Environmental Management of Hospitals in Khulna City

ABSTRACT

Environmental management of hospital has become a matter of major concern in recent days with the growth of health facilities in both public and private sectors of Bangladesh. Environmental management of hospitals means to manage those functions of the hospitals which can be harmful for the urban environment. Traditionally hospital waste is the major concern for environmental management of hospitals. In this study beside the clinical waste management, the locational and site characteristics of the hospitals are also studied. In Khulna City there are 7 public and 65 private hospitals and clinics. These hospitals are clustered in some particular areas which are less density populated areas. Most of them are located in the residential areas which are not suitable for city’s environment. The hospitals stand beside the road and there are no facilities for car parking and this create problems for pedestrian movement. The hospitals in Khulna City generate about 1581 kg of waste per day. Generation rate of waste par patient per day is little higher in the private hospitals (1.15 kg) than the public hospitals (0.69kg). Wastes have been categorized in four groups, namely, infectious; sharps; syringes, saline bags etc. and general waste. The first three types are hazardous waste which is about 17% of the total waste generated in Khulna city. None of the hospitals have a proper waste management system. Most of the hospitals dispose their waste in the city corporation bins with other wastes as there are no particular legal provisions for the management of the clinical wastes. Some hospitals are taking the service of a NGO named Prodipan for better management of waste. The management system of waste comprises of the disposal system, collection, transportation and final disposal method of wastes. If clinical waste is not managed properly, waste collectors, related health professionals and general people may be affected by various contagious diseases. Intervention is required at hospital environmental management – from the formulation of appropriate laws for hospital building and waste management including segregation of waste, transportation of waste to the final disposal method. Among different treatment options, incineration has been found as the most suitable one for Khulna city. A public and private partnership initiative can be appropriate to run such a project of environmental management of hospitals in Khulna city. 

1.1 Research Background

Health services and facilities, one of the basic necessities of life, are now the constitutional mandate of the government. The main thrust of the current health program has been in the provision of primary health care services, which has been recognized as a key approach to attain health for all by the year 2006. The UN declaration conveys the rights to food, shelter, education, medical care, retirement benefits, even holidays with pay. Government has also adopted the policy of health for all through the primary health care services and the WHO constitution prepared in 1946, calls for equity in stating that the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.. The constitution of Bangladesh is no different from that. It describes that the state shall regard the raising of the level of nutrition and the improvement of public health as moving its primary duties.

The trend of urbanization is increasing day by day in the world. In 1950, only about 28.9% of the world population lived in urban areas while it went up to 43.3% in 1985 and it is estimated that in 2020 more than 62.5% of the world population will be living in urban areas (Palem, 1986). Bangladesh is also experiencing rapid urbanization in recent years. The level of urbanization was only 2.43% in 1901; it became 8.78% in 1974. But in 1981 it sharply went up to 15.54% and in 1991 it became 20.15% (readjusted). Migration, no doubt, has been the most dominating component of urban population growth. The rural to urban migration rate was 51.80% in 1991 increasing from 40% in 1981 (Khan, 2006). To meet the demand of this rapidly growing urban population, the numbers of health centers are growing fast too, particularly in private sector. In the year of 1982, there were 544 government hospitals and only 164 private hospitals in the country; but this number rose to 647 government hospitals and 626 private hospitals in 1998 (BBS, 1999). These private clinics, hospitals and pathological laboratories are concentrated mainly in large urban areas to meet the growing demand of the urbanities. 

Infectious wastes have the potential of transmitting infectious agents to humans. Unintentional injuries may occur when the community is exposed to inadequately disposed waste (Turnberg, 1996). According to WHO (2000), as a result of the re-use of non-sterilized syringes, 8-16 million hepatitis B, 2.3 to 4.7 million hepatitis C and 80000 to 160000 HIV infections are estimated to occur every year. Many of these infections could be avoided if syringes were disposed of safely.

In many low-income countries, healthcare waste rarely receives special attention; rather, it is handled as part of the municipal waste stream. However, awareness of the potential and actual problems of handling and disposal of healthcare waste is now increasing. Whilst it is thought that poor management of healthcare wastes presents a higher risk to health than poor management of municipal waste, there is little guidance available on the actual extent of the risks involved (Monreal, 1991).

In Khulna, per capita solid waste generation is quite low; however, due to huge and densely populated city, solid waste problem in Khulna city is very acute in comparison to many cities of the developing countries. Daily production of solid waste in Dhaka City is more than 1500 Metric Tons. Of those 100 Metric Tons of hospital and clinical waste is a mixture of toxic chemicals, radioactive elements and pathological substances. 15 to 20 percent of medical wastes are highly dangerous for human lives. These waste when dumped with other municipal wastes in the open land poses threat to serious health hazard to the city people (Anam, 2002).

Due to expansion of medical facilities in the Khulna city, many hospitals and clinics are being established. But the environmentalists are becoming very much alarmed at such rapid growth of hospitals because of the hazards that lie behind the establishment of these facilities. Waste products from these clinics are not treated or destroyed properly, rather thrown into the dustbins thereby creating health hazards. These waste products mix with solid wastes from different households and are polluting the air, earth and water. Besides that viruses like sudomonus, staphylococcus, streptococcus, ecolyentercococus etc. are produced from these wastes products. Infections result from these viruses including infection of the liver, stomach, breathing infection, infection of the reproductive organs, meningitis, AIDS, STD, heamorrtetanus, diarrhea, tuberculosis, various skin diseases, etc.

Bangladesh lacks both effective waste management facilities and relevant government policy and regulation to guide health providers and punish offenders (Khan, 2006). Environmentalists feel that it is actually the absence of specific rules and regulations and government orders in the National Health Policy, which cannot force the clinics and hospitals to undertake proper waste management. Although the Medical Practice and Private Practice and Laboratories (Regulation) Ordinance, 1982 stated that if someone was interested to setup a clinic or do private practice, it had to be done hygienically. But it did not state in clear terms the rules and regulations, which should be followed while setting up a clinic or hospital. There is no technical guideline about what steps need to be undertaken for waste management (Kazi, 2001). Also there is no guideline regarding how to preserve harmful waste products, the type of container to be used, which technology to be used for the treatment of waste, nature of transport, the precautionary procedures to be followed by the workers for waste management. 

1.2 Statement of the Problem

Concerns are growing about clinical waste management globally including in the developing countries like Bangladesh to prevent the possible health hazards as well as the degradation of the environment. With recent rapid growth of private health sector, the need for safe and proper disposal of medical or clinical waste has become important not only for metropolis like Dhaka but also for other bigger cities in Bangladesh. Because, in many cases in these cities most of the hospitals and clinics both in government and private sector have either non-existent or out dated clinical waste management system. Khulna metropolis is one of the worst affected (by improper clinical waste management) cities.

Khulna is the third largest city of Bangladesh. The rate of urbanization is quite high in Khulna district where 50.1% of the population live in urban areas ranking third highest in the country. Khulna SMA is experiencing high rate of increase of population in the last few decades mainly due to in migration. In 1961, the population of Khulna City was only 1,27,970, but in 1974 it increased to 4,37,302, in 1981 it was 6,46,359 and in 1991 it went up to 10,01,825. It is estimated that the present population of Khulna city is about 1.3 million which has an area of about 45.65 square kilometers. 

To meet the demand of this large and increasing population, a good number of health facilities have developed in Khulna. The nearby small districts also depend on Khulna for better treatment facilities. This regional importance has also initiated the growth of health sector in Khulna. Besides, couple of large government hospitals, many private clinics, some NGOs and KCC is providing health care facilities in Khulna. There are about 248 health centers in Khulna and the number is growing fast (Khandaker, 1999). According to a report in the daily "Prabartan" on the 11th November 2002, there are about 150 clinics and diagnostic centers in Khulna. These are mainly located within or around the central city area. Only 15% of them are concentrated in Khalishpur area, 5%in Daulatpur and 7% in Fulbarigate area; the rest are located in the "Sadar Thana".

1.3 Objectives of the Study

The main objective of the study is 

– To analyze the clinical waste management scenario of public and private hospitals in Khulna City.

Under the main objective there are some specific objectives. These are:

– To identify the location and site characteristics of the public and private hospitals.

– To identify the risk of health hazards of general people and the people who are involved in waste collection and disposal system.

– To identify present collection and disposal system and quantity of clinical waste in hospitals.

– To recommend some environmentally sound measures for service delivery system and clinical waste management those would be sustainable for Khulna city.

1.4 Rationale of the Study

The world environment is going to threaten condition for rapid urbanization. Now-adays about 600 million people in urban areas of developing countries live under life and health threatening condition. For the better life and better healthy environment the health services of the hospitals should be the best one. 

In 1992, UN arranged a conference on environment & development (UNCED) held in Rio-De-Jeniro for sustainable global development. Adopted by participating nations including Bangladesh requires all countries to establish waste treatment & required disposal criteria so that by 2025, they are all to dispose of all kinds of wastes, including clinical waste, according to international guideline (Pruss, 1999).

For the large unplanned, uncontrolled and under financed the health facilities in the cities are aggravated. Rapid urban growth and urbanization is over whelming the capacity of municipal authorities to provide the basic environmental health services.

Environmental management in hospitals is very much poor in Bangladesh. There is no awareness about the issue among the professionals and the general people. No one either the authority or medical education is concern about this. There are no specific rules and regulations to build a hospital. The clinical wastes can spread various diseases by vectors like mosquitoes, flies, water, air etc. Recycling of contaminated needles, syringes etc are also a very common practice, which has a great chance of injury-related spread of HIV (Human Immune Deficiency Virus), HBV (Hepatitis B Virus) and HCV (Hepatitis C Virus) among health professionals, waste collectors and general people. An urban planner bears the responsibility to create a healthy and environment for the urban dwellers. So this type of study has a great importance for the urban planners.

Khandker (1999) in his work titled Clinical Waste Management in Khulna City mentioned that the average daily clinical waste generated from each of the 248 health centers in Khulna city was about 6 kg. So, the total waste generated in Khulna City was about 1488 kg. per day. There was no separate clinical waste management system for the city; waste was collected and disposed with other solid wastes. About 30-40 disposable syringes were thrown away from each of the facilities. The total number of disposed syringes and needles were about 8680 per day. It was estimated that hospital staff or tokais for reuse collected 10% of those syringes. These syringes and needles are dangerous for health because of contagious germs. It is highly responsible for injury related to HIV and other diseases. Awareness regarding the health hazard associated with clinical waste was lacking among general people as well as related health professionals and conservancy workers. 

The research bears an immense significance as it investigates the existing environmental management system of hospitals in Khulna City both public and private organizations; and the potential health risks of the clinical waste handlers and the general people of Khulna City as well. The study also draws some recommendations for the health centers and the waste management organizations to develop sustainable environmentally sound clinical waste management system for Khulna City.

As the planning is only for the people so an urban planner should be responsible to create a healthy and sound environment for the inhabitants. Therefore this type of study has the greatest importance for the urban planning study.

1.5 Research Questions

This study aims to find the answers of the following questions –

– What are the location and site characteristic of the public and private hospitals?

– What are the risk of health hazards of general people and the people who are involved in waste collection and disposal system?

– What are the present collection and disposal system and quantity of clinical waste in hospitals?

1.6 Scope and Limitation of the Study

Environmental management in hospitals generally refers to the clinical waste management. Clinical waste refers to all wastes generated from the health centers. But this study has given more emphasis to the location and site characteristics of the hospitals and the solid portion of the waste management system. Chemical waste, radio active waste, etc. need special treatment, which have not been included in the study.

For the study only public and private hospitals of Khulna city have been selected for survey. Other types of health facilities like diagnostic centers, EPI centers, Family Planning Centers, health centers of educational institutes, industries and the private chambers of the doctors have been excluded from the study.

The study includes an in depth study of the existing rate of waste generation, present waste management system, the factors that affects the management system of wastes generated from the hospitals and location and site characteristics of the hospitals. The study identifies the available institutional arrangements and problem associated with clinical waste management. The study also tries to develop the best possible method for the environmental management of hospitals in Khulna city providing appropriate policies through coordination between public and private sectors.  

The environmental management of hospitals means the management system of clinical waste which can be said efficient if it is a safe, effective, and sustainable and it is hoped, affordable and culturally acceptable method for the treatment and disposal of healthcare waste, both within and outside health-care establishments (WHO 2001). Clinical waste management, as well as posing technical problems, is strongly influenced by cultural, social, and economic circumstances. A well designed waste policy, a legislative framework, and plans for achieving local implementation are prerequisites for the sustainability of a proper waste management system. 

6.2 Specific Recommendation for Hospital Environmental Management

Some specific recommendations for hospital environmental management are given below:

– In the legal provision there have to be a clear guideline for the establishment of hospitals.

– A clear definition of hazardous health- care waste and of its various categories should be included.

– A precise indication of the legal obligations of the health-care waste producer regarding safe handling and disposal should be imposed.
– An inspection system should be adopted by the Government to ensure enforcement of the law, and for penalties to be imposed for contravention.
– An appropriate, safe, and cost-effective strategy which will be concerned principally with treatment, recycling, transport, and disposal options has to incorporate in national plan.
– In hospitals an open bucket or bowl is kept beside each bed for the disposal of all types of waste. It is recommended that this bowl or bucket will be used only for the disposal of general waste. An additional small covered bucket should be kept beside each bed for the disposal of infectious waste.
– It is proposed that there will be four small covered plastic drums (currently used by Prodipan) for the four types of waste in each ward or for each 15 beds. Each operation theater will also have four containers. The diagnostic centers will be provided with a set of four drums.
– Each of the containers will be colored according to the international color coding policy i.e. infectious waste - yellow with label ‘INFECTIOUS’; sharps – yellow with label ‘SHARPS’; syringes, saline bags etc. – brown and general waste – black.  
– The hospital authority will have to have strong monitoring system to ensure that the wastes are being segregated properly.
– Waste should be collected daily (or as frequently as required) and transported to the designated central storage site.
– The vehicles should be cleaned and disinfected daily with an appropriate disinfectant.
– The storage area should have a waterproof, hard-standing floor with good drainage; it should be easy to clean and disinfect.
– The storage area should be inaccessible for animals, insects, and birds.
– The waste must be disposed finally within 24 hours.
– The daily generation rate of clinical waste is about 1581 kg at present in Khulna city and it is assumed to be 2085 kg in 2017 (see table 5.15). So a truck with 3 ton capacity will be good enough to serve the hospitals of the city. 
– The truck has to be divided in four compartments for the four types of waste. Though the size of the compartments will be determined according to the rate of generation of different types of waste. It is proposed that there will be a large compartment with about 80% of the space of the truck to carry the general waste; the rest of the space has to be equally divided in three compartments for the carrying of other three types of waste.
– There are different methods for final disposal of the clinical waste. Among them incineration is a perfect method, which is suitable for all types of clinical wastes both hazardous and non-hazardous. This is because that the waste normally average very high in heat value which equals that of low grade coals.
– For the protective materials medical waste worker should wear helmets (with or without visor), face mask, coverall, industrial aprons, leg protectors and disposable gloves (medical stuff) or heavy-duty gloves (waste workers).
– Sufficient training programme should be taken for the medical stuff and waste workers. The training program could be developed by the national government agency (Department of Health) or local Government (Khulna City Corporation) or by an international or development agency working in this field (Prodipan).
– For increasing the awareness of the people proper actions should be taken such as poster exhibitions on health-care waste issues, including the risks involved in scavenging discarded syringes and hypodermic needles.
– Information poster exhibitions in hospitals, at strategic points such as waste bin locations, giving instructions on waste segregation should be included. Posters should be explicit, using diagrams and illustrations to convey the message to as broad an audience as possible, including illiterate people.

Conclusion

The hospital environmental management means proper management of clinical waste has become an urgent necessity. The locational setup of the hospitals is also an important issue for environmental management. The hospitals in Khulna City are located not in the exact area and for this problems arise day by day. About 107 metric tons of hazardous waste is yearly generated in Khulna city. If not managed properly, the patients and personnel involved in hospitals, scavengers and the people around the hospitals will face a severe risk of silent epidemics of infectious diseases like viral hepatitis, typhoid, gangrene, AIDS etc. Therefore, proper attention is required for the segregation, collection, transportation and final disposal of waste.

The average hospital waste generation rate is about 0.94 kg per bed per day and hazardous waste is about 0.16 Kg per bed per day. The proportion of hazardous and non-hazardous waste is 82.03% and 16.97% respectively. Though the per day generation of hazardous waste (300 kg) is much lower than the total amount of daily solid waste generation, yet also the danger that they posses is very high.

At present there is no such laws and regulations of hospital waste management exists in Bangladesh and also there is no such provisions for penal action against improper disposal of hazardous waste. Therefore, it is necessary to formulate appropriate laws for the management of clinical wastes. Identification of the hazardous and infectious waste and their segregation from the general waste is necessary at the source of generation. The collection and transportation system should be safe. Hygienic and cost effective measures have to be taken for the final disposal and treatment of the hazardous waste. Incineration can be the most appropriate method for Khulna city considering its performance and cost effectiveness. Both private and public sector will have to take initiative to mitigate this emerging problem. 

Specific regulations should be incorporated for healthy disposal of clinical waste. The DoE mandate only says that, clinics and hospitals should only be built in non-residential areas. This is in-fact very much unrealistic in the context of Khulna. Because as an emerging city area Khulna is already starts to face the challenges of housing accommodation for the residence lives here. The existing laws of environmental protection should not be generalized for medical facilities. A separate environmental mandate for medical facilities should be formulated. An ERA (Environmental Risk Assessment) could be done on clinical waste. Priority should be given to infectious waste disposal. 

Primary segregation of hazardous waste is mandatory. Separation at the point of generation and safe handling should be practiced to combat occupational health hazards. Then it may be wise to allow private sector to set up a plant for safe disposal and collection of clinical wastes. GOB or DoE should monitor such activities. Contextually appropriate treatment facilities are urgently required for the disposal of clinical waste. Government should come foreword to combat the hazard arising from indiscriminate use of recyclable clinical waste and unsafe disposal of other clinical waste. There should be a general consensus among the owners of the private clinics and administrators of the government hospitals to follow some code of conduct regarding disposal of clinical waste. Environmental lawyers, process waste engineers, sociologist, economist, human right volunteers, enforcement people, media, policy makers along with medical professionals should be come foreword to sole the problem of clinical waste disposal for ensuring the better environmental management of hospitals. A city – clean and green, is necessary for every citizen to live. So there should he heartily approaches to solve the problem created by the clinical waste.