducted and planed during the Study. The later contains tools such as manuals and posters used for the Pilot Project.

This is the Volume IV, Main Report; Healthcare Waste (English) In this report, the project cost is estimated by using the August 2006 price and an exchange rate of US$1.00=RD$33.00=JP¥116.00

The Study on Integrated Solid Waste Management Plan in Santo Domingo de Guzman, National District, Dominican Republic

Location Map

Dominican Republic

Santo Domingo Metropolitan Area (composed of 5 municipalities)

Duquesa Landfill

National Distr ict (The Study Area)

10 5 0km 15

Santo Domingo Metropol itan Area

Improvement of healthcare waste management .

1

SITUATION BEFORE THE PILOT PROJECT AT THE TARGET HOSPITAL

Syringe with needle mixed with other waste Blood leaked from the bags and spreaded on the floor

Transferring the waste into another, many syringes scattered on the patio.

All mixed waste was transported though the route of busy street outside the hospital.

Temporal storage of the hospital. Collection worker without any protection

Improvement of healthcare waste management .

2

PILOT PROJECT OF IMPROVEMENT OF HEALTHCARE WASTE MANAGEMENT

Workshop to instruct waste separation

Demonstration of separation by nurses

Installed container with red bags, and “base de galón”

Installed posters

Internal transportation of infectious waste. Temporal storage for common waste

Improvement of healthcare waste management .

3

Temporal storage for infectious waste Transportation of infectious waste PRESS TOUR (13, SEPT, 2006)

News paper articles about the pilot project Declaration of healthcare waste management by Minister of health and Minister of Environment

Improvement of healthcare waste management .

4

under the witness by Mayor of Santo Domingo, to expand the experience of the pilot project to other hospitals for proper healthcare waste management (25, Oct, 2006)

i

CONTENTS

Page:

1 Outline of the Study......................................................... 1-1

1.1 Background................................................................................................. 1-1

1.2 Objectives ................................................................................................... 1-1

1.3 Targets ........................................................................................................ 1-1

1.4 The Solid Waste to be covered in the Study............................................... 1-1

1.5 Organization of the Study........................................................................... 1-1 1.5.1 Technical Team............................................................................... 1-2 1.5.2 Working Team ................................................................................ 1-2 1.5.3 Committee of hygiene and hospital waste management................. 1-2

1.6 Technology Transfer................................................................................... 1-3

2 Current Situation ............................................................. 2-1

2.1 Definition of “Healthcare Waste”............................................................... 2-1

2.2 Legal Frame Work...................................................................................... 2-1

2.3 Institutional Frame Work............................................................................ 2-4

2.4 Previous Projects before the Study............................................................. 2-5

2.5 Current Situation......................................................................................... 2-5

3 Pilot Project ..................................................................... 3-1

3.1 Objective and Methodology ....................................................................... 3-1 3.1.1 Project Design Matrix..................................................................... 3-1 3.1.2 Schedule.......................................................................................... 3-3

3.2 Investigation for Planning .......................................................................... 3-4 3.2.1 Profile of Target hospitals............................................................... 3-4 3.2.2 Characteristics and volume of waste .............................................. 3-5 3.2.3 Results of Investigation .................................................................. 3-5

3.3 Planning of Healthcare Waste Management .............................................. 3-6 3.3.1 The Committee of Hygiene and Hospital Waste ............................ 3-7 3.3.2 The Scheme of the Healthcare Waste Management ....................... 3-7

3.4 Implementation of the Pilot Project............................................................ 3-8 3.4.1 Separation ....................................................................................... 3-8 3.4.2 Internal Collection and transport .................................................. 3-11 3.4.3 Temporal Storage.......................................................................... 3-11 3.4.4 External Transport, Treatment, and Final Disposal ...................... 3-11 3.4.5 Monitoring .................................................................................... 3-11 3.4.6 Cost ............................................................................................... 3-12 3.4.7 Workshop for expansion of the Project ........................................ 3-12

3.5 Conclusions and Recommendation .......................................................... 3-12 3.5.1 Conclusions................................................................................... 3-12

ii

3.5.2 Recommendations......................................................................... 3-13

4 Action Plan of Healthcare Waste Management............... 4-1

4.1 Description of the Action Plan ................................................................... 4-1 4.1.1 Outline ............................................................................................ 4-1 4.1.2 Institutional System ........................................................................ 4-4 4.1.3 Technical System............................................................................ 4-9 4.1.4 Preliminary Cost Estimate ............................................................ 4-20 4.1.5 Waste stream................................................................................. 4-21

4.2 Action Program......................................................................................... 4-23

4.3 Program for the Implementation of the Action Plan ................................ 4-24

4.4 Program of Phase I: .................................................................................. 4-25 4.4.1 Target Hospitals............................................................................ 4-25 4.4.2 Expansion Región-0 SESPAS or National District ...................... 4-25 4.4.3 Activities and Chronogram of the Action Plan............................. 4-27

5 Evaluation ....................................................................... 5-1

5.1 Institutional Evaluation............................................................................... 5-1

5.2 Technical Evaluation .................................................................................. 5-1

5.3 Environmental and Social Considerations.................................................. 5-2

5.4 Financial and Economic Evaluation ........................................................... 5-2

5.5 Overall Evaluation...................................................................................... 5-3

6 Conclusion and Recommendations ................................ 6-1

6.1 Conclusion .................................................................................................. 6-1 6.1.1 Current Situation............................................................................. 6-1 6.1.2 Action Plan ..................................................................................... 6-1

6.2 Recommendations for implementation of the Action Plan ........................ 6-4

ANNEX A. Field Survey on Medical Waste Management B. Data C. Cost D. The Manual for Cleansing Personnel E. The Specification of Materials F. The Specification of the temporal storage facilities G. Monitoring

iii

List of Tables

Page: Table 1-1: List of personnel of the Technical Team ..................................................... 1-2 Table 1-2: List of personnel of the Working Team....................................................... 1-2

Table 1-3: List of the members of the committee for hygiene and hospital waste management................................................................................................................... 1-2 Table 1-4: Workshop and meetings with Technical/Working Team ............................ 1-3 Table 2-1: Categories of Health-care Waste ................................................................. 2-1 Table 3-1: Project Design Matrix for pilot project: Improvement of the healthcare waste management................................................................................................................... 3-1 Table 3-2: Number of personnel and beds in Ciudad Sanitaria..................................... 3-4 Table 3-3: Characteristics of waste from each center.................................................... 3-5 Table 3-4: Quantity of Waste Generated Based on the Study of SEMARN (Kg/day) . 3-5 Table 3-5: Roles of Committee members...................................................................... 3-7 Table 3-6: Unit Cost obtained in Pilot Project ............................................................ 3-12 Table 4-1: Categories of health-care waste ................................................................... 4-3 Table 4-2: Members of the Committee and their Responsibilities................................ 4-5 Table 4-3: Members of the Task Force and their Functions ......................................... 4-5 Table 4-4: Waste Amount of the target year (ton/day).................................................. 4-9 Table 4-5: Colors, Labeled and Type of containers according to the waste classification4-10 Table 4-6: Basic Data to Calculate the Trucks ............................................................ 4-15 Table 4-7: Truck Requirements for the Action Plan ................................................... 4-15

Table 4-8: Truck Requirements for the Areas IV, V, and VI in Region 0 of Health for Phase I ......................................................................................................................... 4-15 Table 4-9: Comparison of Individual and Centralized System ................................... 4-16 Table 4-10: Infectious waste treatment technical options ........................................... 4-17 Table 4-11: Basic data to formulate the A/P ............................................................... 4-20 Table 4-12: Basic Costs to Formulate the A/P ............................................................ 4-20 Table 4-13: Action Plan by Phases.............................................................................. 4-20 Table 4-14: List of the Target Hospitals for Phase I ................................................... 4-25 Table 4-15: Action Program Phase I (2006-2008) ...................................................... 4-27 Table 5-1: Unit Cost for Infectious and Common Waste Management (US$/Ton)...... 5-3 Table 5-2: Cost Reduction Due to Implementation of A/P vs. Non-Implementation ... 5-3

iv

List of Figures

Page: Figure 3-1: The Scheme of Waste Flow........................................................................ 3-8 Figure 3-2: Base de Galón ........................................................................................... 3-10 Figure 3-3: Poster ........................................................................................................ 3-10

Figure 4-1: Relation of the Organizations concerned with the Healthcare Waste Management .................................................................................................................. 4-1

Figure 4-2: Relation of the Organizations related with the Healthcare waste management................................................................................................................... 4-4

Figure 4-3: Pictures of the Infectious Waste Container (The red bag with a container, the base of gallon with a gallon bottle) ....................................................................... 4-11 Figure 4-4: Collection and Transport Network Scheme for Final Year of Phase I in the

Health Regions IV, V, y VI of Region O (2008)......................................................... 4-14 Figure 4-5: Example of a Tentative Compartment for the Infectious Waste .............. 4-19 Figure 4-6: Actual Waste Stream (2006)..................................................................... 4-21 Figure 4-7: Waste Stream Phase I (2008).................................................................... 4-21 Figure 4-8: Waste stream Phase II (2011) ................................................................... 4-22 Figure 4-9: Waste Stream Phase III (2015) ................................................................. 4-22 Figure 6-1: Waste flow of Current Situation (2006) ..................................................... 6-1 Figure 6-2: Expected Waste flow of Target year (2015)............................................... 6-2

Figure 6-3: Relation of the Organizations related with the Healthcare waste management................................................................................................................... 6-2

v

List of Abbreviations ADN National District Municipality (Ayuntamiento del Distrito Nacional) BOD Biochemical Oxygen Demand CAASD Corporation of Aqueduct and Sewerage for Santo Domingo CD Capacity Development COD Chemical Oxygen Demand C/P Counterpart DF/R Draft Final Report EMUCD Environmental Management and Urban Cleansing Directorate

(Dirección de Gestión Ambiental y Aseo Urbano) DIGESA Directorate General of Environmental Health DN National District (Distrito Nacional) EIA Environmental Impact Assessment EU European Union F/R Final Report F/S Feasibility study HW Hazardous Waste IC/R Inception Report IDB Inter-American Development Bank IEE Initial Environmental Examination INAPA National Institute for Potable Water and Sewerage INDRHI National Institute of Hydraulic Resources IT/R Interim Report JBIC Japan Bank for International Cooperation JICA Japan International Cooperation Agency M/M Minutes of Meetings M/P Master Plan MSWM Municipal Solid Waste Management MW Medical waste NGO Non Governmental Organization ONAPLAN National Planning Office ONE National Statistics Office (Oficina Nacional de Estadísticas) ONFED National Organization for European Development Funds PAHO Pan-American Health Organization PLD Dominican Liberation Party (Partido de la Liberación Dominicana) POS Public Opinión Survey P/P Pilot Project PRD Dominican Revolutionary Party (Partido Revolucionario Dominicano) R/P Progress Report SABAMAR Project of Environmental Sanitation of Marginal Barrios SEC Secretariat of State for Culture SECTUR Secretariat of State for Tourism SEE Secretariat of State for Education SEESCYT Secretariat of State for Higher Education, Science and Technology SEIC Secretariat of State for Industry and Trade SEMARN Secretariat of State for Environment and Natural Resources SEOPC Secretariat of State for Public Works and Communications SESPAS Secretariat of State for Public Health and Social Assistance St/C Steering Committee S/T Study Team (JICA) STP Technical Secretariat of Presidency S/W Scope of Works SWM Solid Waste Management T&M Time & Motion Survey TWG Technical Working Group UASD Santo Domingo Autonomous University (Univ. Autónoma de Santo Domingo) UNDP United Nations Development Program USAID United States Agency for International Development WACS Waste Amount and Composition Survey WB World Bank W/S Workshop WHO World Health Organization

Chapter 1

Outline of the Study

1.1. Background

1-1

1 Outline of the Study 1.1 Background

The Santo Domingo National District of the Dominican Republic had a population of around 950,000 in 2002, and there are 230 hospitals. At present, the main issues in healthcare waste management in Santo Domingo National District are:

Infectious hospital waste is not separated before collection and transport, and is disposed of together with general municipal waste in the final disposal site. Consequently, there are increased risks of infection to the solid waste management crew, as well as adverse effects on the surrounding environment.

The hospitals, Ministry of Public Health and Social Assistance (Secretaría de Estado de Salud Pública y Asistencia Social, here after referred as SESPAS) and international donor agencies have been making efforts to improve the existing situation. However, the problems have not yet been solved.

While, in November 2003, the Government of the Dominican Republic requested Japan to implement a development study. In response to this request, JICA dispatched a Preparatory Study Mission in March 2005, and the Scope of Works was signed on April 26, 2005. Finally, for the implementation of this Study on Integrated Solid Waste Management Plan in Santo Domingo de Guzman, National District, JICA selected Kokusai Kogyo Co. Ltd. The study for healthcare waste management was conducted as part of this study.

1.2 Objectives

• To formulate an Action Plan for healthcare waste management with the target year 2015.

• To transfer technology and knowledge of the management of healthcare waste to personnel and institutions involved through the process of implementation of the Pilot Project and making the Action Plan.

1.3 Targets

Target hospitals: 230 healthcare centres in the Santo Domingo National District.

1.4 The Solid Waste to be covered in the Study

The waste generated from the healthcare centres excluding radioactive waste.

1.5 Organization of the Study

The organization of the study was composed of three teams, Technical Team, Working Team and the committee for hygiene and hospital waste management of the target hospital for the Pilot Project. The study team worked with them.

The Technical Team was playing the role of necessary decision making, especially for preparation of the Action Plan, the members of the Technical Team are from SESPAS and Ministry of Environment and Natural Resources (Secretaría de Estado de Medio Ambiente y los Recursos Naturales, hereafter referred as SEMARN).

The Working Team and the committee played the role of implementing the Pilot Project for the improvement of healthcare waste management.

The members of Working Team are composed of personnel from SESPAS and the target hospital of the Pilot Project, Ciudad Sanitaria. This hospital is a complex of four healthcare

1. Outline of the Study

1-2

centers as are shown in the list of members. The committee is defined by the legislation to be set up at each hospital in the country.

1.5.1 Technical Team

Table 1-1: List of personnel of the Technical Team

Name Position Organization Lic. Luis Felix Roa Director of Health Environment SESPAS Dr. Bruno Calderón Ocupacional Health SESPAS Ing. Román Brache Ocupacional Health SESPAS Ing. Alba Heredia Basic Sanitation SESPAS Ing. Hildebrando Rivera Solid Waste Unit SESPAS Lic. Elsa Ferreras Environmental Quality SEMARN

1.5.2 Working Team

Table 1-2: List of personnel of the Working Team

Name Position Organization Dr. Julio Manuel Rodríguez Grullón President Dr. Nelson Gómez Región IV SESPAS Lic. Raúl Rosario Dep. Riesgos Ambientales SESPAS Ing. Luis Alonzo Dept. Ocupacional Health SESPAS Dra. Mercedez Castro Bello Director of Committee of

hygiene and hospital waste management of Ciudad Sanitaria

Ciudad Sanitaria Luís E. Aybar

1.5.3 Committee of hygiene and hospital waste management

Table 1-3: List of the members of the committee for hygiene and hospital waste management

Name Position HOSPITAL LUIS E AYBER

Dra. Luisa Lafontaine Director Dra. Sonia Valdez Epidemiologist (President of the committee) Lic. Fátima Espinosa Administrator Sr. Juan Gómez Chief of cleansing dept. Yolanda Nicolás Chief of Laboratory Lic. Santa Rita Pimentel Chief of Nurse

COMITÉ DE HIGIENE Y MANEJO DE DESECHOS HOSPITALARIOS DEL CEMADOJA Dr. Sergio Castillo Director Dra. Ana Julia Cesin Epidemiologist (President of the committee) Lic. Delfis Taveras Lab. Researcher Rudys Morales Technician of X Ray Santiago Reinoso Chief of cleansing dep. Lic. Elba Felix Nurse of X Ray Lic. Nurys Tamayo Administrator

COMITÉ DE HIGIENE Y MANEJO DE DESECHOS HOSPITALARIOS DE LA UNIDAD DE QUEMADOS Dr. Carlos de los Santos Director Lic. Arcadio de los Santos Administrator Dra. Rosario Alt. Valdez Duval Infectology service Lic. Rosa Margarita Beltré Pérez Nurse Lic. Dulce Milagros López Gónzalez Surgery operation Lic. Ana Isabel Herrera Plaza Pharmacy

1.6. Technology Transfer

1-3

María Elena Peña Quezada Hygiene and desinfection service CENTRO DE GASTROENTEROLOGIA

Dr. Miguel Castro Director Sr. Sócrates Canario Epidemiologist (President of the committee) Lic. Leocadia Altagracia D'Oleo Administrator Lic. Alba Gómez Chief of Laboratory Lic. Brunilda Zayas Chief of Nurse Sr. Luís Jiménez Chief of cleansing dept. Ivelisse Rodríguez Pharmacy

1.6 Technology Transfer

Understanding and experiences of the healthcare waste management was shared during the process of Pilot Project implementation. Especially, as the decision at the workshops and discussions were reflected in the Pilot Project, the teams were encouraged to conduct the project.

The major activities related to technology transfer are shown in the table below.

Table 1-4: Workshop and meetings with Technical/Working Team

3-May Setting up of Technical/Working group, and deciding the target hospitals 12-May Working Team Setting up the committee for hygiene and hospital waste

18-May Working Team + committee Discussing of necessary materials and methodology for the pilot project to solve the problems.

19-May Working Team + committee Definition of target area and responsibilities of members of the committee.

24-May Working Team + committee Investigation, problem analysis

30-May Working Team + committee Investigation and planning the implementation of the Pilot Project

31-May Working Team + committee Preparation of the workshop to initiate the Pilot Project 7-9/June Working Team + committee Workshop for initiating the Pilot Project

12-Jun Working Team + committee Commencing the Pilot Project (2 months) 7-Jul Working Team Intermediate evaluation of the Pilot Project

27-Jul Working Team + Technical Team Workshop for expansion of the Pilot Project

8-Aug Technical Team Planning the Action Plan

Chapter 2

Current Situation

2.1. Definition of “Healthcare Waste”

2-1

2 Current Situation

2.1 Definition of “Healthcare Waste”

In general, the healthcare waste indicates the waste generated from healthcare facilities, and it contains both infectious and non-infectious waste.

The Norm for Environmental Management and Solid Waste (Norma para la Gestión Ambiental de Residuos Sólidos) also shows that waste from the hospitals or other health care centers is composed of infectious, special and general waste.

Table 2-1: Categories of Health-care Waste

Infectious Waste Special Waste Common Solid Waste (Non hazardous)

-Culture media and samples -Chemicals

-Recyclables (paper, cardboard, glass, plastics)

-Anatomical Infectious -Pharmaceutical -Biodegradable

-Blood and derived products

-Ontological medication

-Sharps -Radioactive

-Animals -Heavy metals

-Biosanitary -Pressurized containers

Source: The Norma, Art.5 From those wastes, special waste is supposed to be treated properly depending on its type; on the other hand, general waste should be collected as municipal solid waste. Additionally, a large portion of hazardous health-care waste in volume is infectious waste and requires proper management.

2.2 Legal Frame Work

There is sufficient legislation for proper management of healthcare waste in the country. This legislation is the following:

• General Law for Health (La Ley General de Salud), • General Law for Environment and Natural Resources (Ley General del Ambiente y

Recursos Naturales), • General Regulation for Hospitals (Reglamento General de Hospitales), • Norm for Environmental Management and Solid Waste (Norma para la Gestión

Ambiental de Residuos Sólidos) • Environmental Norm for Integral Infectious Waste Management (Norma Ambiental

para la Gestión Integral de Desechos Infecciosos). In addition to the existing legal instruments, SESPAS is preparing the Regulations for Hospital Waste (Reglamento de Residuos Hospitalarios). Meanwhile SEMARN has initiated a process of putting into effect the Environmental Norm for Integral Infectious Waste Management (Norma Ambiental para la Gestión Integral de Desechos Infecciosos).

2. Current Situation

2-2

The existing legal instruments basically describe what should be conducted and by whom for proper healthcare waste management.

a. General Law for Health 42-01, March 2001

Ley general de Salud (Ley No. 42-01) Section IV : About the Solid Waste established that solid waste management is under the jurisdiction of SESPAS; however, those wastes which are hazardous are under jurisdiction of SEMARN. Healthcare centers are required to inform SEMARN about their locations and operations, since they have possibility to discharge hazardous waste.

Ley general de salud (Ley No. 42-01) Section IV : About the Solid Waste Art. 46.- The Secretariat of State for Public Health and Social Assistance, in coordination with the Secretariat of State for Environment and Natural Resources and other institutions concerned, will elaborate the official norms that regulates solid waste disposal and management which usage, collection, treatments, disposal, conversion, industrialization, transportation, storage, elimination or final disposal results hazardous for the population’s health. Art. 47.- The institutions of the health system and all those health establishments that, because of its operations, use materials or toxic substances or radioactive, pollutant or others that can disseminate pathogens elements or be harmful for the health, must have a waste elimination system developed according to the norms by the Secretariat of State for Environment and Natural Resources and the other institutions concerned. The medical waste will be stored differently, technically treated in its origin and/or given to the municipality or institution concerned, for its adequate transportation and final disposal. Art. 48.- The sanitary authorities must inform the Secretariat of State for Environment and Natural Resources about the establishments or places that can be hazardous for the population health or their life because of the undue and unsanitary accumulation of the solid waste, looking forward that they order their cleaning and carry out the respective administrative and security measures.

2.2. Legal Frame Work

2-3

b. General Regulation for Hospitals, Decreto 351-99, SESPAS, August 1999

Reglamento General de Hospital is a principal law regarding the hospital management in general. For the waste generated from the hospitals, the regulation established to create a committee. According to the regulation, to manage the waste, each hospital is supposed to set up a hygiene and hospital waste management committee. Hospitals have responsibility of handling the waste correctly from its generation, treatment, and transportation until final disposal.

c. Norma para la Gestión Integral de Desechos Infecciosos, SEMARN, Julio 2004 (The Norm)

The Norm established in detail manners for managing the infectious waste. According to the Norm, Any entity that deals, transports, treats and disposes infectious/hazardous waste must obtain the permission or license from SEMARN for their operations (The Norm Titulo VIII).

At the same time SEMARN is in charge of supervising any center/entity, which deal the infectious, and/or any hazardous waste from healthcare centers (The Norm, Art84). Moreover, every specification regarding the management of infectious waste including those which are generated by hospitals are described in this norm.

d. The Norm of Healthcare Waste

There is a norm, la Normativa de desechos hospitalarios, which was approved in July 2004 (Aviso No.68-04), by the cabinet of National District. However, this norm might contradict the legislation because la Ley General de Salud already defined that SEPAS, SEMARN and other related institutions should coordinate and make regulations regarding hospital waste.

Therefore, to emit this norm of the National District, ADN should expect the regulation by SESPAS, ADN should find the solution by coordinate and consult with SESPAS how to apply the norm for the National District. The competent authorities to carry out the regulation are defined; that are the General Law on Environment and Natural Resources (64-00), the Law of Health (42-01), the Norm for the Integral Gestion of Infectious Waste, and the Regulation to be elaborated by SESPAS.

Reglamento General de Hospital (Decreto No. 351-99) Chapter XIII

Hospital Waste Article 49.

Every hospital will organize its hygiene and hospital waste management committee, which will be in charge of the identification process and its classification, according to the national norms.

The committee will check that the system and the procedures of the local elimination and final disposal are safe and adequate, and that the staff fulfill with the security norms established for this procedures.

The hospitals that do not fulfill with this disposition, its habilitation will be revoked and they will be administratively sanctioned, and if they cause any harm to the community or the environment they will be legally responsible for those damages.

2. Current Situation

2-4

2.3 Institutional Frame Work

The main institutions that relate to healthcare waste management are hospitals, SESPAS, SEMARN and ADN.

a. SESPAS

The responsibility for healthcare waste management is split into two departments,

• Department of Basic Sanitation • Department of Occupational Health under the Directorate of Environmental Health. These two departments have various tasks not only ones regarding healthcare waste management. It is difficult for them to concentrate solely on the issue.

b. SEMARN

The main role of SEMARN in healthcare waste management is to supervise any center/entity, which deals with infectious, and/or hazardous waste from healthcare centers (Art.84 of the “Norma Ambiental Para la Gestión Integral de Desechos Infecciosos, Santo Domingo Julio, 2004”, Secretaría de Estado de Medio Ambiente y Recursos Naturales (Environmental Standard for the Integral Management of Infectious Waste—SEMARN July 2004, Hereinafter referred to as the Norm)) and to give technical support to SESPAS as required

According to legislations, all healthcare centers are required to inform SEMARN of their location and operation as they have the potential to generate those kinds of waste (Ley general de salud (Ley No. 42-01) Art48.). Also, any entities that deals, transports, treats and disposes infectious/hazardous waste must obtain permission or a license from SEMARN for their operations (The Norm Art.78, 79).

Subsecretario de Gentión Ambiental of SEMARN is in charge of it. However, there is not sufficient personnel to be in charge.

c. ADN

Although ADN does not have legal responsibility for hazardous waste, it has to provide a service to collect and dispose of common waste generated in healthcare centers. Since large scale healthcare centers generate considerable amounts of common waste, it has to be collected every day so as not to degrade the sanitary conditions of healthcare centers where people come to improve their health.

In ADN, there is a section for biomedical waste in its organization of the environmental management and urban cleansing direction.1 The section for biomedical waste is in charge of effective collection of solid waste from clinics and hospitals in the National District.

• To plan, coordinate and supervise the workers of cleansing at clinics and hospitals in the National District.

• To look after the correct classification of the solid waste at clinics and hospitals. • To coordinate with private hospitals and clinics for collection and final disposal of the

waste they generate. • To inform the role to the technical department about execution of programs and

activities for the division, evaluate those results and propose the measures for improvement of the service.

• To plan, assign and coordinate the workers of the area. • To supervise those workers’ collaborations 1 Direccion de: Gestion Ambiental y Aseo Urbano, Manual de organizacion y funciones, Direccion de Gention de Calidad, Santo Domingo de Guzman, Distrito Nacional, Agosto de 2005, p15

2.4. Previous Projects before the Study

2-5

• To prepare budget of the area. • To report the activities which have been implemented. • To look after an adequate attention to the citizens.

2.4 Previous Projects before the Study

ADN tried to initiate the project regarding healthcare waste management. Consequently, two hospitals, Robert Reid Cabral infant hospital and Nuestra Señora de la Altagracia maternity hospital installed incinerators in 1999. The project was going to be concluded among SESPAS, National hospitals and ADN; however, due to change of government, the project was suspended. Hospital Luis E. Aybar, Moscoso Puello, Dario Contreras and Los Minas were also supposed to install the incinerators with this project, but it was also interrupted due to the same reasons.2

In spite of this, several incinerators were obtained through a request from SESPAS to the Executive Commission to Reform the health sector (CERSS) in 1999 which was part of the project of Provincial Systems of Health financed by the World Bank and a parallel project financed by the IDB 3. Currently, ten (10) hospitals at national level have their own incinerators: Hospital San Vicente de Paul en la Provincia de Duarte, Hospital Luis Bogaert en al Provincia de Valverde, Hospital Pascasio Toribio Piantini en Salcedo, Hospital Jaime Mota en Barahona, Hospital Central de las Fuerzas Armadas, Hospital Maternidad Nuestra Señora de Altagracia, Hospital Maternidad los Minas, Hospital Moscoso Puello, Hospital de Niños Robert Reid Cabral, and the Complex Luis E. Aybar in the National District.

2.5 Current Situation

Although there are laws and regulations, almost all of them are not followed.

The interview survey conducted by our study team in 2005, to 9 major hospitals in the National District (See Volume III Annex) and investigations for the pilot project, revealed the actual situation of managing the healthcare waste as follows.

a. Committee of hygiene and hospital waste management

• Obligation to create the committee for hygiene and hospital waste is not followed by the hospitals. Consequently, no such committee existed among hospitals which were surveyed.

• The necessary statistic regarding healthcare waste, such as amount of generation, characteristics of the waste, occupational accidents and cost are not kept.

• No routine-training program exists at any levels. b. Separation

• Waste separation at the hospital is not practiced. • Two (2) hospitals out of nine (9) are using red bag for infectious waste, however, in

many cases the red bags are misused by mixing all types of wastes. • Containers differ in characteristics and size; they regularly have no lid; they are not

washed or disinfected. Plastic bags do not meet thickness specifications and are inadequate for the kind of material they contain. Sharp material is placed in plastic containers which do not make such material visible to protect the staff which handles them.

2 Dra. Altagracia Guzman Mercelino, The report of preliminary survey of integrated solid waste management in Santo Domingo, National District (Japanese), p26 3 Documento de Evaluación del Préstamo Propuesto por la Cantidad de US$30 millones para la República Dominicana para el Proyecto de Apoyo a la Reforma del Sector Salud en Apoyo a la Primera Fase del Programa de Apoyo a la Reforma de Salud, World Bank, June 5th, 2003.

2. Current Situation

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c. Internal-collection and Temporal Storage

• Intra-hospital transportation of hazardous waste is done without following the safety and hygiene rules or procedures. Carts do not have security characteristics and hand carrying or dragging of waste is usual. Carts are not disinfected.

• Temporal storage places do not fulfill the minimal health and environment protection conditions. Bags with waste are placed mixed in containers placed in public parking lot zones. Bags found here are torn and there is a considerable contents spillage.

• Collection and internal movements’ staff do not have elementary protection gear (uniform, rubber aprons, shoes, gloves, breathing filters, etc).

• Some hospitals have incinerators; however, they do not meet the standards and regulations of SEMARN to incinerate infectious waste, and are not maintained well.

d. Collection and Treatment

• Even when hospitals separate the waste at the source, all the waste is mixed when collected.

• External transportation is done in vehicles not meeting conditions for transporting hazardous waste.

• There is a private company that is able to transport and treat infectious waste and has a permission of SEMARN; however, this company had not been contracted by any hospital at the time of investigation.

• ADN or the private collection companies collect the waste from hospitals as common waste. However, waste collection by ADN is irregular and deficient, which causes accumulation of waste. Thus, it produces hygienic and esthetic problems in the premises of the hospitals.

e. Problems Faced by ADN Regarding Inadequate Management of Healthcare Waste

• Large hospitals are big generators of common waste which can be considered as ICIs, industries, commercial and Institutions as defined in the Action Plan of municipal waste. Currently, ADN doesn't have a differentiated service of collection for ICIs, which is especially required from hospital that might have daily collection. On the other hand, the authorized private companies (Klinetec and SERTEX) can provide service to the hospitals as ICIs, however, their capacity should be confirmed.

• Collection of mixed healthcare waste causes an occupation hazard to the municipality’s worker. Therefore, the municipality’s workers refrain collecting the waste at the hospitals. On the other hand, when appropriate separation is made, the collection workers from the municipality or authorized private companies are able to verify if appropriate separation is made; they can refuse to collect such waste if it is observed mixture. Collection workers from the municipality or the private company can be considered as additional monitoring tool.

f. Final Disposal

There is no special cell or space which meets the regulation of SEMARN at the landfill site to dispose infectious waste, in the National District, not even in Duquesa landfill. However, Duquesa has made efforts to construct a special cell to dispose of infectious waste in the Landfill. Currently, Hospital Marcelino Vélez Santana in Santo Domingo West is using this cell.