Healthcare facilities are established with the goal of providing proper healthcare services to the public.
However, unmanaged healthcare waste is causing contamination within communities.
This contamination poses risks not only inside healthcare facilities but also to the surrounding environment.
The primary groups at risk include medical doctors, nurses, healthcare staff, patients, and visitors to healthcare facilities.
The general public is also at risk whenever healthcare waste is improperly disposed of in the environment.
Sound management of healthcare waste is often neglected in healthcare service delivery worldwide.
Unfortunately, in many cases, healthcare facilities mix their waste with municipal waste systems, potentially spreading hazards to the entire community.
Therefore, healthcare waste must be treated due to the significant health, climate, and environmental risks it poses.
Current Situation in Nepal
According to the WHO, healthcare waste includes all waste generated within healthcare facilities, research centers, and laboratories related to medical procedures, as well as similar types of waste generated from scattered sources, such as waste produced during healthcare provided at home.
Transportation vehicles should be labeled and meet hygiene standards. The transportation process should follow an efficient and effective routing system when transferring waste from one location to another.
The Solid Waste Management Act (2068) defines health institution-related waste as harmful waste produced and discharged from hospitals, clinics, pharmacies, medicine shops, blood banks, pathological laboratories, animal health-related bodies, or health research centers, among others.
The quantity and composition of healthcare waste vary among countries. Generally, low- and middle-income countries generate less healthcare waste compared to high-income countries.
The generated waste is categorized into two main types: non-hazardous and hazardous.
The first category comprises 75% to 90% of the waste produced, while the remainder is hazardous.
Non-hazardous healthcare waste includes items like paper, plastics, food waste, and office waste, while hazardous waste involves infectious materials, sharps, expired medications, radioactive substances, and chemicals.
In Nepal, healthcare centers generate between 1 and 1.7 kg of healthcare waste per bed each day, with 55% to 75% of the waste produced by healthcare facilities being non-hazardous.
According to the Department of Health Services (2023), there are 215 public hospitals, 2,551 non-public health facilities, 187 primary health centers, and 3,778 health posts in Nepal.
Additionally, there are 7,582 Basic Health Service Centers (BHSC). The total amount of healthcare waste generated is substantial.
Environmental, Health, and Climate Risks
Depending on the nature of healthcare waste, the associated risks can vary. Hazards from infectious waste and sharps can lead to gastroenteric and respiratory infections and viral hepatitis A, B, and C, among others.
Hazards from chemical waste can cause burns. Hazards from genotoxic and cytotoxic waste have mutagenic or carcinogenic properties. Radioactive waste can cause headaches, dizziness, and vomiting.
Direct and indirect health and environmental risks can also occur depending on the treatment methods applied.
Inadequate incineration of waste products can release harmful gases, which are potentially carcinogenic.
Similarly, the incineration of heavy metals can result in the spread of these metals into the environment, where they can persist and accumulate.
Globally, the healthcare sector produces around 5% of greenhouse gas emissions.
The Nepalese sector is close to that mark. A recent study, Baseline Assessment of GHG Emissions of Nepal’s Health Sector 2024, carried out by the Ministry of Health and Population in collaboration with the World Health Organization, shows that the healthcare sector produces 4.1% of the country’s total greenhouse gas emissions.
Healthcare Waste Management
The Solid Waste Management Act (2068) calls for the systematic and effective management of solid waste.
Similarly, the responsibility for processing and managing medical waste rests with the person or institution that generates the waste.
Healthcare waste treatment methods depend on various factors, including their applicability to healthcare facilities.
The Healthcare Waste Management Guidelines provide detailed procedures for managing healthcare waste.
Similarly, the guidelines propose various healthcare waste treatment options depending on the types of healthcare facilities, among other factors.
The most important aspect of management is waste reduction at the source. Unfortunately, waste minimization practices are not widely followed in many healthcare facilities in Nepal.
However, one notable example is the replacement of mercury thermometers with digital thermometers.
The volume of healthcare waste can be significantly reduced through proper segregation at the source.
Non-hazardous waste produced in healthcare facilities can be segregated and recycled.
In Nepal, recommendations have been made for color-coding containers based on the type of waste for collection and segregation.
However, the simplest and most effective categorization remains non-risk and risk waste.
Section 43, Sub-sections 1 and 2 of the act under Management of Medical Waste state that the authority responsible for granting a license to establish a health institution, as per the prevailing law, shall confirm whether appropriate arrangements for solid waste management have been made before granting the license for establishment and operation.
Despite the recommendation for segregation at the source, it is not practiced in every healthcare facility in Nepal.
As a result, much of the waste is mixed with municipal waste in many facilities.
Healthcare waste should be collected and transported to a designated storage area, which must meet specific requirements.
Transportation vehicles should be labeled and meet hygiene standards. The transportation process should follow an efficient and effective routing system when transferring waste from one location to another.
The final step in healthcare waste management is treatment, which depends on various factors.
Some recommended methods include autoclaving, which involves steam sterilization under pressure. It has a low investment cost and is easy to operate.
Another method, chemical disinfection, involves using chemicals to kill or inactivate pathogens.
Encapsulation involves filling containers with waste, adding an immobilizing material, and sealing the container. Inertization is a disposal method used for pharmaceuticals.
Tribhuvan University Teaching Hospital (TUTH) is one of the prime examples of proper healthcare waste management in the country.
TUTH has enhanced waste separation at the source, installed a bio-digester to treat organic waste, and autoclaves to treat infectious waste. In addition, harmful gaseous emissions caused by the use of incinerators have been minimized.
Legal Provisions
Section 7, Sub-sections 2 and 3 of the Solid Waste Management Act (2068) state that individuals, organizations, and entities producing hazardous or chemical waste must manage such waste as prescribed.
While awareness of municipal waste management is at an optimal level, healthcare waste does not receive the same level of attention among stakeholders.
Additionally, hazardous and chemical waste shall not be discharged into solid waste collection centers or transfer stations.
Section 39, Sub-section 8 of the same act, under the provision on punishment, states that the local body may impose a fine ranging from fifty thousand to one hundred thousand rupees on anyone committing the following offenses: throwing, storing, discharging, or causing the discharge of chemical, industrial, medical, or hazardous waste haphazardly; and throwing, storing, discharging, or causing the discharge of hazardous waste produced by any industrial enterprise or health institution haphazardly.
If the same offense is committed again, the offender may be subjected to a fine double the previous amount, and the local body may also recommend the cancellation of the license to the concerned authority.
Section 43, Sub-sections 1 and 2 of the act under Management of Medical Waste state that the authority responsible for granting a license to establish a health institution, as per the prevailing law, shall confirm whether appropriate arrangements for solid waste management have been made before granting the license for establishment and operation.
A license shall only be granted if appropriate waste management arrangements are in place.
Additionally, while granting the license pursuant to Sub-section 1, special conditions to be followed or standards to be maintained by the health institution regarding solid waste management may also be prescribed.
Challenges Ahead
There are numerous reasons for inadequate healthcare waste management services.
Although the law enforces fines and punishments for improper healthcare waste management, very few such cases have been reported.
The National Climate Change Policy (2019) prioritizes the proper management of harmful and hazardous waste and the use of biodegradable waste for energy production by segregating the waste generated by the healthcare sector.
While awareness of municipal waste management is at an optimal level, healthcare waste does not receive the same level of attention among stakeholders.
This lack of awareness hinders policy-making, enforcement, and monitoring. Even if awareness improves, inadequate training for healthcare staff and healthcare waste management teams remains a major challenge for proper waste management.
Government hospitals often lack sufficient funds, making financial allocation for healthcare waste management an even more distant issue.
Insufficient financial resources prevent healthcare facilities from prioritizing healthcare waste management.
Additionally, many healthcare facilities are scattered across the country, making waste management even more challenging.
This creates difficulties in designing an effective waste management system.
Furthermore, specialized healthcare facilities may have unique technological requirements for waste management, adding another layer of complexity to the issue.
With the growing number of patients receiving health services at home and healthcare centers simultaneously providing home-based care, immediate attention is needed for healthcare waste management at home.
The Way Forward
The Sixteenth Five-Year Plan (2081/82–2085/86) aims to make producers, importers, and polluters responsible for hospital waste management, as well as implement the concept of extended producer responsibility and reduce emissions.
To achieve these targets, healthcare waste should be managed sustainably by reducing waste and ensuring proper segregation.
Developing the appropriate system based on healthcare institutions’ requirements, local context, and financial availability is essential.
In alignment with SDG Goal 3, which aims to ensure healthy lives and promote well-being for all at all ages, addressing the healthcare waste problem would eliminate many direct and indirect threats to health.
The National Climate Change Policy (2019) prioritizes the proper management of harmful and hazardous waste and the use of biodegradable waste for energy production by segregating the waste generated by the healthcare sector.
The application of safe and environmentally sound treatment of hazardous healthcare waste is the ultimate goal of healthcare waste management.
The Second Nationally Determined Contribution (NDC) 2020 targets that 1,400 healthcare facilities will use non-burn technologies to properly manage healthcare waste by 2030.
Additionally, comprehensive coverage of healthcare waste management during the approval process, environmental assessments, and periodic monitoring is a sustained approach to managing waste effectively.
Managing healthcare waste is neither effective nor efficient for healthcare facilities operating in highly populated cities such as the Kathmandu Valley due to limited space and their proximity to the public.
In such cases, central treatment facilities play a crucial role in healthcare waste management.
These facilities can handle waste generated by multiple healthcare centers and operate 24/7.
Similar facilities are currently in operation in Birgunj Metropolitan City and Nepalgunj Metropolitan City.
Sound management of healthcare waste supports global efforts and Nepal’s commitment to the Stockholm Convention on Persistent Organic Pollutants (POPs) and the Basel Convention on hazardous waste.
Effective healthcare waste management offers numerous environmental benefits.
In terms of achieving the Sustainable Development Goals (SDGs), sound healthcare waste management contributes to SDG 3: Good Health and Well-Being.
In alignment with SDG Goal 3, which aims to ensure healthy lives and promote well-being for all at all ages, addressing the healthcare waste problem would eliminate many direct and indirect threats to health.
