E1 204 >I I I S'f1\ ' JS )1 I IK 1' . ''I'l I Health Care Waste Management in Ghana MOH Policy and Guidelines for Health Institutions PO Box I -1 -* Ac r;i (Gh.min Plbonic 233 21 660 693 r-;, 2;3 21 6(j,$(5; Abbreviations 4 4.2.3 Colour Coding: 14 Glossary vi Table 2:Colour Coding for Storage and Chapter 1: Introduction 1 4.2.4 Storage 16 1.1 The Nature of 4.2.5 Internal Storage 16 Problems (Impacts) of 4.2.6 External Storage 18 Health Care Waste. 1 4.2.7 General 1.2 Objectives of the Requirements for Waste Policy and Guidelines 2 Collection Containers 19 1.3 The Policy and Legal 4.2.8 Standards for Context 2 Disinfection of Reusable 1.3.1 Legal 3 Health Care Waste Chapter 2: Scope Containers: 19 of Policy 5 4.2.9 Collection and Chapter 3:Policy Transportation of Health Statement 6 Care Wastes 20 Chapter 4 :Tecnical 4.2.10General Requirements for the Tr Guidelines 9 4.2.1lRequirements for the Transporta 4.1 Classification of 4.3 Contracting with Health Care Waste 9 Health Care Waste 4.2 Overview of Contractor 22 Implementation of Safe 4.4. Treatment Options Health Care Waste for Various Waste Streams23 Handling and Disposal 4.5 Recommended System 11 Equipment 24 4.2.1 Sfeps in Health Care 4.6 Waste Minimization25 Waste Management 11 4.7 Waste Water 4.2.2 Segregation and Treatment and Disposal 25 Containment of Waste 13 4.8 Spillage Procedures26 4.8.1 Procedure for 7.2 Dissemination Handling Spillage of Strategy 40 Clinical Waste 27 7.3 Implementation 4.8.2 Spillage of Road Map 41 Chemicals 28 7.4 Responsibility for 4.10 Health and Safety29 Implementation 43 4.11 Record Keeping Chapter 8: and Documentation 30 Monit Chapter 5: oring and Review 45 Traini 8.1 Monitoring and ng, Capacity Building and Control 45 Research 32 8.2 Audits 46 Chapter 6: Information, 8.2.1 Periodic Education and Management Audit 46 Communication (IEC) and 8.Z2 Extemal Random Audit46 Advocacy 34 8.2.3. Audit Tool 47 6.1 Information, 8.3 Reviews 47 Education and Bibliography 48 Communication 34 APPENDIX 1: SAMPLE 6.2 Advocacy 34 FORM FOR ASSESSMENT Chapter 7: OF WASTE GENERATION49 Imple Appendix 2: Clinical Waste mentation 36 Audit Tools 50 7.1 General Principles of Appendix 3: Equipment Implementation 36 Options and Initial Cost 7.1.1 At the Institutional Outlay 52 Level 37 Appendix 4: Relevant 7.1.2 Local Control of Infection Arrangements 39 Policies and Other 7.1.3 At the National Guidance 53 Level 39 H e ALT H CAR E WA STE 'MAN AGE MEN T PO LI CY Clients - Paticnms and their caregivers, visirors to the hcalth facititics Etiologzc Agents: (.)rganismns or otlher- ageInts that causc .a rculai diseasc Hazardous Waste: W`aste that can have a significant advcrsc fttcr on ub)lic health and/or thc environment dILIc tO irs ( nfcctiouL1CS;, roxicity, corrosiveness, carcinogenicity or otlhe properti:s. Health Care XVaste: All untreated solid and licitiid vwaste (both lh;azardous and n1on-hazardous) gciierated duting the administration of nmeclical carc, vcterinmavy care or the perforenarncc of medical research involving humans an(d animals. l lese include infectious, pa thotogical, radioactivc, jl1aUnIacCItrica,l and otrier hazardous wVAStCeS. Inzfectiouis Waste: \Vaste containinig pathogellic ovrjanismlls likc l)Wrcrla, VitusCe, piara.sites and fungi in suUficient qLuMitULies to caRuse dliseasc ini susccptiblc h1osts. Pathogens: Disease causing agents Pathological Waste: rissues, organs, bodly parts. f(mlescs, etc. rhat have the potnt.ial to be infectious and are rhteretote soMenmLes classifieCd as a s1UbC'atCg0o-\ ()f iniecCotLs LCS. Sharps Container: P'uncture resistant waste conraiuner used for disposal of needlcs and associatcd sr'n'ges. Sharps: .\lI itemls ilhat pose a risk of injuiry and infecnion duc to thilitr, puncture and cuting prolperties e.g. needles, scalpels, knives, glass s,ringes. piprtes and similar items having a point or shar) e(lge or that arc i.kclv to break dullng tranls,porranon and result in a pnintcd or sharp cdge. vi I H EALT H CA RE WA ST E MA N AGE MIE NT FO LI C Y HE ALT H CARE WASTE MA NAGEMENT PO LI CY vhicih are incffectve. There is also no valid monitoring mechanism to verify complpanicc tO ag-rced norms and practices. A survcy carned otu in 2001 to assess health care waste management in health facilities in Ghana showed that wastc managcment practices were below acceptalle standards and1 poscd nisks to staff and counniLlities. Kycy findings of that survey ilclude: o .\bscncc of a national po1icy ind guidelines and standard opcating prloccdurct-s o Different systerms in place for xvastc segregation o No colouir coding in place and wvasrc \v\erc not la,ibelled; o (;ontaincrs for wvastc were unaccepta)blc and not standardized. O \'chic]Ls for transporting waste wer-e inadcquate; o Storage sitcs for waste wVithiln tlc facilities wcre open, accessible to unatrhorised persons and an.imals, brecdjng grounds for flies, rodents and other insecrs; o l;inal dlisposal of waste was unacccptable; burying and open burning were tht notll andc in somc cases infectious zwaste was dumped on peIn groundls. lII orderl. to addr(eiss these shortfalls, rinc i\ltstr of I-lcaltli set ulp a wvorking grolup madec ul of sakcholders in the sector, borih public and( private to devclop a policV and guidelincs for managing health care waste. 1.2 Objectives of the Policy and Guidelines T he pohcLi seeks to enstire that lcalth care \waste is managcd effectvely in compliance With existing laws and regulations and others to bl passed ini future in order to protect hecaltlh care workers, thIc cLents (patients, caleriv ers and visitOrs) and the environimecnt fromll potentially' diseasec-causing xvastc m.-aetnals. "hc Gciidehi-ics provide standards, procedures and processes for liandling he;ltth care waste in the sector istiLtutiOtils andc mechanuisms for perfoirnance and per. fot)snriancc monitoning. 1.3 The Policy and Legal Context WVI aste management in Ghana is a mul -secromal effort Vith the iaynistrg tf I .ocal Government and the l˝ironmencal -IProtection Ayencr playing key roles. l'his responsibili is discharged rhI thIro the District. Municipal and 2 HE ALT H CARE WASTE MA NAG E M E N T PO LI CY MeLropolipan \ssemb es which are directly un(ici' the Nltinistrv of 1,ocal Gx( CEImlmlt antd the officeCS of thc Environmenital Pote otion .\ge T. [ het Ullll)at.' IrSpi Ibilit for ctisuing that wvaste is disp ised of, howvever, lies with ilihe prson ol institunon hIIat gelner-atCs the waste iII 1rne With theC p)inlciple Otf 'tllc pollulter trays. Health care i1stitutions arc therefore responsible for the wasle that is gel:neratetcd by thlirl activitics and ;re req cCl d to take practical stelis to ensure tleir separaton. storagc, treatiir and sia,frc disposal. 1.3. 1 Legal T hlere is no specific law that addresscs rhe management of hlealth care waste In Ghara at the mnomenit. fhc b)est provision sigghtCd is foLnld in thle National Iiiildiing Regulations, 1996 1L1 1630 which stat-s in Section 145 (8) thal hazardous refuise shall le handled sepaLately fioml donicstic rcfuse. l-Howcec, V'arious laxws assign responsibillimes that imIinge pm n o waste maI-nage:ment to the- District Assemblies and thie Envir-oinienital Protection Agency. l l-his situLation leaves room for the performanice of the funCt.on tO fall rthroug0h the cracks There is thle need for a speci6c law that addresses how lihalt1i c-arc wastC should be handlel in ordel ro avoid any arnbitpiries, especiallv since tre laick of proper managcmernt ot heilt:h care waste has grave conseq1uences to societV. Some ol khle laws that have relevance to Health (Care \Waste Management include: • 'lie Cmistitution o)f the Rcepub)lic of Ghana, 1992 lieC ItviMol-enrital ProLiction Agency Act, 1994 (\ct 490) *• 1nviLonmrental AsscssmCIlt Rcgulalions. 1 999 (.I 1 652) * Ti. Locil Governmnent Act, 1993 (Act 462) National Building Regulations, 1')96 (J,I 1630) * T-own ancl CounItty Planning Ordinanices, 1944 (Cap 84) V Vaccination Ordinance Cap 76 * Quarantine Orcdnance Cap 77 N losquito Ordinance C:ap 75 * Infectious Disease Ordinance F Food Rnd Drugs L-aw 3051) (1992) Ioicuavies and Fiuncral Facilitics .\ct, l90)8 (Act. 563) 3 HEALT H CARE w ASTE. MAN AGE ME NT P D LI C-Y - h" .l(j C.rIrnil ( lode )i96(' (.c-t N!; I'hc Constinirion of Ghana enshrines the human rights of the individual and requires thc President to report to 1Parhlament at least oncc a year all thle steps taken to ensure the realization of policy objectives contained in Chapter 6 and in particular, the realization of basic human rights, a healthy economy, the Ligh)t to work, the light to good h1ea]tlt care and tde right to education (Section 34(2)). Section 41 of the Constituion lists certaini duties and responsibiites associarcd xvith the cxcrcise and en'oyrmnen of rights and freedomns, am(ong wlich is the dut\ to protect and SafCguaid t51e: envuilo`nm1erit. Thc Criminal Code, 1960 (Act 29) 296(1) provides that whoever placcs or pcrmirs to be placed, any car-non, filth, dirt, rcfise, or rubbish, or any offensive Or o(hlcrwisC ur\Vholesomc iatter. on ,inv stieet. yard, cnclosure, or open spIce, CXCCept at suLtCh places as may rhe set apart bv the local autlhority, or health officer for t1nai purposc commits a pullishable ofEcnce. The colde went furtlher in section 297 (1), to statc that vlhell an offence h.-s b)ecn conmiltted under section 296 (1) lbut tihe offeidcr hias not becn identified or discovered, the fact of any carrion Or Other substancC mentioned in that subcctCion beintg fotlund in front of any prcnises shall be pr1nmi facic evidence of its having been placed thlere by rht occupier of the PICn1imses. By- going to thinS cxtricm, the lawv sceks to enasure tha; tesidents take responsibitiry for the strects in front of tlhemn as well as their prcliscs. Th'lere arc similar provis ionS In the other lavs cited above. The National Building Regulations, 1996 (LI 1630) stipulates in Section 145 (1) that a builiding for residential, commercial, industrial, civic or cultural use shall have a facilin! for refuse disposal. It wlent furtlhcr to state in Section 145 '2) a requirement that each dwelling unit shall lhave a standardiscd dustb;ibn or other recepttacle approvedl by the District .\ssclmlbly in which all efus.,S generated shall be stored tcmporanily. It provides for transfer stttions, lO bc located witthin reacch and preferably protected from rain and the prevention of sprecading, pest infcstation and scavenging acuvirics. 4 H E ALT H CARE WAS T E MA N A GEM ENT PO LI C Y T he t olllc\ and (Gtiinlciiles apphl pLirnaiilv to all hecalth insuori oms \wwlUrl.'d public, private. quasi-t1(\ovcrnmental, non-governmineltll or- Larh-l ;i, I bat olperarc in ItheC COunItr at aU levels: Tevvi/i'eacing/Speeialist I lstLI>. Regiona] [-lospiltls, District H-lospitals and Sulbdistvnct Hcaltl InsUtLtiUiIs .1c I Centres /Clinics and ComnLtyilv CClinics. Health Researc-h Institti0n1s. I .alva (()iis Akltcvnmaic Hlealth Care lProviclers, Niortuarics, Funeral -loines and Und(cerAlwrs. Phatinacics and Chemiist-S are also included. 'X"hilst refeencc n-iav le madc rt1 gcneral domicstic \vastc genierated by dtese instiLuo01s, thCe fCLIS of hliC lPolt\ a1ld GuiCIClin1es is health care wasre that is consicdered hazardous. Intsutuntons and comnlpanies with rcsponsiNility for trearm-tent, transport and disposal of w asrc an also cxpccteCd ro farniljarizc ticlvlelVC5 withl the provisions of the Policy a,iul ( uikiulullS and nmi '; comply with thie,ml. I i I Ii i H E A L T H C A RE WNASTE MANAGE MENT POLICY A 11 vaste that meets the definitions of hazardous wvaste shall be considered as suclh and be treated in lnc wvith this polic) and otiher legal requircmenTs in force at the tinc. 3.1 F:vcrn hcalth institutJon shiall have thi responsibility to serparate, store, labcl, trcat, transport and dispose of all waste in the manner prescilbed in this policy and other laws and regulations regard-ding Health Care \Vaste Management so as U) safeiŽuard the safety of its workers, clients and the environment. 3.2 All health institnions and their officers have a duLc' of care to: * Storc wvaste correctly and prevent its spillagc or loss of anv kind; * Segregate \vastes that reqtire different merhods of(disposal; ' I,al)cl waste to idcrufe ' its source an(d contents; Pvass wvaste on only to pci-sons authorized to reccive IL, Reccive W"aste only wvhen pproerly authorlsed to dlo so and only from an authorised person; • Describe the xvaste (on rhe appropriate fomis) in sufficient detail thaT subsequent carriers and disosers can deal with it safely and are liable for an! ncgligenice on the part of rtie instiution or its officers. 3.3 Health institutions shall ensure thai ever) xvaste thcy generate and pass n io a transporter or waste maniagemenit company to be transported to a disposal SitC or to lhe disposed of, is accompanied b) a signed statement ccrrifying that the waste has been properly segregated, stored and treated in accordance With this policy and guidelines and no longer constiattes a hazard. ]n cases where thie institliflon lacks the facilitv to trcat and thierefore hands in untreated waste, the certifcatc shall cisclosc this fact. fhere shall be affixed to every wvastc a label whlich indicates thie classification, The processes it has gonic through ancl theJ initials of the officer(s) who processed It. H E A LT H CARE WAS T E MAN AGE MEN T PO LI CY 3.4 1 hc ap)propriate coloir coding anid maten-ial s,hall be ad(opted fCm ww;s:c C 1tR1it1CIS )v! all h1calth ilStiiUtiOlS ill oLXdc2r to tacilitate idceoibficatioll of ilw( l (p wVas*e wsingl tile .)-CO)t.lt system. I ICatIl ( ate \\'AStC shall therefore b) scgl ciu;:d aw follo>\x's: Classification of Waste Container Type /Colour Nion-hazardous waste Black container Othier infectious waste ]l1liliinieeuuca8t.l &; ( tli:- (lk-T1roI ........... .........! \\.1>1ye h4i} .l 3.5 A llhealtl institutions shall recrLitr and tran hlealtlh care wvaste minana',;,cmer officcrs anlld COSUC that thcCe are WCtell c(.lizpc(. to h1aIleC heaklh carc WvastI. I callth care \Vastc maliagctimcnt tramlitig should b( incorlpoarted in both prc- andl in- st:txi:c< training of hcaltl pcrtSormcl T1'his training nortwirlstacliing, whecre it is tL)rfC1tV )o dCo so for reasons O cost. cfficicy, or othier reason the wvaste managenact ItMIcIIoM mav be outsouirced to a 1U1V ceLtified wastc maaiagement. 1 cop11anv. 3.6 Accurate records on \vastc mniagetncint activitics shall be kept b\ :ll hicalrh institutions an(ld waste m11a ,nagemCent cotnpaies. 'h1cse records shall bc miadc available for inspection by the dcsignated a1uthJorities. Such recolds shlall be1 mainltained foc a minimnuma of fivc years after the disposal of the vastce. 3.7 Places of final disposal of treatcd wastc shall be identified and acquitied, wellici Such acqutisitiOn iS necessaryS , In accordanc witlh cxisting legal regulations and shall Le protected fromii unautioriscd cntLy, lesrs and scavengin g actiritics. 'lhe dtsposal method used shall bc in linc with the approved methocl for each type of waste.. Every region/instituricon is responsible for drctmnininig tlhe disposal mlerhlod for I particular waste, based oni thlc recotunmendations in Section 4.4 of the lcclnical Guidelilnes (Cliapter 4) in thiis documnenit, whiichi spells ourt the apprc ved ald pareferred disposal melthods. HE ALT H .CARE WASTE MANAGE ME NT POL ICY 3.8 V herever pracricabkc, the disposal Site approved by tihe District, Municipal or 1\ leropolirln Assembly in consultation wVidt an officer of rite FEnvilronmelitial Protection Agency for the disposal of waste shall havc a scCtion designated for hllc disposal of treated healtlh care waste. 3.9 1'rovidedl the principle of treating and disposing of waste as close as possiblc to the point of generation is observed, health insthittions in the satne vicinitV maV share facilities in order to mirnimize costs. 8 HEALTH CARE WA STE' MANAGEMENT P O L I C Y I npursuit of thle poLicies set oUt in the preceditng sections, tiie technuical guidelints provided below shall apply. 4.1 Classification of Health Care Waste IHcalrh care waste includes all untreated solid and liquid waStC (botih hazardous and non-hazardous) generated during the administration of medical carc, or thc performance of miedlical research involving humans and animals. flhse include infectious, pathological, radioactive, pharmaccutical and othel 1IazltdoULs wastes. Gcneralk-, bcttween 75-90% of the waste produced by healti-cire providers is non-risk or "general" health-carc wvasic, comparable to dloilCstic wvaste. The reIllaininllg( 10-25"9,) of health care wastc is regarceCI as haza'dIus. Thes gLuidelinIes there-fore identify r%vo broad catcgorics of licalhti carie w produrcvd within tie j from ) nts oigenertio.ll, hositmal enrironflienr tnd rhciefore reqmives special h:lcdlivig. ki[chen waste, aids. a swi .st. It Includes S\svectp1os frcnm Imtvns ot colidol'. offices I picces of wood crc workshop. slovs, w;iste I rom, kitchts, eftc INFEGOUOW'S XAS1TE . . ...... ' Lthoraton waste een,r.cd I Th1is refers to waste gCrie-jaccd I>v bohii lp-lirs/ol- e liv ntir<>logial plucitvi iaini a,n,as s luch I,t knowni or Ii kel s to Coiliain it, rictg,oll. ptilogciu1c jijtcro-org-atisnis It incltidts matieral that caii lIe Po..*ItenjtIl\e Infctcdj Isljo'le. cNpcl-ime.wni slicrimco ,l (animnals), tissuc eitilit-ic. I u nine, stnol) 'j nc. tfacces (stooli) trem | lallori'torl E:etinsxetital specilnme PATHOLOGICAL/ORGANIC HU!AN/ANIMAL I* nternal bod r ovgais TISSUE rmptiir,ted 'itmbs, plactos hiis rtpc of -stlst tnicloles -nsputatit-lns anid other bods- foertis tiastics resluti(mg fiom norgita i;i,i~ ,- -Il.Lt iili.il- i,n:-h ;-!..-!C 1 11'i)'.1(.11 .1110 !Sil , ,. , - 5 0 t I l.z., *ll * ITl: I< *10;!!1I]!r;! .:! : k.9t 1)..l(t.I I , H EA LT H CARE WAS YE MAN AGE MEN T PO LI CY iTYp *CLAZ,SIFICA*TIONAN[ D) DES[-CTIrfoN (XONTFI'Nl /I A\AM1p ;:> i L .'il}ll ei\lX t-- ,\r- - . '\ Ais l l-.-' --'--- | . , I . , .R A ,,,I Ic(I '.i ' ,' I. , I\ \ I-!I * P 511. 1 I RADIOACTIVE WASTIE U .AW)R I-' OR \%- L d .1 '' I I F) ALKAIA'-~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~I'tr~I ) I _ _ . I I: ... I .-- . i ' * ioI kI' Il 4 I.A VY){ IF ()Y'A \.SI Mectic *I:~ ro-c(in((llEl(l\X.i --- -i .IXrtQ1'! , ~Ih IAl.i....... :CI~~ll~ ' . r V4 I.r\.01\INI?RII ORASHANTS -I)F; )1(tth10"1Trl) t:eSlot , -i dtalto)c u 4.2 OvrviewK[ of IVImpe enaio(f;aeHelh aeSat H andlosing WAnd Disosa System- 4.21 Overv iewonmlmntto fSf Health Care Waste Mngmn Ihe -tages ini H.e'lth I are aste NI.anage'ent. (I (AVNI) 'rc productoni/genraition of warc, segregation of che 1va.st fC a I'''. ; 9,,,,,,0 Iwo. .I jr y)lt uecep)ta,c1cs (conta;inciisation), inrerna,l storagc (in the wardJs a,nd other ! 1til1,~~~~~~~~i H EA LT H CARE WASTE MANAGE ME NT PO L ICY departi,llents). pachaging/lahelling and iinternzal transportation to an cxNernal storage site iL tiansit storage Sit e.g. an on-site central srorage point. \ll thbcse Stai1es take placc %vihilifl the Facility and are follomvcl by transportationl ro a treaCOtineC 1 plant. (on ov off-sitc) and Final dlisposal. T' Ie sla;ge>s in I l(.WVl arc sLimmarized in figurei 1. In cach instirurion, thc head of the flaciliy 11ust cnstic that ilhc steps arc folowvecl to cnsure adc(luate co'llccrl )I( an(d disposal of the health carc \vastes. 1;u:therinorc, inicroplanning s1`10111d b)C C;liei'd olJt starting fromn The fcilit\ and suibdisirict lcvel to enstitrc the rno( I cosi -ctd-Ccice e Incalls o)f coilecing,. tranispo)rtling, trcartiln. ;1nd(i final diS1posal Of tlie \vlSte. Fig 1: Steps in Health Care Waste Management - L~~ ___;.) ----- -- -1 - 1)e-ar rqn 't) in mind thie following considlecailolls: 1he nauruc of waste, level of to)xicit\ and risk to heal1Th-. * Legal - the prevailing rcgulatr 1s (on health and environincnt) • J-;iiiancial - jinVestmeTt and runni)'ng costs, as again st The ftacilitv"'/distr ct's /rqugion's budget. Te lchical0 -technologies aalbeon flbe market and( eNisting options In tile sub-r-egion1. Paj1nT ) ,Ad /(]Uanti fltlv 0f \as\ e enerliares:d dalk 12 HE ALT H CARE WAS T E MAN AGE MEN T PO LI CY *Susraiiabilitry - vicved alonysidC tlte ava lebil ly ne ctlugy sources al1d OthCr utilities to run e1uipmLIlIcnlt. IL.ocal comm unity' prcecrcnccS - whiljsi sorne C1mmuniIIItIeS 111mnV have anM avrsinll for some treatmielit ONtiof-s available for sonw Lvl)cs of xvastc t-o cultural, religious andl othier reasons; (e.g. usc 0i steaM aRutOCIaXrCS 0 incinerLtion, of body parts), others mav wclcorrc treartment options sol[:i on the lbasis of tmchnological feasibility- and cnvirunrimnental friendicliniess. l;or whiatcver reasons approved, trca tiuncnli itpii(ns alrc chiosci he ;a loccality, health care institutions and waste inanatelieni companics siall ensure ilthat safety and efficiency are not conlPrtomi1iscd. 4.2.2 Segregation and Containment of Waste fhlec fco luliniig guidelines shall apply to waste scgregation and containment: * acIh type of Waste reCCuieCs a (lifferent ietilhod of disposal. ThcrcfoeC. 1t is iimiportant that health care waste is segregated ilro tile various sub- cat,egories for safety reasons, to facitrarc ininulizaton and application of the. dlifferent disposal niethiods, wvhich arc reqluillre for cdifferent tplics otr waste lbased on the classificationrs in Tablc 1 - Appropriate halnd'iiwr treatmncit and disposal of waste by SLl-CArC(1Dr\ wil l help to reduce cosis as tihc typc of waste influences thc disp1osal mlllhod usCd, hlience disposal costs. Non-segregarion of hic wvasre rendcrs all licalth care waste ge:ncfared infectious or hazardous andc results ill I1ghWe1Cr m.anagemncrt cosrs. Senegation shlould be at source; that is it slhould take placc as closc as possible to thie point of guenration of tlh v waste and should always be thle rcsponsibilitY of the waste produceI. l1,ach waste stream segregated mnust be placed in ani appropriately coloulr- coded container as shown in Table 2. * l:or effcctive planning, each level ot the lhcalth systeCm shiould makc cStimates of their o\Vti wastc p)roduction: this imIpliCs that chIC fciCl1imx should estimate the waste it getierates. This includes all wastcs ,v,clcuated cduring clnical care (itncludinlg surgery). routine IlIld Mass iMmuniz.ation. 'Ic cstirmates shlou` l be collared by thiC D1T-NTl in each cistrict to obtain thic district wastc gencarctd and furtlier-, by thc RHN'IT to cstiimat 13 HE ALT H CARE W AST E M AN AGE ME N T PO LI CY regional waste generation. Each region shoul(l then submit returns on tihcsc levcls quarterly to GHIS headquarters. TFlhe teaching hospitals and GHS shoukl submit their returns to the 'N101H or an appropliate bodv or department designated b\ the fMOH, which should furthler collate the statistics into a composite estimate of the national health care wa,ste. A sample foriml foi assessmenit of waste generation is shown in Appendlid. 1 for use bv health facilities and other Icvels of the health care svstcm. 4.2.3 Colour Coding: Colour coding of waste containers and plasuLc bags should he used to facilitatc efFicient segregationi of wvastcs. 'I'hc rcco (mmenlded colour-coding schemne for Ghana (adapted from \W1HO) is as follows: BLACK Gcnrcal \wastc (e.. kitchen waste remnants of food, p,apecr. cardboard, sweepings etc) YELLO\XW hnfectious waste (c.g. sharps, paticnt xvaste (e.g. s\\al)s. drcssin,gs cic). humnan/animal tissue and cultures/specimens). BROWN 1-lazAlr_dous \vasre (c.g. expired drugs, vaccines, chenmicals etc) Table 2 shows the colour coding for the storage medium an d transportatioln ot health care wvaste. (Colour coding for the plastic bags should always correspoind or matclh with the waste contailers both at the internal and exterrnal storage sites. 14 :)ST1I.I. -P3,J1PUL't Vtillq 3iE-\jo ZX1A1 11alO 1UdiG. q.]fU ~n~Z~ZUEU .lS,tl r -^l,ttsl 2t1tDfl lS' \30 (1,1 Dil glOj DIt'!l1OI1C[Ci1 aq; 3SntU- p31Stl S.1,i UIU 0) ,:)A0(IV ; IIcIt j ii p)PLAOidl SLIO1WtpL)U.1tUOD3I )Ij) 0)3 Vti;IP.IODDU -LIIU"JUOD [)DTh)-.tl)l0, OUIn, p;)llDjxt'l A;)-lmTldo.;(idiU III p-D)99INDIA D(I p1noti,s.DSA J.i1'.D iDJ.LI nN. - l'"I- Kr '; t\ cu tiI:) k * ------------------ *t' ;' ...:. -!1..._.1:"'1-'-,.- .t. - I u - _-j.ii .:W' '-" , ' j!' 1!I';' 1 - " i - _ I . '. . . . _ _. . . _ _ . _ . - . . __._._ . _,___,,,,__ .. !,~~~~~~~.o in:o :Z a l- - __ -- ' :t,r- '~.r.~rr ) tI01 d N t 3 ' ' " 1' N, -I " M1 ','f V l: HI1 ;~~~~~~~~~~~~~~~~~~~~I K , ,I:;S. i;1*1''I 1 Cl _ _1. lI 11111l\ hil'l )tI'1EJt >1)UI$Jlc ' *,r) jl'l' AtsiVKl;| " ' '-.) W~~~~~~O '(> ti \RA JO117 UOr? 1USq )S'\ uo ejosuj l7iltt E1l3 *u a .ieso Lb -:upo Jnoj t -~ ~ ~ ~~ AIo lNWDNA -.LSV ~~V3 H-- -- r----1VX ; i- - - H EA L TH CARE W AS tE MANAG EM ENT PO LI CY Contaiiers musr be robust and resistant to corrosion. After use, they must be \Xell scaled to preveni- spillage (lu ing handling and transportabon. 4.2.4 Storage ,Storaic is thc process entailing hovW the Waste is contained during the time lapse bcr\\vcen its gcneration and collecoion for final disposal. 1his is classified into Intcrnal Srorage and Extcrnal Storage. Consideraiion for sroragc inust be bastd on the classiFication or hvie of waste being dealt wvithl and ihe potential risk )to infcction to health-care workers and waste disposal staff. Labels otl containers slhoukl6 be permanent and lcgiblc for the enutre storage period. 4.2.5 Internal Storage Intet-ial storage is the temporar 'y placcniT of wastc at the pOint of generatio0n (c.g. ward, OPD) beforc transfer to external storage points and should not exceed 24 hours. Internal storagc considerations shiould be based oni flhe cla;ssIfication or type of wvasre being dealt witih and the pornltial risk of infectimn to health-care workers and \vasrc disposal staff. -he following measures shokuld be talken to ensute safe management of \vaste at the points of gencration: i. Storagc time sh,ll be reluced as munch as practicable. Mutiple daily remcoval of the waste is recommendiecl: ii. I verv site xvithin the Health Care Facility e.g ward, thieatre, laboratory, pliannacy, kitchen, laundry etc.) shiouid be provided with su ffIcien1t number of suitable waste containers; iii. Polvthene bags must be placed in rigid containers with thie openin,g foldig outwvard over the rim to mirli-mize contamination of thie surrounding. hl-c top of the container should havc a wider diameter than the blase, iv. Disposaable polytilcne hags sh,lIl be of appropriatc size wmth a minimum of 60 iTucrojns and maximum of 100 microns in thickness; 16 H r L Tr H c A R F w A S I E ANAGME t r P o I C Vx Filled bags slhall b)e sealed o4l using a plastiy sturp whilich \xvhen f,lslencld Can'otI be ti.-opened; tilhc l)gs shouldc be sealed whcni `i'4 full. To srvc ;is ,t rcindCdc, tIC bags sloulUd have a mark showing thec mark. vi Sharps shall bc stored ill pulcture-1esisSarI containers maJc of hllck cardboard, s5or ig plastic, pwvoocd or mnctal; Vii Sharps shall not bc manpulatccd (c.g. by brheakling or bendihn) hbc(nqc disposal and needilcs shall nor hc rI:ecappcd before discarding sinlCc rlths i ,1 Commron Causc Of punCture inllulr; rhe use oF devices likCl nfl( (citrers wvhich frecs rllt syrinte of tihe nedle by cdestroying and rm:nvo-viig [1wL latter is a sate alternlative (still undeler consideraion for- usc: in develtopin)g. Countries) may be considered an exceprionl to this rule. viii. Puncturc Cesistant containrcs shall be placed as Close as posslble to rth area where shaip itCms are usedl; ix. Infectious andl haz;ardous wavastc shall he segrecgated at the poinl ot oni gil rather than at rile Lanllsfel: O' Cx\teral StOra,ge Sitet ro facilirate apCrop i;nc packaging, colour codirng and transportationl; x. Storage bins shall be placed in roofed bulil[-in areas protected frf)mfl \watcr, rain, wind, aniRmals a Td pests such as rodents, cockroaches et atid scaenwe.nrig s; ; b xi. Bino-hazar karks anld orther varning signs shall he conspicuouslyV posted oni doors leadiing tO storae sui I to ptc\ener people fr(oTm untnecessaarilv galninlg aCCess to the ac: sii. Access (etllranlee) to sloraeg arca shall l)e securelv l(Ic(l xvilw unattendecd; xiii. Storage areas slhall have sutieict spIace to afford eas accss nc inoa of \vaste: xiv. 1-Icaltit care wvaste slhall be (ollected one waxy to external sv raige site witlhoult returning to tile po;llt of generation: thus the neecl t(i sizahl receptacles for effecting the transfer xv . ITransfer of Waste lags funl' intcrnal to exicrilal storage sh,all l.)e Lb )ne wit car( to prevClnt rupturinl, or opening of b)ags whicl caln cal ntam-l aim th environtnent; xvi. \Vehicles carwlts etc) used for transporting waste from intcrnal t() et ernal storage Sites shall be madie of a smooth surfacc material (e.g. plastic) for Ceasy cleansi5ng and disinfcction 17 HE ALT H CARE WASTE MANAGE M E NT P OL ICY xVii. ihc ConairnCrs u*sed for internal Sto-rage as wvell as thle storage sites should be cleanied, disinfected and furnigated frequendy 4.2.6 External Storage lxternal storage refers to storage at the transit point xvherc waste is stored aftcr removal from internal storage until it is collected and transportecd foir treatinenit and final disposal. The external storage is usually situated within the.J health) carc facility, vhile treatment and/or disposal sites could be on-site or ouLtside the faciliry. 1 'lic freluency of removal of waste stored dependcs on the volum-ne and nature of waste generated. The following measures should be taken to CnsurC the safe cdisposal of tlle Waste; lacilities for external storage slho lIl(l IheC iitIpIetviol)s to) llW8$tl . * Tlhc 1 sh1ouldc be of sufficieilt strenigthl to prevenit d-m;a1Y1,ge dLuri: ng;: handling o r LI, U * iThev should be leak proof; Thev shiould have close fitting licis, * ThleV shou,ld be fitted witli hantidles for easy mnanipulation; * Thcy slhould be ligiit weight and convenicnt for lifting; * lliey slhould be dcsigned to minimlize plysical contact. 4.2.8 Standards for Disinfection of Reusable Health Care Waste Containers: Adec1uate disinfection will be based on swab rests or similaT sampling proceclriCs for relevant biological indicators eclducec by ani envcIio1menta- heaih1h officer (or oLther comilpeLCnt pets(,l,) and processed by an accreditel laboratory for bacterial and fungal cultUrcs. 19 HEALTH CARE WASTE M ANAGEM ENT PO LI CY -Thlec frequency of teSting should be as follows: Initial testing prior to commcincement of operations - this is to bc carricd out daily for S days Tcsting during usual operation - veekly sample swab tests of clisinfected rcusable hicalth care risk waste containers beforc reuse. Q(uarteily reports are to be compiledl by the responsiblc person (Waste (Control Managei) regarding the level of disinfectiorn and copics sciet to the DIIFTl and from DFHNFT to RFHMT and then to GHS and MOI\D0-1 heal-uarters as a1ppropriatc, as well as to thle relevant district asscnielicss andl I. P. \. 4.2.9 Collection and Transportation of Health Care Wastes (Collection and transportation of health care waste from Health Carc Facilities should dovetail into the general wvastc management plan of the Distnict .\sscmlllv. .\t the institurional level, all health care wvastc shouldI be sorted on sitC before collection and transportation. The rccommenided colour coding m11uNt he usedC. This will allow easy identification of content of containers thus p)reventilng catcless handling aild thc risk of secondary infection. Wastes from hicalth facilities shall bef packaged and transl)ortd separately based on tihc ado)pted classification as sho\vn in 'lalvlc 2 Transporters of wvaste shoul,d b(e trained in identification and handling of differelnt waste streams. 4.2.10 General Requirements for the Transportation of Health Care Waste Collection, transporration andi disposal of hicalth care waste shall onlIx be dlonc b! accredited Waste Management Contractors and certified bv tie District \SSemlbly. Relevant departments of the District Assemblies should \vwrk. it collaboration with tlhc l-Icalti, (Care Facilities in the district; All neccssarv care musl be takJen to prevent odour nuisance 11 thie neiighbourhoods during transportation; 20 H EA LT H CARE WAS T E MAN AGE ME NT PO LI CY \VllCl in lfecrious wastes and(I other wastes have beenl mixeld togtelei, fhee- nllmst be Consli(cLed infectious ,ind marnancd as SLIch. I ealth care wva,ste rlLust lbe trainsp)orted c)ictev to hlic disposal or trea;tT1ilwn1t SIrc \vithinl rhc shllocrtcst possilblc Tilie ) Vechicles Lised for tralnspoItALion of health care waste imist be so cowistrti(ed ;t> to prcvernt the scartterng of packaged wastes, odour nuisance, and tstk hs Ic lix p rc)(.o C; \astc must nor bc cotmspacted or sulhjectcd to any other treatmcnci. rhat i u-tid causc bags or containels to` rIuptUre; All veh7iclCs usCel for thle tranlsportation nf health care WasWt shall CrI1eV IIIQ biohazardi niark on all sdles: Labels sh(oulld be firmlr attached to containers So that thicv clo not 1h(eCIll m detachcd diurinig transporration and hiandlinig; 4.2.11 Requirements for the Transportation of Radioactive Waste Containers RadioactiVe WasLe containers must be brightly coloured (nort;illk l l kiwo). shrulid be marked "Radioactive \Wasie( and should bear the internationmal radi(i alIIe symbol to distinguish it from conrainers meant to receive other vpeS of \va-ite 1ll radioactive waste packa1ges or ConMtainers should have labels 1 amnl he radiation symlbol on themi. 'lhc label should be completed and signeld l\ tec offlcC in chlarge of vaste mnanagenctit in the organization. 1hI lablcis shoul heC firmlv attached to the containcrs or packages so that th1-c\ do nl)t hecolinc detached during u ransporttation and hantdling. The printing on the labelAs sly ttld be permanenti and legiblc for the entire storag;e and transport atlin period. Radioactive waste should be adequately ECpackaged and contained for transpmi ri`o ensure safery, not only of those involved in the transport opratlto, b)ut also t-OI' those who Could be affected as a result of transport operations in accordan11ce with the International ALtomi. c Energy :\gency (ITALA) Rcgulations for the Sfec Tlarasport of Radioactive tMaterial Requirenients. (1996, Safetv Standardts Sies ST-1, IAEA, Vicnnra). Drivers transporting radioactive Mnateria1l have to) he suitably traillned and carry conringenllc plans on the velicle detailing ation to be taken in the event of an accident 21 H EA LT" CARE WAS T E M A-N AGE ME NT PO LI C Y: Thhe Radiation Protection Institute of the Ghana Atomic Encrgy Commission is preparing a 1egulation on the Safe Transport of Radioactive Mlaterials, whiicl shluld l)e complied v itl 4.3 Contracting with Health Care Waste Contractor Whcre the facllit) is not equipp)ed to carry out on-site trcatnicilr and disposal of health care \V,wIste, the institution should engag,e a \V';astc MI\aInagement (;olrtIactor based om E.l\ duidelilCs i.e. thie conttactor must be licensed by the District .\sseblvl to collcct and transporr ims wastes to a designared site for treatitnewi aInd disposal. AS 'i mlw}limlilTn Iequiretie1iit, a contract entcred into between .t aste al.lmcment Contractor anld the hCalth care insututijol should contain thc * ITvpe and jiuantity of \v,wste to be transpor1tcde * Finlal dcstination of waste to be transported (municipa,l disp)osal sitc oi- thc vastc treatment facility Of another health care facilitv); * \W; hat cold lbe recycled, if anmtling; * Tcnrms of sub1contracting, if pernutted. Icporti-ng format and information flowv and feed-b;ick mcchAiIiSmS, (ondmions for termination of contract; Fivancial standing of t.hc contractor. lieofOrc cormlmliSSiOmiilg a Healrtl Care W-aste: Contractor, ihe head of the instirutIon/facility should verify the par-ticulars of thc (:onitI:Ictor \vItlt respect to the follon\vgi:'s \Nhether licensed by the Distlict Asseblyl;l), 1 v pe of liccnse e.g. \vhceter for collection, transportauton and / mt dlispos):ak * (ly of waste that call be handled by the contractor (scopc of contract); * T-imes for renewal of the Lcense, whiclc should be cloIne annually; C ontractor's capacity, e g fleet size, wvork-force, creditwo-rthiness ctc; K knowledgc / experience in handling health care wastc; A\nv other points of inrv1icsi 22 HE ALT H CARE WA ST E MAN AG e MtE NT PO LI CY 4.4. Treatment Options for Various Waste Streams Ihlie ricom nclednLc trcacniCntr otions for varitous wvaste streamns to Li,tldel ae}ac lcvcl of he..th insUtttLto'ls ire lplovidled in Table 3. 'Feiy arc: based on technology available and cost considerations. Howevv(r, wvithin limitis rIo\vidcd(l by this policy, saFery considerations antdl cxisung laws, each regiJl should determine ilhc con&guration of treatment options that is fcasiblc confsRlenri'g td'h resoul(:t cCs a\ailablc to it an1d OthlCle tegioinatl !)CCLlrietll'CS. 1 01r instance, CCJL1ilpmen1 WithI te1C clpaCity' to handle tnore Wa,sLe than indidvidUal InsUtUtrionls generaITc c-an be s(ratgicallv located to scrve tnorc than one 1institUtion0} fot COSt effecCt ncss if spatial location periits accessibility. W\here, considering the volutne of wastc gencraicd, thic cost of segregationi andi transportation to that centre is fnuch cheaper than buying incinerators for cacih facility only to process Very small Molunis of waste that are gctieratcdl infreqJuently, iI will be bettcr to shavc reSOLIurCS. Such consicderatiolns a1re1 im11poirtant for facilitating the rationial u1sC nf re:sourcet:s. This neccssitatcs a process of micro planning using a bottomI-uLp ap roach. Table 3: Treatment and Disposal Options. \VASTE TYPE - TREATMENT / (LEVEL OF FINAL HEALTH SYSTEM DISPOSAL * EQUIPMENT) (;cle.ll . food. pap'ctU, iiIsiitrsg 111eI i wi r ;r. paickIlig 11titi;llI k tC (cOistLOltCd corn! Hc.ilih CC1111'V/( )Ut- PhrIcnII (I111c - * COIpIIstrllg, "A U O'i I ,L ItrOr DistrictC potrir,t3iodigesrion. , IllczncrI-c,icanon i , ~~~~~~~~~~~~R cplOI:il l ssSpil A,l' - I ttcoltct;~ tOls, |Biodgestuon. liii, 1- '-. *.1 AII leveli L.aIdfill _________ -- Clhern1tc:t C ical di lesfCitoi, iItinIcr.toartonM ll t 11 tls : PartCnrT \\.I; All ICeelS -- ILICrUr.IT010or C o (utz' Cl . e I i . u / | I;ie - -- __ ;_ , _ _c ' _ _'__ _- -- - -- - -, I% ups Ind tales (I toslitog o C ijecrabIcs; sy;p. slhouild be _. . _dlued :1nd waShcd down tdle dcaons - All 23 l~~~~~~~~~~~~~~~~~~ I t I I I I V I L t~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ J)I st,i,,,, P-110. 11)(1JtW Vklllg)A 2Ilpe)Ol -ddl .I1IS1.7$S.IMI tI .),1\t) -siomlgII;t{S S.1d . sIl0 1| v(IttIJ RII!(I/I#4|) )16(I,II X i 5>:tXl~ ~ ~ ~ L llll,,LI rACI[P °DIUDLLLl)D ;wt[ JOI DS-MU11. )W°k! L9IJUA ;)Illl I S>(IilSOII S :lL11 S() Dii1rlS 1 lIDU T< 1 .D31nbJIU sr XWO ul,'Inlttl DU:1;ejC0tOS'SU;MlD;DFUI '1B'tS.t. I I ( 1,,,,, \ . <, ., s ~~tsv.Ioj 11tI iAJ X. tSaullDprtwa~~~~~~~~~~~~~~~~~LII ,111L.7301 .sasi .. n, .\,>;,O[l uul0oP I '''l c5CBSll;.-Tl:. _~~~~~~~~~~~~~~~~~~~IJ I_IV _ I I!j 1) LI It ~ ~ ~ ~ ~ ~ ~ ~ ~~'7''17P' [ ~ ~~~~~ ~ ~~~~ 3- 1, 1 da A 3W ) V N V '' 3!''S ' M°3 U ID Hl'oE L -1 V. a HE ALT H CARE WASTE MA NAG E MEN T P OL ICY J .1 , I it I J(- 4.6 Waste Minimization I ICealth EaCIhus Must ai 'l. reduLcing the impact of licaltlh carc risk wa>ic In the ir opcrations b5 nrinimnizing the getneration of healtlh carc risk wastc ar soLuice aid, to a lesser extent, recyclhng TIhis max' be achicved throughi thic fo[lowving mCasuLes: IKecping individual wastc streams segregated, thereby kC9eeping.L 11hazard:couIs WRsIC segvcgated from the non-hazardous. Improving inventory control by using L1) ol(ld stocks OF drugI,s a:"cd clhcmicals heforc orderincg or using new siockls ordering lz.mid us clhemicals onlyv whlcn neecded and in minimilal quantitics to akold (ooate[dilcC inv en111 to\ (onsideration shouldi be givcn to recycling as muclh waste as p ssirO Rjed pmtms (final disposal of slkidpe) )um it huspitmdm . ia L m lid m f c 'le, mm: i (.d 'm , The initial cost outlay of equipment recommended to be used at various lcvels is pli(- ncw(l in Appendix 3: 4.8 Spillage Procedures Whilst all effotts should be made to avoid loss or spillage of any kind, in the event of the latter occurring, a clear procedure must be followed. A ready supplh of all necessary equipmenlt nust be in place for usc whenever sucli an event occurs. It is important that information and training for staff is provid(ed pri(r to an\ 'Such eventualiy. 'fhle aim of a spillage procediure is to: * contain the spillai e * limit the escape 26 H EALT H CARE WAS T E MA NAG E MEN T PO LI CY p protect slaff, pat:ients and v1isiorS pr()tCcr tihe CmWiIOflU0leCt resiore the area CO no01nalcY aS q_ui Ck1ly as possiblC. minimize the (c t-cct of thc spillagc on normial -crvice provisi(0n 4.8.1 Procedure for Handling Spillage of Clinical Waste '[hc main risk is tha of cOSS infcctuon, and the procedtuic consists o luinine protective clothinlg co0nsistcnr with tlhe r isk, in Inost cases disposable gloves, and apron if appropria1e, an1d placincg the wvastc items into the appropriate vellr\v ha. or into a sharps box, In the case of ncedles, blades or othcr sharl) iclies, taking special carc not to reccive a shalps InljulrL). Sharps must not be retrieved by hand lhe follo\ving guidelins shall thereforc apply • Staff cleaning spills shlall wear p roecuivu clothinig s,uitablc for rhe spillagc at hand. S Standard cleaninig equiplmlleL inicluding a mop and clcaning tbuckt plkus cleaning agents shall bc teadily availaleb for spills management and slhall bc stored and sign-posted in an area known to all staff. The procedure for spill ranagcmenLt will dClpnd on the followillg: o Nature of thic spill, c.g. l)lood, UtrinC and facccs. o Possible p-a1l1ogenIs tlaat may!! be involvcd. o Size of the spill i.e. spot, splaslh, puddle, large spill. o VI vpc of surfaCe IIv(ul\'Col i.C. lInolCum. carpeztt, tvood, lalliatead. c(c. o Area involved i.e. preparatoty laboratory, ward, comnatllr)l acccss areas, ctc. o Likelihood of bare skin contact \vith the soilecd area. For a small spill, disinfect Usin,g a disinfectant cleaning solution prelerabl) clhlorine based suclh as Blkeach and clcan. For a large spill, flood withi disinfectant, mTop andl clean the area WItL disinfectant cleaning sokluuon Llusing a mop and allowv to air dr- or clean wvith absorbent paper (wvhere availablc) wvhich is tlhctn placcd In a yvllow bag. Large spills of cultures or concentrated infectious agcnts shall als(- be flooded wvithl high-lcvel clisinfectant (like bleach) before cleaning and tlhcn decontaminated \vith fresh disinfectant. 27 H EA LT H c ARE WASTE MA NAG EM eNT P OL ICY xvu.i Ihlc containcrs used for internal storage as xvell as the storage siLCs should b3c cleaned, disinfccted and furmigated frcqcuntly 4.2.6 External Storage External storage refers to storage at the transit point vhCere waste is stored aftetr removal from internal storage until it is collected and transported foir treatienr and3 fina] disp)osal ,The external storage is usually situated xvithin thc hc;alth carc facility, whlilc treatment and/or disposal sites could bc on-sitc or ouItSidC the facilirt-. '[lhe frceucncv of removal of waste stored depends on the. volurmc and naturc of waste gencratcd. The following measures should be taken to cnsure thc safe disposal of thc waste; F;;6iliticS for exterlnal storage slhotuld be removed from kitchen. laundr%, W1a1d etc but be within the precincts of the facility and shall bc easily aiccessible to collection vehicles; li 1ilc [acility shall 11be cnclosed and( surrounded hv an impctvious wvall of app)ropriate heiglht and provided wvith a gate anci lock, ui. 'J'le xvalls and floors shall be smooth, \vithout cracks, impcnious, easy to clcanl and disinfect; cleaning and disinfection must be carried out as frequCentl\- as possible. I11c site shall be spacious and xvell ventilated and may, for cost cffectiveness *in managing wastes in small facilities, accept Wxaste frotn (thTer Health Cire Facilities if it has the capacity to process the increased volumc and the tvpe of waste. A..\ loading and unloading of waste shall take lplace within tihe diesignated collcticon area around the storage point; Vi. 1 arger volume waste bins - 240 litres and above - should bc available at ilhc external storage facilit, to receive \vasrt contaificers froin tlhc internal storage points. These bins slhall be marked for easc of identif6cation of conltnlt and the markings must correspond with thec colour code used for p)olythene bags in internal storage; lcalTh care wvaste shall not be comprcssed during collection; \NaSte bins shall be wvashed and disinfected after each collcction and more fFe1CUCnrl) if rcCluircd. ;aste x,water fi-omi the point of generation and storagc area c, mu.st be *dralincd into sclptic tanks and soakaxvays and must not be alloVed ro drain (,I I into storm wVater drainage or streams; hjuid \vastes 1Iust be: 18 H E A L T H CARE WA STE MAN AGE MEN T PO LI CY app1uropiatclk treared (e.g. disinfcc iiot, neurCali7.AiiOan) pior lo final disposal. x I .xternal so ragC facilities mIust 111eCt Certalin blsic Stan(lars( t()r thle ypc of wvaste stored e.g. refrigerators for stronn,f organiC Iiss(lWs SInould he considereod and provicded in facilities. This will ci;ure liar the eilmperairurc of body parts will be sucl) as to lex\vm further decomp)ositon or muftiplicaton ( of pathogens; where re ge r atu Cis no.r availablc, thecse materials should be disposecd of Witlhout l ela1 Y xi. lBio-hazard marks anct other warning signs shiall be Conslpiu)uslly postecd on doors to prevent peopic from unnecessarily gainling access In thIe areal xii. OnlV aut.I.riz ed persons shall have acccss to extcrnal sroragc area Xiii. Staff slhould be trained to understand cle. principles of sCgrea.ltion and to followv pvocedures for colour coding, storage and CIocumLenr01aiuon. xiv. Recorcds on waste generated and processed inCludilng th)e t\P(' of wvaste, volumcs and/otr weighit, and the personis wvl1. processcd tlhcim at the v'arious stages should be kelt. 4.2.7 General Requirements for Waste Collection Containers Contaiiers for waaste collection shiould meet tihe follow;ing re(JuiCeucnItsr I hw\ shi ,ull hc non-transparkc:r. * i1he1 >hi)ul(l be iili,t)CL%i()LlS to nv,i&itir<. * Tlhev shiould be: of suffiCient strengthl to prevent daIage duing handling iTh e 1 sh.ould be leak p)roof; Illch sh1oulId have closc fitting lidls; * TlheV shIould be fitted withi hancdles for easm manipulation. T- lich shiouldk be light weiglit and conivenicni for liftinlg; * l'hev shiouldl be designed ro minturnize physical contact. 4.2.8 Standards for Disinfection of Reusable Health Care Waste Containers: Adcequate disinfection will be based on swab rests or similar sampling poeecldures t(or relevant biological incticators conduced hy ani c-m-irlInmcn tal 1healili offieer (or other competent person) and proessecd by an accreodited lal)oratory for 1bacterial and fungal Cultures. 19 HE ALT H CA R E WAS T E MA N AGE ME! N T PO LI CY Thlie frequency Of testing should be as follows: Initial testing prior to commencement of operations - this is to bc carried out daily for 5 days. Tcsting during usUtal operation - weekly sample swab tests of disinfected reusable health care risk waste containcrs before reuse. Quarterly reports are to be comapiledl by the responsibIc pcrsoni (Wastt C( tol Maagei-) regarding thlevel of disinfection and copies senit to the DIEMNVE and from DKMT to RFHMIT and thcn to GHS and NIGH h1ld(juartcrs as aappropriate, as wvell as ro the relevant district assemblies and 4.2.9 Collection and Transportation of Health Care Wastes Collection and transportation of health care waste from Health Care Facilities slhouldl dovetail into thie general waste management plan of tlle District Asscilmblv. At the institutional level, all health care wastc shoulcl be sorted on sitc beforc collection and rransportation. The rccommeinded colour cocling -must be used. This will allow easy idlentiFcation of conitent of containers thus prcvcntilnl caclcess handling and the risk of secondary infection. Wastes fromn lhcalth facilities shall b piackaged and iransprtecd separately based on flhe adopted classification as shown in Talble . Transporters of \xaste should be trainied in idcenrtification and handling of diffcrent xvaste streams. 4.2.10 GeneralRequirements forthe Transportation of Health Care Waste Collection, transpmoration and disposal of lhcalth care waste shall only he clonie by accredited Waste M\Ianagement Contractors and certified by the District Assembly. Relevant departments of the District .%ssemblies should wVork inl Collaboration with hCe Hlealth (Care Facilities in the district; All nccessarv care must be tak-en to prevent odour nuisa:nce t0o th]e lei,pghbourhoods dukiring transportation; 20 H EA LT H CARE WAS T E MA N AGE ME N T PO LI CY \Whcre in feifuCtiUs WastCS an(l dther waqcI have l)cti. nmixcd togelici. thee ntthc be conisidrcd infectious and maniaged as such. I ICallth care wastc nmUSI bC transpouted ditrectlv co the disposal Or treatiahu nr !rc withil rhc shortest possible rimc;, VehicICs used for transpottation of lihalth care Waste Must be so Coii)iRCictcd'(.1 Il to prevcnit the scattering of packaged wastes, odour nuisance, aind utist bc leals proo[; \Vasrc rmust nor le comiipacted or subjectcd to any other treatmeni rthai cimtd cause bags or cofntainers to rulptuec; All vehicles use:d for the tralisportationi of health care waste shall c:aire ilc bioliazard miark on all sides; Labels shOuld be firmlr atrached to containers so that thiev co iot 1)(ec une detached dutring transporration and handling; 4.2.11 Requirements for the Transportation of Radioactive Waste Containers Radioactive waste containers must e brightly coloured (norially yellov). sli'muld be marked "ladioactive \V.aste'' and shooik] bear the inteinaitloial act ( \ e sym)bol to distingu.1ish it froml containers meant to receive otlhe tyres () wTs; All radioactive waste p S aCkckages Or contain1ers sIhouIld have: lal)CIs l) earin hlle radiation syrnbol on theim. hlle label shiould be completcd and signd be rt(h officer in charge of waste manatageniciit in the organiizationl. Ihe lablc s shou0ld be firtily attachcd to tIlC colntaincrs or packages so that tlc\ di)o niit becomilc detached diuingll Itransportation and handling. Ihe printing onl the libels shmiold be permanenit and legible for lthe nttiett storage and transportation period. Radioactive wa,tste should be aidequately )aCekaged and contatned for transpwl tt) ensure safert, rIot only of thiosc involved in the tranisport operation. bwu also tif a those who CQuld be affected as a result of transport operatlonis il accord(lie with tile International Atomic Frnergv Agency (IILA.) Regulations for tie Safc Tr arnsport of Radioactivc Material Rtccuirerncntq, (1996, Safety Standards Sci o.s 5T'-I, IALA, Vicinna). Drivers transporting radcioaCtive material have to1 1 t suitably trained and carry contingcy plans on the vehlicle detailing action to be taken in the event of an acicident. 21 HE ATr" CARE W AST E MA-N AGE ME NT PO LI CY: Thc Radialioln Protection Inst6tute of the Ghana Atomic Encrgy (,ommission is preparing a regulation on tile Safe Transport of Radioactive Matcrials, wlicl should )1e complied with 4.3 Contracting with Health Care Waste Contractor V-he-:c the faciliht is not equipped to carry out on-sitc trCattlmlenT and displosal of lhealth care \vast, thec insuilution slhoulcd enaage a \Vaslc Management (.Contractor basedC on EPl \ guidleCics i.e. the contractor imust bc licelnsed liv lhe lDisrici A\sserTnblv to collect and transport its Wastes to a designated site for treatment ancld disposal. As a1 1inimum T equireiflelit, a contract entcred into between a W,'astc ianair,cment (Contractor and thc hcalth care instrtutiton should contain thc foil(m 11i4, * vpre and (juantity of wasTe to be transportcd * Final c3Stination of waste to be transported (mTLnicipall diSpoS site or the xvastc trcatmlent facility of allotlcr health care faciliv)y W \Vh haT couldi be recycled, if anytdilng; * Terms of sub:,contracting, if permitted, Reporting format and information flow and feed-ba;ck iiechai iisms, (Conditions for tennination of contract; Financial standing of the contractor. JBeforc commisioning a Healthl Care WYastu Contractoro the hecad of the institution! facilit- should verify the lalrticulars of tlc (Coi )-aQtor with respect to thle follouwlg: \NVhether licensed by the Distict Assemlibly; 'IN-pe of liccnse e.g. \vwietier for collection, transportauion and / oj disposal; * l vpe of waste that can be handIled li the contractor (scopc of contract);. * Times for renewal of the license. whiclh should be dlone annually; * C(ontractor'S capacity, e g. fleet size, \vork-force, credirwvorthiness ctc; Klo\%.noledlgc / experiencc in handling hcalth care wvastc; A\mv other points of inr'l-cst- 22 HE ALT H CARE WASTE MAN AC EM ENT PO LI CY 4.4. Treatment Options for Various Waste Streams Il recc(rnme n nded treatmncti options for varlous waste strcallmls to guidl each lcvcl f he.Ith inlstItUtions are p:ovidcld in Lable 3. itvc are: bas d on technology available and cost consider ations. Howcvcr, within litnits provid-ed lVy this p)olicv, safetx considerations andl existing laws, each regoti shiould ictcrminlrLe (lic configuration of treatmcint options thlat is feasiblc consid(1ring uhe resturlce s aVailable to it and dthCe rClegional pclliaC cS. lCor instanc, CC, LlprtoT withi tlh capacity to handle more Wa,sSL tian inldividual InStltUtions ge:neral-c can be statCgically locatcd tO sctve morc thlan onc institution for cost cffectiveness, if spatial lncation perinits accessiblihu. Wflhere, considuring tile volusne f \vastc gCncradte, thc cost of segregation andl transportation to that centre is inuch cheapcr thain buying incinerators for cach facility only to process very snmll Volunes of waste thalt are gencerated infrequently, it will he better to sic resourCes. Such consicrlations are imiortant for facilitating the ration,al 15sc (nf resources. This necessitates a process of micro plann1fing using a 1bottomll-Lup appro)achl Table 3: Treatment and Disposal Options. WvASTE TYPE TREATMENT / (L EVEL OF FINAL HEALTH SYSTE M DISPOSAL ____L_EQUIPMEN-)I Getict l w.k-cc (food pr 1 3 iodiges ikin. ng. It., , l it.,1 I'm ....... . i- ,p;c JlV NVY 31SbM 3 H1Itf HE ALT H CARE WASTE M AN A G E MEN T P O LI CY I - I - I J 1 . 4.6 Waste Minimization I leaitth facilities imust aifl at reducing the impact of lhcalrhi care risk wv;i in trV-jir opcratiolns b) miniinizilig the generation of hiealthi care risk wastc am souvCe avdl, to a Icsser cXtc(lt, iecycling. This rnav be achiev,ed through thc followving mCasuIcs: Kecping individual waste streamns segregated, rhercby kceping Im/ardoltis wastc segregated from the non-hazardous. tmproving invCntort control by using uLp old stocks ol (lILIs Illd clhcmicals hreforc ordering or using new siock: ordering hXazarioIIS clcmilcals onL whien needed and in rminirmial (qiuntiLies t(o axv (m1 (Ut(MCed invCnt(r\'. (onsidcration shoulo bt gbic n to reccling as nIucIh Waste as pssile in inscanccs wxhere this does not increase health risks or costs e.g. re-vcIiIL of u171C0nraMTlInatecl cardboard boxes and wvaste lpaper. 4.7 Waste Water Treatment and Disposal Waste %vartCer Fron-i I Icalth ("are faciLities is of sitnilar (jualitY to urbani wastc \ Ir.ur but ma!v also contain various potentiallv hazardous cormpontlist it- the recomeinc-dauions in Table 5 (Treatmcnt and disposal op()tis) artc not) ollowed. Hlazardtous copntIeJ)nts of waste wvatcr ftom I Health Care tacilitits ii1cluc] chc following: i) lBacteria, viruses and heliinths discharged from wards treating paticnts with infectious diseases. ii) I lazardous chemicals from cicaninig and disinfc;tion peXpo:1;rions iii) Pharmaceutiicals fromt pharmacies and various \wards iv) Radioactive isotopes. \W aste in categories ii, iii and iv must be segregatcd and treated appropriatcl 25 I H E A L I Vi C A R E W A S T E M A N A G E M E N T P O L I C Y \Vaste water in category i and other general liquid effluents should be connected to the sewerage system if available, or othetrwise to a technically sound on-sice svstemn. HIowvever, during epidemics or where hiighly) infectious pautentrs arc involved, high-risk type xvastes sliould bc pre-treared by chemical disinfecuion before disposal. Table 5: Recommended Treatment and Disposal Equipment Reconilended Eqtiiment Facili!y / Lcve1i I I ilghl ctticient (higl rcinperaturv, filterecd Tachiag -ospirail Oige capaicirv ,ncineiaror.s' !flcifleifl tArS) EqUtpiienr / Coiirolled COmbulL)StiOfn RepoIni anvd Districr Itospir;ls (nicdiuim c:ip-icIim (Irritinele l FAcilitIes. | iinciIeralors). SuI,djsism( fiscilitieN (sinanil clpticir- I m1IcmentarsO r:ici1jties ia a1ii iccIs Prwcoed pIrS (Fin:1I di5pos-i1 of ,hid,.) c,, h u id, h iI: d viiitc-, t' kw -. The initial cost outlay of equipment recommended to be. used at various lcvels is l) it1. ) I I in Appendix 3: 4.8 Spillage Procedures WVhdst all efforts should be made to avoid loss or spillage of any kind, in thle event of the latter occurring, a cle-ar procedure must be followed. A ready supply of all necessary equipment rus't be in place for uis whenevec suchi an evnt occur-,. It is important that information anid training for staff is provided p)ri)r to anv; such eventuality. Th e aim of a spillage procedlure il 'o: • conitairi the spillage * l'.nimit thlie escape 26 HE ALT H CARE WAS T E MAN AGE ME N T PO LI CY * protcct staff, paitlcnts aandl visi"IoS protccr the: c1lVn(m1lCr1nt rest:lOCC thc area to 1o1nilacy aS CluicklkV as possi'le. rUruiltnit thae (-ffeCt of the spillage oni normal service provision 4.8.1 Procedure for Handling Spillage of Clinical Waste I[he main risk is Ihat of cross infcction, andl thc p)cCedutC consist;St oi(I' dcmiilmn protective clotling cOnsiCeStC \\ltth tlhe risk, in1 most Cases disposable gloves, and apron if appropriate, alid placing thle vaste items into the appropriate I(ilOW la') or into a sharps box, in the case of needles, blades or other sharp iicems, taking special care not to receive a sharps injtiuy. Sharps must not be retrieved by haild. Fie followving gUlidelines shall therefore apply * Staff cleaning spills shiall wvear protectvc clothing su-itablic for rhc spillagc at hand. * Standard cleaning ecluipinent including a mop and cieaning bucket plus cieaning agents shall bc readily available for spills mantagemcnt and shah be store-d and sign-postedL in an area known to all staff. The procedure for spill managemient wvill depernd on the followiing: o Nature of thc spill. e.g. blood, uriic and faeces. O Possibe pathiogcns that my;t be involved. O Size of thlC spill i.e. spot, splash, puddle, large spill. o T Vpe of surfa:Ce 1inVlved i.e. lrinolecu. CUl .arpet, wood, lamtilale .d e1c. O A rca inv0lved i.c. preparatory laboratory, ward, conillloii access areas, etc. O I.ikehhood of bare skitn contact wVith thle soiledl area. For a small spill, disinfect USilng a disinfeianI cleaning soluti(.)n preLferablv chlorinec based such as Bleach and cieani. For' a large spill, nood with disinfectant, inop and clean thle a Wea vLt disitfectaIit cleaning SOlut-on using a rnmol and allow to air div or clean with absorbent paper (\viere available) wvhich is thien placed in a velo\v bag. Lacge spills of cultures or concentrated infectious agents shall also be flooded witli high-lcvc]el cisinifectant (like bleach) before cleaninig and thlein decontlllllinateCd with frelsh disinfectant. 27 HE ALT H CA I RE WASTE MANAGE M ENT PO LI CY 4.8.2 Spillage of Chemicals 'ile essentlal steps are: Contain the spillage to prevent furthet sprcad Plrevent exposure of: o Othicr persons in the vicinity o Staff dcaling with the spill *.-\bsorb andI dispose as quickl); as possible lDeco ntainin-atc the area and returt) it to normal i.se Simuilalr principles apply to any othier chemical spilla,gc. For clhemicalls like ,//tarake/dyde., wvhich readily evaporate to prodLucc very nirrita t fumes, a respirator dlesigne(d for LIse With organic vapours should be worn. TIhe licjuidl should be moJ(pp)(ed L 1 as 1ulicklV as possibIc 'With absorbent, disposa;ble. nmaterials. wVhilch muist hlen 1)( douhlc baggcd and reinoved to The open-air wvasie sloras2ge Cofllr)(wi-iud as xoon as possible. Ilix ;m ca of the spill should be well ventilated, and \,ill re(iLltire sufficiC1nt timc for thieC \-,'poLr to dlisprsc lbefore being reoccLlpiedl. ,A leam)n i anorthr clhcmical whose hanidling siould be mentioned. The mailn risk is that of skin absorption on contact Vitl merculy, and by inhlalatioll ot Imercun' apour, whllch 11 axV slowly vapolisc inltO the air from exposed surfaces Of 1111cML1V. TJhe risik is increased in hot, confined areas. i\l ecIClr readily combinies with other metals to formn 'amalgams; which in turn iT erC-u1-V vRapour, and from vwhiclh mercury may ibe abc sorbecd v skin contact. PreeC\nllT \Vith rings, (by removal of jewellk-n-. or \vearin'p, of dlsposalc govQ,;), and \vitl) any metal equipmenit, as they ma.y be dilficult or inmipossible To deC ont II u m1)11a te. The aimn of the spillage procedure is to collect an)' significant quanrity of free mel-cur-y (thiat coukli possibly be recycled) and to chemlclicall com-ibinc any small rem:mmi g rcsidu-eis as quicklv as possible \vith1 a hot suLsp)en1sion1 of sulphur and slakd linic (calciumin hydroxide) that may be nbtained from tilhe facility's laborITo(r\y. After drI-Ong out, the powder mixturt is collected into a tlghtlv cap1ped platSTic bottlc. 28 HE ALT H CARE WASTE MAN AG EM ENT P OL ICY 4.9 Contingency Plan L.ac h facilrv slhall deivelop a contingency planc tO p)1o\'icdc guidanice tro \Vlastc rnanalgcmcnt and otlier staff as wcll as visitors to faEiliCi o(:n 0()Il sLl:CS to be implmlullunied iII thc cvcrtt of unexpected inciclents. This plan is t() incltucd among othiers I)C,1SULI(CS to manage spillages, fire, floodinig and otheCrI hazatrds peCu.iar to rlte localtr. 4.10 Health and Safety ''lhc N [iniistry of Local Government and Rural Devclopmnent thirough thc DIstrlct Assemblties 1oinll. vwith the Ministty of Hicalth and its implemtnentirig agrclcis as wvell as otler corporate and individual employers wlitilin thic hcalth sector are; rcszonsil)lc for providing the necessary rCsoLIces for correct atid htfcuvc haltih care wasrt nmanagenent. Mlanagcrs in the abovc lMDA-s and otlher (organizatiOn1s arc cxcctcd io provide safc systcls of workl for staff gcrlaul11 , handlCInIg. St'0i0g,, tranSporting trcating and carrying our final disposal of wasic. Thecy, are t) instirtutc a systcm of regular mcdical scrcecning and imn-munizations for all sa,,ff tnvok\ed il Wvaste mranagcmrcnt. Tfhc, arc to proxide appcopriate information and training f;or all rclevat stLaff. Thley arc ro coricluct regular monitoring and periodic rcviewvs of thic s\s-tcm so that deficiencies arc correctedl within a reasonable timescalc and the sVstem continuolusly imprl oved in the Ltght of expericnce gainiecd. Indivicdual emplloces of the health sector are expected t(o eCNCiSCC rceasnablc carc to prIotect thelmselves and others whion may be affcctcd by tliei ;tCtli onSo( inactionls. In order to avoid any injurics or infection of people, hecalth care Waste handlers ti'lUs t a) Go-operate in matters of hcalthl and safety I)) (Correctly use personal protective eq1uipillcmlt and any otheirc work ecquipmcit designated for the task. c) (Correctkl apply the informatiotn and training received aL induction and subssecuently in lhandling issues such as: 29 H EA L T H C A R E W A S T E M A N A G E M E N Y P O L I C Y Taking all necessary measures to ensure that re-usable containers are effectively disinfcctcl before re-use. ii) Providing adeq1uate scrvicc storage areas for health care waste. iii) Making provision for mitnimal manual handilillg of hcalth care risk Nvaste. d) lReport any perceived hazards in thcir \vorking environmnent OiJ deficienicies in the safe system of \vork io their- manager. In the eveint of an inluvj arising o(t of \asrct handling, it mist iinmdiaclc be: reportcd to rhc re]eeant manager or suierv,isor and action taken b;ised on the infection prcvention and MIV / AIDS pol-icies of the lO1H / (;HS. 4.11 Record Keeping and Documentation I ,ach health institution, is requircd to maintain recor-ds of its wastc managemenT. In additon to srores and logistics management rccrdR-s at the insttuitional level discussed untdler Section 7.1.1, issues reg,arcding the type of Wvastc, wvlere il is gencratcd, when separated, by wvhorn aixi c\ en vtllhcr sub9seqiuent actionl ulntil final disprosal or handing over to a \vasicc dislosal comlpany, when\\:I such is thlic c,ase, shall be dOCumllCT1ted. The Follokving arc imipo)rtant sleific in for tion, w1ich should bc docmerntre(d bV eaLCh illstitutionl: I) Inforination oni Waste types ancl Handbing Processes * IDate * TIhe t\ ple and vo lu-mCe/\eigliT of \vaste generated, * '111 I.pc, origin an(l wcighlt of waste received fromn othicr- health care facilities (in cascs vhecre facilities are shared); * The Tmeans of transportation, tyvpe and volume transportedl T Xhe plar 'culars of the c(mmiTussioned wvaste contractor (namne: of company, type of licClnse, site of treatment and / or final disposal): * Disposal Iethorldo ani(l c]qLatities per method: cg. v.olume incince-ated, volullme aT cvery point o)f interm(cdiate treannent vo(lulme final:ly dispsedrs cl t~. ii)' In ]addititP1i, rcsults of rests for srandards for dlisinfec'in shoultl he circilalel tl)c t Dl- I'I's / RI INUIs, ( ITS, INMOH, DAs all(n P \ ()c ,I 30 HEALTH CARE WASTE V MAN AGE MEN T PO LI CY cluarterly basis as spccifiec under the scctioIl on MonitOring and Conitrol. i.ii) Rccords of environmental performance for Incinerators slioLdlci also bc sent to thic above aut1horitics every 0 months. iv ) The I HJI'Ls and Rl-MIls shall ensure Yccord compilatlion and analysis lwv t]le health facilities unicl- rthcir Jurisdliction. 31 H EA LT H CARE WASTE MANAGE ME NT PO t. ICY it is essential that training in tlle safe and correct maiiagemient of calllh care waste is provicled to all staff includLiLn healrI manag,es. i. Pre- Service and Post-J3asic training of health \vorkers should inclucdc health care \vaste management. Therc is the neecd therefome to rce\vIC health-tuaining institutio,0s' curricula to incorporate wvastc management. ii. Htealth care wvaste mnanagcmert should also be incorporated into in-service trailning curricula. TIhis trainilng should be tailored ro the needls of staff iil. Ilcalth marnagcrs shall ensure that all tleir staff under,go in-serAice training, in health care waste managemtnt. iV ['raining (urricula, Guidelinew, and Training N\Lann)als on hebaltll Carc \wast.e managemgent shall be developed to facilitate l'rc-Service, In-Secrvice and Po\st Basic training. -. MrStandard Operating Procedures (based on the national guidelines) shall hl developed and communlicared ro all p ersons involved in t[le handlini, transporting and disposal of health care wastes as wvell as their skipervisors. vi. llThese standards shoulcl forlm thC basis For the in-service training to b1e rovided for managers ancd staff involved in the c day-to-day disposal of health care wvaste. Thicr- training should also cover cOntingency management of incidents involving health care managemn-ent. vii. Ihe MOH shall co-ordinate the drawing up of training curri-cula Lwhich should be adaptable for regional and district training in healthi care wastc managemcnt and should be budgCted for in the annual budgct at all Icvels oF the l ealth care svstem and the necessary fuLnds allocated to it as a matrcr of priority. 32 H EA LT H CARE WASTE MANAGE ME NT -P- OL ICY viz. (Colla)oration between the health sector and universities as well as other rescarch institutions should be strengthened to facilitate the development of and adaptation of tecllnologies available for health care waste management. 33 HE ALT H CARE WAS T E MAN A.G E MEN T PO LI CY 6.1 Information, Education and Communication i here is no gainsaying the Importance of educanon of a p-, pl moire- Conscious the soci.ety is of dte isks from. health care \vAse and how to minirniusc themii, the nmore effectivelhealthI care waste managenictitw,ill bc. 16 ou1In cmtizcns understand the classification of wastc, the need &)r \ast n t arndl s'paratioln usinIg the CCOiLinended colouI- co(lcs F[Otl thleir s`ud.(iS in sCol:10'l anidl adcult. educdLtion pr0ogVrUamImIcs, thev xvi-1 liandlc properhl thc wasti hey geticriate as paticnts and visitors o our ospitals, therel cilitang h lth cat. waste managcinent In the hcalth facilities. This is even more critical consicinng the prevt'aiing situatio in wlhiclh, in the face of thie inadequacy of hiealrh pcrs,.onnd, relatlivcs of patielnts have to play inore roles in caring for theit relarives onS admissiSon0. Ihlc II";.( planI viU invol\e the use of mass mnedia to eclucatc tllch plhlic on the Importance of lcalth care wasrte management, tihC codiinig systel alld whlat 1e ot wastC is to be placed inI a particular type of vessel ancl tlic othfer cssertial velee:it.s (ot su,chl education. Releva"nt aspects of the education should al.s() hb incorlpm )atcdl into tlhe curricula of l,asic schools and adult education prograrnnws. T he public lhealtlh units slhould Incorporate igonfnationi on health care wasic anage(t;l 11ment ito outreach cCIaLnx1 progiranlnes. linallv, at thie instirutrimlal level, sI,n s,, Ind Str cS shiould be strategically posted to educate and guide the public. 6.2 Advocacy Advocacy slhould be undertaken vigorouslv to solicit support for the policy font all stakeholders. The fincdings of the evaluation of hacalth care waste marnaemncit practices undertaken by thle health sector shIould be dissemninated to all the mliniStni in-volved at the highest possible level. The attention of tlle deCvelopmenclt. lpartincrs IIJ alJ civil societv organiLzations should be drawn to the ceiSting sitmatiol nl order 34 HE ALT H CARE WAS T E MAN AG E M ENT PO LI CY to obtain the widest possiblc support including financial commnitment and the development of a legal framework. Feature articles in the print media drawing kcy messages from the findings of the study should be published. This is necessary, for wvhlpping up the multi-scctor collaboration and financial support that is required for tihc success of the programme. There slhould also be media encountIrs, all in an effort to move health care waste management to the top of our priorities. We ought to bc saying that if we cannot handle the waste that wegenerate izn the process of crinfg oulrpeople an1d this can become a serious sozirce of health problems, then our people are betle,' off withoutl a health .ystem. Our health i'stition; shorlold be safeplatces to (cquire uwe-not infections. To secure the cornuitment of pnivate health institutions, the MOH slhould involve themn tlhrough their respective trade associations, in programs meant to implemcnT the policy. The implementation of the policy has financial implications for health insutunons, which may tend to be a disincentive in the face of scarce resourccs. The pilvate healtlh institutions in particular should bc encouraged to participatc in tile trainillg pr an-ims that the i\IH- wvill orgaillse for thle 11ealth insitutic)ns tnder cost sharing arrangements. The assistance of development partners, NGOs and other civil society organizations should be sought in orclcr to reduce the financial burden on the institutions at least at the bcginruing. In thc long tern, more durable solutionls to the funding problem that are consistent xviti the existing cost recoveny polic should be explored. ''lie advocacy program should also encourage health care training institurions to include health care waste management into their curticula. All efforts should1 be made to inform and educate key stakeholders in order to achiieve unity of purposc and action. These efforts should include insti tions that arc responsible for approving newv health institutions, e.g. Private Hospitals and Maternity lomes Board, to ensure that tley insist otn dte health care waste management readincss of newv institutions in terms of facilities, humnan resources, plans and othler aspects of capacity to deliver. The same rigorous standards should be maintained in the monitoting of existing institutions and sanctions should include the withdra al of certihcates until the relevant shortfalls are corrected. 35 HEALT H CARE W AST E MAN AGE ME NT PO LI C Y. Hc ealth care waste milnagri-cnt involves morc than onle sctor. I m-.dcuswl collaboration is tliercforc nccessarv for tde cffcctivcless (d liw unpIcn(>ic:11tat1t)ll 4t tli-j1k ll w mltll:11(- ;lt11C(: dick lkc. flxl.l-]l () : ll: dlliffucillx 111i1lstille. -1, w ith lth( m1 % I-hil.11 o,)lll.;. sruIlIlII-c 7.1 General Principles of Implementation O ne of the key ptinciples thlat inform the implementation plan outhincl II tlice ensuing secions include 'the polluter pays' plinciple which rcquircs rhe generator ofxvaste to he legtylI and filnanctiAlty tsponsible for its disposal. Ih ihc v principles ale: The Basel Con7vention - concerned w"ith trans-bounrdar movncmicts of iiaxardomlt waste inclucling healthi care waste The Precautionary P'rinciple, w-litch advocates rhe adoption of I-(-;tSelIC> k1 protrct health and safety whren I li magnitudc of thle particular tisk is uncerltCIn. The Proximity Principle, which rtCtuitres h1aardous WastC inclucling hIcalhrh carc wxaste to be disposedl of ar thic closest possible location to, its source II uIr to minilise the Lisks involved in its transport. The Environmettal Policy seceks to guide developmnct in accordanceu wvilit uaIiT\ requiremcnts to prevent, rcLuce and, as far as possible, clininatc poLlunota and nuisances. The National Environmental Sanitation Policy, 1999 also rCquilc' all e11a care institutions to estal)ish his titunot.al o vIJwaser nmanagemcnt svstems for tit- O iltpimar managuement of wastes. It recItLites Healthi Care L`acihties to pre-trcat 11(health CaIre WastC (e.g. bVl autoclaving) prior to storage. Ilhc polic)' further states tiat District Assemblics shall provide separate collection of hazardous and hcalth care \VaStc. Ttalns1ioct of such waste shall be in closed no-compaction vehicles, wVhichl sh1ul.d I)c cleandcl and/or disinfected at thc end of vcvvr collection dav 36 H EA LT H CARE WAS T E MAN AGE MEN T P O L i C Y 7.1.1 At the Institutional Level A tt de institutional level, the Public Health Unuits of the larger public health institutions shall have the overall responsibility for thc management of health care waste This is in line with the MIOH's policy to set up public healtlh uni'ts to be recsponsible for all public health activities in hospitals. Each health care facility sh all establish a Health Care \Waste Mianagement CoTmlittee (HC iMC) appointed by the heead of tde insutution, or make an alternative arrangement to supcirvise, advise and moriTor waste management within the facilities. In smaller institutions or ptivate scctor institutions, tde appointment of a properly trained HCW Manager \vith thc r-equisitc autholity, to effectively implement HCW policics and guidelilnes shall sufficc. 1The membership of HCWMC shall include: o The Head of the Institution or His/Hcr Appointee (who 'ill serve as the Chl.,trman) o All Departmental Fleads o Infection Coni-ol Officer o The Radiation Control Officer (likely to be a trained radiographer) o The IMatron or Sister in Charge o Tfhe Financial Controller o Thle Public Health Unit Head/Environmental Health officcr (who wi.l1 be the H-] CW\Y Manager) o Union Representatives o The Local Authority lRepresentatives o Representatives of the Local Conmmunity. TIhe Healtlh Care Waste Managemeent Comrmittee shall meet regularly (at least (luartcrly) to discuss issues related to health care waste management in the hospital. lThe Coommittee shall begin its work with an iritial asscssment of the l-JCVNI practices and procedures currently in place. This should providc baselinc infor-mation for the monitoting and review activities. 'Ihlc Conmnittee shall review any HCWNM plans already in place and develop ncw (loes in line \vith tllis policy and guidelincs. WVhere thlere is no plan in existcnce, the 37 HE ALT H CARE WA s.T E MAN AGE MEN T PO LI CY COiYIlittMcC shallI dCvelop onC LIsinIg a participatory approaclh tii ord(rt to ehst thec SLIp[)( dit Of all Co)nCCIernCed lighlt 1COm thc O(utsCt. -rhe conmimittee shall implement tllc plan so develh pcd bv ap)o.ntinig and supeciAising substantive officers. Therc shall be p)elodtc sitc visits to ob)scevc the HC.\Vl staff at wvork in addition to the re:;gular reports that thc substantive staff are required to submit to the Committee. Training rot thc f-IC\VN staff shal be a pniority; both pre- and iii- service training shall b)e offered to all staff to ensure that thev ar-e very much abreast wVith developnients in the HCWNI. ithe {(Aw Mfanager slhall do supervision of the labourcrs and othIe auxiLIarY staff. l-lo\eve r, this Function shall not be th-e prcsecve of the Line managers. Consideting the fact that waste is generated in all sections of the ins,rutio)ns, it would be expedient for the managers of the respective departmentlts lo 1havC authoritY OVCt thlC auxiliary staff. 'there should thereforc be effctive coordinaion bcrbetween the 1-1(X Mia,nagcrs and the heads of department in iwhich the auxiliaii staff work so that supervision will bc effective. HCW\ Managers themselves should pay StUrLlsc visits to all departmcnits to observe their staff at work and to ensure thar the wvork is bcinIg done as plannied. These visits will also provide opporru,nintes fou coachliing whilst cngcidering disciplinc. Participatory planning and evaluative mietlhods should be adoptcd wvithl the insitutio(ns taking the stance of a learning organization. HowM /Mne,, can le done befter should beI the focus. *I'he activities of the health care waste management staff shall be doculmnntcd. Pcoper srore keeping measures in cespec[ of logistics should be adopted. 'thcsc reccrds are usefil in validating evaluative findings. For instancc thie numler and ty-pc (in tenrs of colour coding) of polythene bags and plastic waste containers in store, numbers issued out and the quantities rcceivecl, when issucs and(1 rcceipts took place and whlo received or issued them and to whomn they wcrc issuCed vill all b)e valuable information that could be used to validate records of wvaste processed. This documenitauon shall cover all thte aspects of Waste manlagemtllent: Thc type, volume and/or weight of waste, where it was gcnerated and the person proccssing ir 38 HE ALT H CARE WASTE MAN AGE ME NT POL ICY slhouki all bC documented. r\ lalicl attached to the blin or plastic bag shiould also pr'vlde this informarion. 7.1.2 Local Arrangements L ocal afrangcmnents Include thlOS aCtivitics that thl institutioll and thif rcsplectivc coin-niuntiLes and district assermlieS Cainl COltie togethcr to involvC rhe!r people in for effective implemenranion of thle Polkcv. Thc inclusion of a represcntative of the district assemrblies and thc community on the HJ\XVCM((:s is tO) facilitltc the involvement of the coMmun1ity and also to safeguard their intcrCst. MtteCUS rclateCd to acquisition of land for final disposal sites, protection of disposal sitcs amkinst unrttuho'zed visits and scavenging are issues that tcquirecoILmmunit) coopcrat6un. Ilvh local authorities should also be involved in the nrgotiatioll for facilirv sharing a liecmeilts with neighbouting institutiols. 13v involving tI e local authoriis in the H-l(:\V\l(:, such dlecisions can be taciit-iracd in a anliannrn Ilhat pronmotes thlC activc support of all. Political and administramtve boundan'es neced not influcnce sticlh coolrati.uoll, what is key is the proximity and cost cffectVCivelneSS. IThe cilisrlict/!i unlmcmpal/rnetrololitran Uiaulioncs are to en force compl>liance To strandards and should take responsibility for external Tra risportation and final dispios;il of waste. is,tncr he 1alth autlorities vho \\ill also be supervised by the rcgional health dlire cior-are xill do direct supervision of the indwidual itStitutions. Infornmation flom egardillg staustical information on lHC\N\J will be con-trunicatcd along tlhesc Lics \\ithd inusilorions reporting to the Distlict Director of I Icaith Services wvho \ill collate the reports from all institutions under his care and fornvardl it to the Rceona-l Diiector- of HIcaltl Services who, in turn, will forward die collated regional informainon to the Head of Occupational and Environmental l{ealth Unit at the Natilonal level. 7.1.3 At the National Level A r rthe national leVel, thltC (ccpl;ational ind Invironinental Health Unit of thc l Jil-[ealth DDivision wvill collaborate with all the divisionslls to enisure 39 H E A L T H C A R E W A S T E M A N A G E M e N T P O L I C f Ihie vaniouLs LecC0lo1giCs for p1roXcessing wvasre slhouldl be assessed and :ati(,n,tlIscd. l1ihe standards of emission, etc shoukl be developed and a sWrUIcru rc l pi InlpKA2 P) monitor tlhem. hle C Ghana Standards Board and the TAl' shlould approue ile technolo,gies. Ile ,N[COH and Mlinistrv of Finance should make some bLud,et alk)10caion0s r(t (I SlSl theC ht.,alth in(SIMnoS with the iniril investMcnt inI heal1th caLrC wa.,re l(',WIMllInI eqiiuincnt. hlic dcevelopment pariners, NGOs and civil society sho uld )ie liCvtedWAA iJ reSOLrce mo0ihzati0n. 7.2 Dissemination Strategy I n developing this policy and guideLines, a parteipatory approach wxas adoplud. Consequcntlv, reprsenratives of stakeholder organizauoons came togctherl in wvorkshops and discussed the lissues of conccrnt regarding I IV\C N. Ti_sapspproach promoted tlhe spint of teamwork and ownerslhip of the policies and gukiCde lines. I ke disseininarion strategy ci nvisioned will follow the same parricipaturx app (;leCh isl in p) rep-pi thn I 5 'I9k The follo\ving acilviocs are enmisaged: a) [hfe Policy and Guidelines xviiU be presented to a tia onal workshop of stakeholders wlho will reViewv and validate the p)olicy as Vcll as the National Action Plan (N A]'). b) lhe documtcni will be presented to regional clircctors and orthcr senior healthI managers, district directors and managements of teaching and regional hospitals and professional health associations for their inlput. Any relcvant amendments arising, from those soulrces wvill be madc. c) 1-he final document will be presented to the H-lonourablle MliniSiC for IHIealtlh cl) It will also be presented to hlealth workers, relevant NG()S, oinion laders ancl the public; anid in those districts in vhich the lb'rdcr 40 HE ALT H CAR e V AST E PA A N AGE ME N-T PO LI CY toWNns involvcd in the \lc,st African Corridor Projcct are locatecd as wvell as othl selccted pilot districts. c) NManagers at the rcgional levcl xvill then be expected to organize di;sseinlatio)n eSsilonS tO explain the contents of thl policy to smafl in tlheir regions, districts, sul) districts and healtlh facilitics. f) ^Funds will thelreforc have to be mobilized to ensure ihat the regional and district disseminations progrcss on schedule. 7.3 Implementation Road Map I he prPoposed btmetable for the dissenlmination of the policy and itS impllmentltlionl are sumnanrized it Table 7. Table 7: Work Plan Strategy Activitics Tirning Rcsponsibile Persuni I Sner ilincil * R ovirs of di.,ft HCN\I policN Fclh. NIiilrch, (,o fIcdL d t:lkii" I aild tleg.1l sid gmI(lintcs bwvovking groiip 2(0i 4 ir.,incw, lk bXtr lit:]ih * \cio11,nenl of Nanioiatl I)11 Pi'Mi-1. Ci(V I I t ,\.I Itr (m I t \\Ni :ichlem PIan (N.-\P) Ail . 2-11)4 * '. 1;.:.1l (,kslIm}o 1t ............ \IcL\ .! 2t'' I 'Hl PI'\Il .21 11 I~~~~~~~~I 1 1k4l 11 11'.stqslnl Legislation - Draft a 1;mw oni I ''~ In Niini-tel of I ic;1iili healih care waste m!InIag!n! 2 Diss~c nil arltil * D),qem ! i! ! 100 II i-onlit, i -_ '; I, 5ovrng Cnrmnn;rev. d!!.i.ric level- Prsentation Of 2! II dor ;n sciior marimgers. RH'I'T & Du-1 N IT Irr eciinig 1 lin rlose lic:jiih * P:i)(le ndcqlaetc pie - Cill'C.(';i91c cutolkc10o1 inal lials. I uI' N. 1 I miilyiLc pi , * 1' ,o -,idc adequiat.e heafl ci 2e ic 2 ' 4 xv;ilTiv pnciak iigg and sTor;ge 711 ;tI! g ' ' Ii Provite mcnicilCr:tors and oilier I ! ' .im 0c1itticdl rclev-i111A cqtiiflCiil i foi- 'pIll l reli ilt-ji of wvastes (I)! lcvcls) 41 JO I I OV3 I ~I0I t. JO LaI;)wdIlZAULW)Cj.1 111~It Jo J3I.1I'~fl 1.ya LLaLId0jA3 tt :jaujta : aaaatuau~~ 3t10(1U3A131111 tAt a p111t11.L CaSaid - IVaItIt I 31aaaa-JIUeIAI. qa C)a taP at - - ta(~~ ~ I - pa -)I IL 33)1 11W - I - 3LSt''a\ tLt3 [iVIj l (.IjO La opLLlno~J- tt- 3ifla3o UIODIZsaa -u LI.~v 3 LIit -_ii1 J31DILILIII .4 -' - LL NUJ'~IIK \:)- d vutitlvi Q Ix,t )1531 a - a. ap a1.Dil Jo mo&I ill a - ~~~~~~~ MJ- L pll- 11aL jkllALLtii\t j 1113) A I 0 WUtL3O.d I NaaWLatJIN W S V~ HE ALT H CARE W AS Tr MA N.AG E MEN T PO LI CY ' :' 'S11 z l 51l 1:"! :'!1\1II 1wi di:91:T! I& rt r1 i'' 1 e . 1(j R10 IS,) DD 1).) : ' ( N[sd-tcsn SuicveN oni progress of - it:.I z ., i :: !, ,,~~~ I 1'SN I1.1 l! :2 I )I IT J .~~~ ~ .I.i .- (.. * "(E Isis.' s :11; 1. S -s 5 t fi r P * i . t 1,! .11 11 ,o11 -1 111, I! (( S - 11 111 ( 7.4 Responsibility for Implementation Thi-S poiACy is mcant to provide guidance for the heaIlth sector ats ', whlcuk. EahSUb SCC101 namely1CI, thec Ghana FHealtb Scr-vice, II-IC I caching11 I-Iospitals, Qua-si-(Governmen1Cft Hospitals, N1i,~Sion Hospitals; and IIIe 1l3rtvatc sctor health 1IflTtLltiOflS 7ic to t .1pIlcm!;t .,s, polc1es and guidelines .'4i NfOl thereforns Ibs the y tsporiibilit for its oiplementation T1hise arc huoweve o(thoer nill stries that play complemtentary r;les: Ihc (l II llct /'III(pI)ImlI IIiI lTh. t)W Ii>C1l)l' t I e: Nr'II St ,~ r\ o Ct II I C \ II;ThlII t .HJI ( Scoi-ie. Ninistry of I c:l- Govctlunnew and rural Development, -and Ictcriniar lserv ics Deparrcsinr. The pcolic-3\ is thereforc meaiont to clovetall the plans and responsibilities of the NID\s. ThrsiLS Whiklt the M1OH through thce Individual 'instituto is respolsicl for- segreigatng, storing and trealtin [oksAN' 3th (istiOcI/munuicipral rnlecronlial ascrnmblies have to ensurc that liv %v,Stc is ii:iii'),s1tit iiiJ c1i'l>su.-s.I i.n the .pj1(tptatc m lannr. IC p1:er->< ihe.t1t4. 43 ,. ~~~~~~~~~~~~~~~~~~~~r HEAL T H CARE WAS T E MA N A GE E MEN T PO LI CY treatillent whe rc possible and transport to the transit pointl. he distcict/munnicip,al/-nctrol)olitan assembLies have to ensure that thcrC arc wvcl- traincd and effective companics in the svstern to do the trainslportation and disposal and in somnc cases, treatment. They are the ones tn screcn, 11cense and supervise the private waste management companiis. 44 wI~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ KEALTH C A R E WASTE MA N A G EM E N T P O LI CY onitOlinlg and review are very critical functions for the effectiveness -fi any progrmimnnic. No matter ho\V wcU a programmr is planned and impiclieented, there are chances that solime details may be overlooked. (;ood supcmislion and monuitoinng, as processes are underway, are citincal in addition tO Post audlJitS, to assure the discov'erv of errorS and their correctoll in good time. Ihe also proVide the opportunity to rCeiC\V the plans as well as training prog-an-unes in order to make theml moMr effectivc. Periodic reviews arc also important in accessing program impact Thus the effec iveness of ilhc programmes \xill l)e a+ssessedl from Sboth the pzoint of vie\v osl~ managemisent fo bocc5tCi andt srne imp)acts. l'he guidelines for 1\No11ito i-ig and Rjv are presented in thec .S,etions X. 1 to 8 2.3. 8.1 Monitoring and Control Ile obsjecCTVe of monitorinig and control is to ensure thar problems and rislks in1VolVCd aRe identifie6d whille preventinig tIle deCVelopm11elnt of fItLIre lprol)lemI.s and enhXslanlcin> sa;fetv. (omipliance wVithi laid dlowni regula7tions and gUidelinTes will be the norin while district assemblies are expected to enforce compliaice. Ihough the, FI-\VINl committees are to advise on thic handling and dis'posal of Waste, daily supervision is to be carried Out by the \vasre control manager (line :inaeral of lab2oiUrers and auxiliarv staff involved inl \vaste mana1tcgmenlt) whio in rnI liS aINS\\''Crable to the head of the inIsitution1. 11 institutional heads lhere fore have overall responsibility for ensuring that procedures are in place. arc being, implemented and sanctions enfor-ced where appropriate. Ihey arc (expectcd to wvork closely with the H(7\\W1\I comiiittee wvhich they (or tlleir rcepresentative) chair and conlduct rcgular spot chccks. In addition to dailv and weekl- inspections of procedures, Lhe followving paraineters are to be monitored: ill Standard ()pxirating Procedures (S(o)ls) which shiould be developed by the V1'ar0LIS stilbsctir.s in health for tihcir staff inlvedL at each stagc of handling 45 H EALT H CARE WA STE MA NAG EM ENT PO LI CY VzstC should be monitored frcqucnd\ by supcrvisors in the lhcalth facility, 1) 1h DHINf[TS andl cltc RJNI TS. The SOi's shLould co'el- areas like waste mninimuation, segregation otf wasie, transportation, storage, trcatinent andl final disposal. In addition, it Shlou(ld Cove l the disinfection of rcusable health care rislk waste containers based on srandards for disinfection as requil-cd b)y this guidelline. b) M\inimum environnmental performancc requirements for contlollcd combustion treatment facilities like incinerators should be carried out a1 telc onset of use of the facility and at least once yearly based on guidclines to be provided by the EPA. Whcre it may be considered maore effcctive to conduct these detcrinlations cent.rally, arrangements should be made to organize testing from national lcvcl 8.2 Audits 8.2.1 Periodic Management Audit Fach regional directovate should arrange to carry out their own internal audit on waste management pracuces in their facilities at lcast once annually. ancl followx up anv serious incident, which is relevant to waste management proccdLrics. This is in an effort to amend procedures whlere appropriate in order to Improve the management of the waste. The results of the audit should be forwardcd to GI-IS / M1OH headquarters and communicated to hcalth institutions involved. 8.2.2 Extemal Random Audit Random audits on waste management will be carried out each year by the Ministry of Health, whiclh may delegate the Occupational and l'nvironmental Health Unit, Institutional Care Division or other appropriate depr.utenclnt to carrv out this funrction oln its behalf. Additionally, audits offered by audit bodies external to the MOdI-I will b)c encouraged to facilitate obiCctivc evaluations, which favour comparisons \vith international norms on vwaste manag,crnent. 46 H EA LT H CARE WAS T E MANAGE ME NT PC) °L CGY 8.2 3. Audit Tool A\udit tools designed for mcasuring compliance with cl-inical waste procedures slhould be uscd for audits. An cxarnplc of such an auldit tool is to be foundl at Appendix 2 8.3 Reviews Therc shiould( bc a review of tile pcrtforlmance to the ipvo,ArI ( mfmcliffC IRVO vcars after tlic liunch of thle policY and( aT tile clnd of thle fifthl year to asscss tlhc compBlince anid thec }lt-el:ammeCS ImpZactS. Thel<'se reviewvs xill ksc the find(ings of studies COnclICeTd on- hiealtlh care wvaste pracuices in the hlospitals ais bxasclinc andl will asscss the progiess of the progranvuie agatinst the kev indicators esTablished. Thc tpe.s () \v,istc disposal nmethods in use. Cmssionis frolm ilix'rlllatotS and wheicthier the cotn)osiin miieets thic standardlS S't l'b the relevant authonities and other I \SUcS Will be trackdl dO\Vll. 47 H E A LTH CARE WASTE MAN AGE ME NT PO LI CY 48 H E AL TH C A RE W AST E MA N AG E ME NT P OL IC Y *} '.1 .' .*, 2 ....1, 1\r \i. s - f Ql,,lil \.fIX,v I.1rlll r 1.~ )2x (V. 1;gh. : V1 . i r. r) = - ~- --- ~ - ~ = -= =~ ~ t "'-- -t-I>-- r -; ' _ _L - -l '- "--'_ _" - _-- _ t i ,1_ t ,~------ -__ _ _ , -.--t---- L -- - ! _. =- - --I - -- L---- -- - _ r -- - - - ---- - --- +-- - !- --- I - -- - ---1----- ----- ---- I .: _ _,,I_-,, _ - _ __ _ _ _ _-___ * _ _ - - I ---- j --- - I - - - ;~ ~ ~~~~ ~~-- X - r -I - -- --, - *~~~ ~ ~ - -, i . - t--- : ... ; 0 * * . t - . .- ... . _ .* . I -._ = _ . . = X , _ _ _ j_ _ _ _ , ,- . - _ - , _ . _ _ _ _ _ __ _;_ _ _ , , ~2- . . . . * I -_ '~~ ~~~~~~~~~~~~~~~~~ ~ ~~~~~~~~~~~ -- f- * I -0 ,l0 0iS _ ___ - .I- … _i~~~~~~~~~~~~~~~~~~~~~~~~~~~I .- _- i ,, .l - _ _- ! . . . _. _ . _ _ 1 Os >L] I filt. 1 A* M ) llp i ' h ].,I ,i , - t d o11 , . I , I '~~~~~~~~~~ I' At. Ii'l Iaes li) ) '1 LI,). rr"t. I1111 I1t\, ,e a q s& U1 JO SIIII.)ll > 1}S(u r ~~~~~--- -- -.- - --- ----- - -. . . .. .:liI ........ _>II'j . __i . - ~ ~ ~ p~~;u Iim ol 3111.ZInvlc; } ---- -- --- - -- - -- , Hv'o :dIIj J--' 1''-LsLis-tU0) wt1ltj!1 i __ "- ' ' li)llulll P* lu ' cil hl I103 'c-' ; I!" - j ~iq i) on isod o,tivl) I . ........ . .- -…*. . .. .. . '' '_ l'lIII' I ,,,,,'"' 1s-.a 1xlo ,lls n UL ' ; ' 14 tiil IIC IC- l''>tIh,r I sd l ) | ! ~ ~ NolI c- - --'~- ----- -j--- - --- -- --t-- --- - -_______ )i -i~~~~~~~~~~~~ viu utlCIi UCI:4Jr~- IV i 1'N1 ,. ,t 12]I. * -,L N;4 /c0') Vl ii N JeSodSi,U puc Eu!IpueH sdju4S qrVZ < -_ D\I 'I - .- - - - - - -I.fII I Ae'infO Iso: le?illul pue suolido juiawdinb3 :j xipueddvy Appendix 4: Relevant C6sntrol of Infection Policies and.Other Guidance 1 GHS, Policy and Procedures for Infection Prevention Control on Health F:cilities, 2002 2. GiIS / \WI-IO GAVI infectiorn Saftry P5oUcy and Strategic Plan, 2000 53 A2.2 Waste Disoosal ____- L2K9. -- ~~~~ACTrJON - - - -- -…I~~- - - -- -- w , I.. I j I I .itf-- Y I-I~~L A - : I ___ -A---,--- i--4 - \ i I -- - - - - -4--- -----i. m I I