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Hospital waste management in developing countries: A mini review

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WMR0010.1177/0734242X17691344Waste Management & ResearchAli et al.

Mini-review Article

Waste Management & Research

Hospital waste management in developing

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DOI: 10.1177/0734242X17691344
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Mustafa Ali1,2, Wenping Wang2, Nawaz Chaudhry3 and Yong Geng1

Abstract
Health care activities can generate different kinds of hazardous wastes. Mismanagement of these wastes can result in environmental
and occupational health risks. Developing countries are resource-constrained when it comes to safe management of hospital wastes.
This study summarizes the main issues faced in hospital waste management in developing countries. A review of the existing
literature suggests that regulations and legislations focusing on hospital waste management are recent accomplishments in many
of these countries. Implementation of these rules varies from one hospital to another. Moreover, wide variations exist in waste
generation rates within as well as across these countries. This is mainly attributable to a lack of an agreement on the definitions
and the methodology among the researchers to measure such wastes. Furthermore, hospitals in these countries suffer from poor
waste segregation, collection, storage, transportation and disposal practices, which can lead to occupational and environmental risks.
Knowledge and awareness regarding proper waste management remain low in the absence of training for hospital staff. Moreover,
hospital sanitary workers, and scavengers, operate without the provision of safety equipment or immunization. Unsegregated waste is
illegally recycled, leading to further safety risks. Overall, hospital waste management in developing countries faces several challenges.
Sustainable waste management practices can go a long way in reducing the harmful effects of hospital wastes.

Keywords
Infectious waste, clinical waste, medical waste, waste generation, sustainable development

Received 5th October 2016, accepted 6th January 2017 by Associate Editor Rodrigo Navia

Introduction
Today there is a growing awareness across the world that waste is et al., 2011). Here, poor sanitation practices might result in the
a resource which should not be abandoned and left to land filling mixing of hazardous waste with the general waste which may
sites. The literature is replete with studies concerning waste treat- exacerbate the problem of waste management by increasing the
ment and recycling techniques and procedures (Arena et al., cost of treatment and disposal (Patwary et al., 2011a). Moreover
2003; Madu et al., 2002; Soares et al., 2013; Yay, 2015). Yet there poor nutrition, inadequate healthcare and lack of vaccination may
exist certain types of waste that are considered too hazardous to increase the susceptibility of the public towards infection from
be recycled and reused without pretreatment. Infectious health- untreated medical waste (Patwary et al., 2011b). The aim of the
care waste is one of such kind of waste. According to World present study is to review HWM practices within and across dif-
Health Organization (WHO), around 75% to 90% of the waste ferent developing countries and identify key issues. This can help
generated across healthcare facilities can be considered as non- us gain a clearer picture of the situation on the ground and iden-
hazardous; it is the remaining 10–25% which cannot be ignored tify areas of improvement.
(Yves Chartier, 2013). This may consist of infectious, radioac-
tive, toxic or genotoxic items. Such waste items pose environ-
mental and occupational health risks. In recent years, the
1School of Environmental Science and Engineering, Shanghai Jiao
generation of hospital wastes has increased significantly owing
Tong University, China
to an increase in population, the number of healthcare facilities 2Department of Management Science & Engineering, Southeast

and the use of disposable medical products (Arab et al., 2008; University, China
3College of Earth & Environmental Sciences, University of the Punjab,
Mohee, 2005; Taghipour and Mosaferi, 2009a). Many developed
Pakistan
countries enforce strict guidelines regarding healthcare waste
segregation, storage and transportation (Marinkovic et al., 2008; Corresponding author:
Tudor et al., 2005). Developing countries, on the other hand, are Mustafa Ali, School of Environmental Science and Engineering,
Shanghai Jiao Tong University, Environment Science Building, 800
found to be resource constrained when it comes to effective hos- Dongchuan Rd, Minhang District, Shanghai 200240, China.
pital waste management (HWM) (Caniato et al., 2015; Hossain Email: [email protected]
2 Waste Management & Research

Regulation of hospital waste

WHO classifies hospital wastes into different streams. Table 1
summarizes this classification.
In developed countries, hospital waste is regulated either
through ordinances or specific legislation (Mühlich, 2003). Also,
in the developing countries, a broad range of rules and regula-
tions regarding HWM have been formulated in recent years.
Table 2 gives a list of regulatory authorities and legislations
across different developing countries.
Legislation specifically dedicated to HWM is a recent phe-
Figure 1.  Flow chart for the selection of publications for
nomenon in most of the countries shown in Table 2. There are
review.
still shortcomings regarding HWM practices in many of these
countries. Most of these deficiencies stem from a lack of knowl-
Methods edge or lack of implementation of the rules. Moreover, lack of a
comprehensive hospital information system further constrains
In this paper, developing countries refer to the countries having
the availability of sound clinical data (Xin, 2015). Consequently,
medium or low Human Development Index (HDI) as defined by
there exists an ambiguity as to what constitutes clinical waste
the United Nations (Anand, 1994; Sagar and Najam, 1998).
and items such as gloves also end up being categorized as clini-
HDI was chosen as it is a widely recognized tool to classify
cal waste, thus increasing the quantity of clinical waste as com-
countries in terms of development (McLaren, 2007) using fea-
pared to that of the general waste (Mbongwe et al., 2008). Poor
tures including life expectancy at birth, school enrollment, adult
implementation and monitoring of the rules is another deficiency
literacy and standard of living based on the gross domestic
reported in some studies (Manga et al., 2011). Such negligence
product (Lind, 2004). A link between HWM and HDI has been
is prominent in small or primary hospitals (Gai et al., 2009;
noticed in other studies (Caniato et al., 2015). Relevant papers
Zhang et al., 2013). Hence broad implementation and monitor-
on the subject were searched using the Web of Science data-
ing of national regulations are necessary for effective HWM
base. The keywords to search the database included “healthcare
across these countries.
waste”, “hospital waste”, “medical waste”, “infectious waste”,
“clinical waste”, etc. The papers included in this review include
those published between the years 2001 and 2016. This was Hospital waste management practices
done to identify recent trends and practices as legislations
focusing on hospital waste management are also recent in many
Waste generation
developing countries. Our initial search yielded a total of 3368 The average waste generation rates (WGR) within and across
research articles in English language. In the next iteration, different developing countries are given in Table 3. Most of
articles focusing on subjects such as History, Agriculture, these were determined in studies that involved only hospitals. It
Philosophy, etc. were excluded, resulting in the retention of is important to note that Table 3 contains results measured in
around 2500 articles. These articles were analyzed individually kg/bed-day and studies reporting results in other units such as
to assess if they focused on HWM. Articles mentioning hospital kg/patient-day (Alves et al., 2014; Goren and Ozdemir, 2011;
wastes only in passing reference were excluded. Similarly, gen- Mugambe et al., 2011; Nemathaga et al., 2008; Sawalem et al.,
eral articles or those focusing on limited categories of waste 2009) or kg/day (Idowu et al., 2013; Manga et al., 2011; Moreira
e.g. dental waste were also excluded from the results. Most of and Gunther, 2013; Tadesse and Kumie, 2014) or metric ton/
the papers shortlisted for this review included information day (Shahida Rasheed, 2005) or metric ton/week (Carla Cristina
regarding hospital waste collection, segregation, transportation, de Lima Sales et al., 2009) have not been included in the table.
storage and disposal practices. For this review, we focused on The unit of kg/patient day has been used in some studies as in
individual developing countries in Asia, Africa and Latin some hospitals in developing countries more than one patient
America with a few from Europe. Hence the article selection occupies a bed at the same time owing to a lack of availability
followed an iterative process in which non-relevant articles of beds (Munir et al., 2014).
were excluded from subsequent searches. In the end a total of It is important to note that general and infectious WGR vary
100 research articles were retained. Apart from these, publica- considerably within as well as across the regions. For instance, it
tions by government departments, non-governmental organiza- can be seen that average WGR in China is higher in Binzhou, a
tions and multilateral agencies such as the World Bank, World coastal city, than Gansu, an inner province. Similarly, Laos PDR
Health Organization (WHO), etc. were also consulted. The has a lower WGR than China. Moreover, it can be seen that WGR
selected publications reported findings across more than 1400 in Iran are higher in certain provinces such as Tehran and Fars as
healthcare facilities in 25 different developing countries. Figure compared to those in Tabriz and Sistan/Baluchistan. Similarly,
1 depicts the process of article selection for this review. WGR in India are higher across hospitals in the province of
Ali et al. 3

Table 1.  Categories of hospital waste according to the World Health Organization.

Waste category Constituents

Risk waste Infectious waste, pathological waste, sharps, pharmaceutical waste, genotoxic waste, chemical
waste and radioactive waste.
Non-risk waste Paper & cardboard, packaging, food waste, aerosols and so on.
Infectious waste Waste contaminated by any type of pathogens and includes cultures from laboratory work, waste
from surgeries and autopsies, waste from infected patients, discarded or disposable materials
and equipment which have been in contact with such patients.
Pathological waste Tissues, organs, body parts, fetuses, blood and body fluids.
Sharps Include, whether infected or not, needles, syringes, scalpels, infusion sets, saws & knives, blades,
broken glass and any other item that could cut or puncture.
Pharmaceutical waste Expired or unused pharmaceutical products, surplus drugs, vaccines or sera and discarded items
used in handling pharmaceutical waste such as bottles, boxes, gloves, masks, tubes or vials.
Genotoxic waste Cytotoxic drugs and outdated materials, vomitus, feces or urine from patients treated with
cytotoxic drugs or chemicals and materials such as syringes and vials contaminated from the
preparation and administration of such drugs.
Chemical waste Chemicals from diagnostic and experimental work, cleaning processes, housekeeping and
disinfecting procedures, mercury waste such as from broken clinical equipment and spillage and
cadmium waste from discarded batteries.
Radioactive waste Liquid, solid and gaseous waste contaminated with radionuclides generated from in-vitro analysis
of body tissue and fluid, in-vivo body organ imaging and tumor localization, and investigation and
therapeutic procedures.

Table 2.  Hospital waste legislations and regulatory authorities.

Country Regulatory authority Legislation Reference

China Ministry of Health, State Medical Waste Control Act 380, Regulation 287 Yong et al., 2009
Environmental Protection
Administration
Jordan Ministry of Health Medical Waste Management Regulations, 2001 Abdulla et al., 2008
Iran Ministry of Health Medical Waste Management Regulations, 2008 Taghipour et al., 2014
Brazil National Environmental CONAMA (2001) Resolution No. 283 Da Silva et al., 2005
Council of Brazil
Turkey Ministry of Environment Medical Waste Control Regulation, 1993, 2005 Birpinar et al., 2009
and Forestry
Egypt Ministry of Environment Decree No. 338/1995 and No.1741/2005 of Abd El-Salam, 2010
Environmental Law No.4 (1994)
Cameroon Ministry of Public Health 1964, Law on The Conservation of Public Health, Manga et al., 2011
1996 Framework Health Law
Botswana National Conservation Clinical Waste Management Code of Practice of Mbongwe et al., 2008
Strategy Agency 1996
India Ministry of Environment Bio-Medical Waste (Management and Handling) Hanumantha Rao,
and Forests Rules, 1998 2009
Mauritius Ministry of Health, Public Health Act, 1925 and Standards for Mohee, 2005
Ministry of Environment Hazardous Wastes Regulations, 2001
Laos Ministry of Health Healthcare Waste Management Regulation, 2004 Phengxay, 2005
Pakistan Ministry of Environment Hospital Waste Management Rules, 2005 Khattak, 2009
Serbia Ministry of Health National Guide for the Safe Management of HCW Stankovic et al., 2008
in Serbia, 2009
Vietnam Ministry of Health Regulation on Healthcare Waste Management Visvanathan, 2006
Nepal Ministry of Population National Health Care Waste Management Chandra Shekhar
and Environment Guidelines, 2002 Yadav, 2002

Maharashtra as compared to those in Karnataka and West Bengal. were conducted across teaching hospitals in the city. Two of them
In Jordan, the results of two different studies at the same location show similar results, whereas the remaining one with a higher
vary from each other. One of these studies involved only four sample size of 12 hospitals shows a higher WGR. The results
hospitals, whereas the other study was conducted across 21 hos- are similar in Lucknow, India where a sample size of eight
pitals including the ones used in the other study. The situation is hospitals resulted in a greater WGR than the one discovered in
similar in the city of Tehran, Iran where three different studies a study involving only one hospital. Most of these studies were
4 Waste Management & Research

Table 3.  Hospital waste generation rates.

Country Location No. of facilities Waste Reference

(kg/bed-day)
China Nanjing 15 0.68 Yong et al., 2009
China Shandong 23 0.6–1.5 Gai et al., 2009
China Gansu 74 0.59–0.79 Zhang et al., 2013
China Binzhou 6 0.77–1.22 Ruoyan et al., 2010
Lao PDR Vientiane/Bolikhamxay 21 0.38–0.62 Phengxay, 2005
Serbia Nisava/Tropica 3 1.9 Stankovic et al., 2008
Turkey Istanbul 192 0.63 Birpinar et al., 2009
Turkey Trachea 465 0.28–0.82 Uysal, 2004
Turkey Sivas 4 1.25–2.6 Altin et al., 2003
Iran Fars 15 4.45 Askarian et al., 2004b
Iran Tabriz 10 3.48 Taghipour and Mosaferi, 2009b
Iran Tehran 6 2.3–3.0 Arab et al., 2008
Iran Tehran 12 4.42 Dehghani et al., 2008
Iran Tehran 8 2.75 Farzadkia et al., 2009
Iran Sistan/Baluchistan 14 2.76 Bazrafshan and Mostafapoor, 2011
Iran Ahvaz 1 3.79 Hadipour et al., 2013
Jordan North 4 1.88–3.49 Bdour et al., 2007
Jordan North 21 0.83 Abdulla et al., 2008
Palestine Nablus 4 0.59–0.93 Al-Khatib et al., 2009
Egypt El Beheira 8 0.85 Abd El-Salam, 2010
Sudan Khartoum 8 0.87 Saad, 2013
Algeria Mostaganem 10 0.83 Bendjoudi et al., 2009
Ethiopia Hawassa 9 3.46 Israel Deneke et al., 2011
Nigeria Lagos 4 0.57 Longe and Williams, 2006
Mauritius Port Louis/North 3 0.37–0.49 Mohee, 2005
El Salvador San Salvador 1 0.37 Johnson et al., 2013
Brazil Sao Carlos 1 1.07 Mattoso and Schalch, 2001
Brazil South 91 3.24 Da Silva et al., 2005
India Belgaum 1 0.50 Patil and Pokhrel, 2005
India Lucknow 1 0.5 Gupta and Boojh, 2006
India Lucknow 8 0.56 Manar et al., 2014
India Karnataka 3 0.16–0.56 Onursal, 2003
India Maharashtra 14 0.08–1.04 Onursal, 2003
India West Bengal 8 0.19–0.51 Onursal, 2003
Bangladesh Dhaka 69 1.58 Syed et al., 2012
Bangladesh Chittagong 1 1.28 Md Maksud et al., 2008
Pakistan multiple 78 2.0 Khattak, 2009
Pakistan Gujranwala 12 0.67 Ali et al., 2016d

conducted in a single city, whereas others spanned hospitals at Shinee et al., 2008), as the number of visitors to a hospital varies
the provincial- or regional-level, thus including more than one with the dry/wet or summer/winter seasons. Similarly the socio
city. Moreover, the studies also differ from each other in terms of economic status of the patients visiting a certain hospital also
the duration of the waste quantification. The duration of the affects the WGR as affluent communities generate more waste
quantification may vary from three days (Al-Khatib et al., 2009; (Al-Khatib et al., 2009; Pruss et al., 1999). Because of these
Phengxay, 2005), to seven days (Gai et al., 2009; Israel Deneke issues, it is difficult to compare the results of one study with
et al., 2011; Shinee et al., 2008; Yong et al., 2009), to 15 days another. Table 4 displays hospital waste categories as reported in
(Idowu et al., 2013) to a month (Mohee, 2005; Stankovic et al., different studies. Most of these percentages were reported in the
2008) to six months (Veiga, 2003). The procedure to quantify the source articles; however, in some cases fractions were converted
weights also varies as in some studies the researchers directly into percentages. Once again, most of these were determined in
sample and weigh the wastes (Md Maksud et al., 2008; Patwary studies that involved only hospitals. It can be seen that again
et al., 2009), whereas in others questionnaires are used to get a wide variation in the results exists. This is mainly due to the
inputs from the hospital staff about waste quantities (Arab et al., fact that, apart from the reasons given above, definitions regard-
2008; Da Silva et al., 2005). The season in which the weighing is ing waste categories vary among the researchers (Caniato
carried out also causes the WGR to vary (Hadipour et al., 2013; et al., 2015; Komilis, 2016). Consequently, various studies report
Ali et al. 5

Table 4.  Percentage composition hospital waste categories.

Country Location Risk waste Sharps waste Non-risk waste Reference

Mongolia Ulaanbaatar 12.5%–69.3% Shinee et al., 2008
Serbia Nisava/Tropica 1.3% 98.7% Stankovic et al., 2008
Turkey Istanbul 41% 59% Birpinar et al., 2009
Turkey Trachea 36% Uysal, 2004
Turkey Sivas 67.7% 32.2% Altin et al., 2003
Iran Fars 27.8% 0.7% 71.4% Askarian et al., 2004b
Iran Tabriz 29.4% 0.5% 70.1% Taghipour and Mosaferi, 2009b
Iran Tehran 29% 15% 56% Arab et al., 2008
Iran Tehran 12.5% 87.5% Farzadkia et al., 2009
Iran Sistan/Baluchistan 51.6% 1.2% 47.2% Bazrafshan and Mostafapoor, 2011
Palestine Nablus 74% Al-Khatib et al., 2009
Egypt El Beheira 25.2% 8.8% 61.1% Abd El-Salam, 2010
Algeria Mostaganem 16% Bendjoudi et al., 2009
Libya Tripoli/Misurata/Sirt 21% 4% 74% Sawalem et al., 2009
Ethiopia Hawassa 6% 49% Israel Deneke et al., 2011
Cameroon South west 16% 14% 49% Manga et al., 2011
Nigeria Lagos 19%–37% 7%–10% 50%–66% Longe and Williams, 2006
Mauritius Port Louis/North 19% Mohee, 2005
South Africa Limpopo 30.3% 8.9% 60.7% Nemathaga et al., 2008
Uganda Kampala 51.1%–69.4% Mugambe et al., 2011
El Salvador San Salvador 38.6% Johnson et al., 2013
Brazil Sao Carlos 25% Mattoso and Schalch, 2001
Brazil Sao Paulo 24.8% Moreira and Gunther, 2013
India Belgaum 16.3% 83.6% Patil and Pokhrel, 2005
India Karnataka 18.7%–56.3% Onursal, 2003
India Maharashtra 31.1%–77.8% Onursal, 2003
India West Bengal 27.8%–42.3% Onursal, 2003
Bangladesh Dhaka 18.4% 2.8% 78.7% Syed et al., 2012
Bangladesh Chittagong 63% Md Maksud et al., 2008
Pakistan Lahore 10.1% Munir et al., 2014
Pakistan multiple 10%–25% Khattak, 2009
Pakistan Gujranwala 25.8% 0.87% 73.8% Ali et al., 2016d
Nepal Birgunj 8.8% 5.8% 75.4% Paudel and Pradhan, 2010

percentage compositions differently, i.e. while some report per- standards require source segregation of different waste streams
centage composition of only one category, other studies classify into labeled and color-coded waste bags/containers. However,
the waste into two or three categories and report their percentage the implementation of the standards varies from one place to
compositions. This, again, makes a comparison of the results another. Pertinent issues include lack of proper source segrega-
challenging. It has been suggested that a consensus on study tion, (Al-Emad, 2011; Askarian et al., 2004b; Farzadkia et al.,
methodologies across the developing countries can make the 2009; Gai et al., 2009), lack of color coding (Abdulla et al.,
results easier to compare (Diaz et al., 2008). 2008; Israel Deneke et al., 2011; Mbongwe et al., 2008) and lack
On average, hospital waste generation is greater in developed of records pertaining to waste composition and quantity (Bdour
countries as compared to the developing countries. According to et al., 2007). Consequently some waste components such as
WHO, high-income countries generate on average up to 0.5 kg/ pharmaceutical and domestic waste are mixed together (Abd
bed-day of hazardous waste; whereas low-income countries gen- El-Salam, 2010; Da Silva et al., 2005; Uysal, 2004). In some
erate on average 0.2 kg/bed-day (WHO, 2011). However, the cases, nothing is segregated except sharps (Stankovic et al.,
total quantity of hospital waste has been increasing in the devel- 2008). Sometimes carelessness of the paramedic staff results in
oping countries over the recent years owing to some of the rea- mixing of municipal waste and hazardous waste items such as
sons described in the Introduction section. such as human organs (Ali et al., 2016d; Gupta and Boojh, 2006)
and radioactive items (Al-Khatib et al., 2009). Hence lack of
source segregation, lack of color coding, lack of record keeping
Waste segregation
and carelessness of the staff are observed as some of the main
In a developed country, hospital waste is segregated into color- issues leading to poor segregation practices across hospitals in
coded and labeled bags or containers (Jang et al., 2006; the developing countries. Lack of source segregation may result
Marinkovic et al., 2008). In developing countries, too, the local in accidental needle stick injuries to hospital waste management
6 Waste Management & Research

staff and scavengers (Wilburn and Eijkemans, 2013) . This in (Askarian et al., 2004b; Bazrafshan and Mostafapoor, 2011;
turn may lead to hepatitis B (HBV), hepatitis C (HCV) and Birpinar et al., 2009; Farzadkia et al., 2009). In some cases the
human immunodeficiency virus (HIV) infections (Prüss-Üstün store rooms are used to store other items such as the cleaning
et al., 2005). Proper segregation can reduce the risk of these dis- equipment (Da Silva et al., 2005). In some cases the hospitals
eases. Source segregation can also help reduce the fraction of lack internal storage areas altogether (Sawalem et al., 2009;
waste required to be incinerated, thus conserving energy and Stankovic et al., 2008), and waste is stored in open dumps or fal-
reducing financial burden on the hospitals (Alvim-Ferraz and low lands in the vicinity of the hospital (Gupta and Boojh, 2006;
Afonso, 2005). Manga et al., 2011). In some instances, the containers are without
lids and are not emptied until they are completely full (Longe
and Williams, 2006), which can result in onsite waste spillage.
Trainings and awareness
In developing countries, official rules pertaining to HWM require
regular training for all personnel engaged in waste management
Waste transportation
activities. However, since HWM is not considered to be a core In European countries, medical waste transportation is regulated
business activity in hospitals, such provisions are sometimes lim- by international regulation of the carriage of dangerous goods by
ited to a few hospitals (Abdulla et al., 2008; Abd El-Salam, 2010; road, commonly known as ADR (WHO, 2015). Developed coun-
Gai et al., 2009; Yong et al., 2009), and few (Zhang et al., 2013), tries such as Korea, also use an online tracking system to monitor
(Israel Deneke et al., 2011) or no (Stankovic et al., 2008) employ- medical waste transportation (Jang et al., 2006) where informa-
ees. Consequently, healthcare workers lack knowledge about the tion regarding waste characterization, generator, transporter and
dangers of inhalation or skin exposure of chemicals (Mbongwe the treatment facility is duly recorded. Only a licensed transporter
et al., 2008). Similarly, needle stick injuries remained unreported is allowed to transport the waste. Similarly, hospitals in these
and unregistered (Phengxay, 2005). Lack of public awareness countries have different pathways for soiled and clean waste
about the environmental dangers of hospital waste such as transportation (Marinkovic et al., 2008). In developing countries,
expired drugs is another concern (Uysal, 2004). Similarly the different mechanisms are used for waste transportation. In some
municipal staff responsible for off-site transportation of the hos- cases, onsite and offsite transportation are carried out by the hos-
pital waste are sometimes not cautioned about hazardous waste pital staff (Stankovic et al., 2008). In other cases, private contrac-
management (Askarian et al., 2004b). It is important to educate tors transport the waste both on and offsite (Abdulla et al., 2008).
all the stakeholders including patients, hospital staff, visitors, In some cases, onsite transportation is carried out by hospital
waste disposers and the general public about the dangers of staff and offsite transportation is carried by private contractors
unsafe hospital waste handling and management (Gerwig, 2005). (Da Silva et al., 2005). Finally, in some cases onsite transporta-
It is important to mention here that even some of the developed tion is carried out by hospital staff and offsite transportation is
countries have been facing challenges to make the hospital carried by the local municipality (Manga et al., 2011). Issues
employee’s behavior and actions more sustainable (Tudor et al., reported in different studies include lack of personal protective
2007). Hence it is essential to regularly monitor the intended equipment (PPEs) for waste transporters (Abd El-Salam, 2010;
objectives of the trainings with actual outcomes. Al-Khatib et al., 2009; Askarian et al., 2004b), lack of proper
push carts/trolleys which could cause leakages and accidents
(Bdour et al., 2007) and transportation in unsuitable vehicles
Waste storage
passing through residential areas (Israel Deneke et al., 2011;
Rules regarding hospital waste storage generally require the Sawalem et al., 2009). An online tracking system can be used to
waste to be stored temporarily in properly labeled separate store implement and monitor proper medical waste transportation sim-
rooms (Pruss et al., 1999; Pruss and Townend, 1999; Yves ilar to those used in developed countries (Jang et al., 2006).
Chartier, 2013). The storage areas need to be well ventilated with
water and sewerage access. These locations should be properly
labeled with warning signs and should have restricted access lim-
Waste disposal and resale
ited to the workers only. There should be separate sections in the In developed countries, a number of different technologies are
storage facility for the collection and storage of domestic waste. used for medical disposal. These include mechanical, thermal,
In developed countries, waste is usually segregated at source and irradiative, biological and chemical methods such as incinera-
stored temporarily in properly labeled store rooms. Moreover, tion, autoclaving, land filling, recycling, electron beam technol-
there exist legal provisions for site decontamination and spillage ogy, bioconversion, etc. or a combination thereof. Some of these
control (Townend et al., 2009). Provisions for safe storage of hos- countries, such as Germany, Slovenia, Portugal, etc. are phasing
pital wastes have been noted in some hospitals in the developing out medical incinerators so as to avoid environmental pollution
countries (Al-Khatib et al., 2009; Hanumantha Rao, 2009). In (Emmanuel et al., 2004). On the other hand, some developed
most of the other cases, however, hospitals lack properly labeled countries, such as Korea, have embraced offsite hospital waste
waste containers and store rooms (Yong et al., 2009). Poor condi- incineration at the expense of other technologies such as steam
tion of the containers and lack of disinfection is another issue sterilization and landfilling. This is because of reluctance of local
Ali et al. 7

communities to allow land filling of such wastes (Jang et al., these challenges, public healthcare expenditure in such countries
2006). In developing countries, different waste disposal practices has not received proper attention from the government. Hence
might be used in different hospitals within the same geographical many important healthcare activities remain ignored. Safe man-
area. In some cases, private contractors are hired for waste dis- agement of healthcare waste is one of such activities. Although
posal through incineration (Abd El-Salam, 2010; Yong et al., healthcare waste in these countries is regulated by legislation,
2009) or land filling (Da Silva et al., 2005). In other cases the however, actual implementation of these rules remains question-
hospitals themselves incinerate their wastes (Askarian et al., able. The number of studies to quantify hospital waste by cate-
2004b; Hanumantha Rao, 2009). Finally in some cases waste dis- gories and to monitor compliance with regulations is insufficient
posal is considered to be the responsibility of the municipality in these countries. Hospital sanitary and housekeeping staff usu-
(Arab et al., 2008; Farzadkia et al., 2009). Waste disposal mecha- ally comprise members of marginalized minorities (Abmad,
nisms can include a combination of procedures such as irradia- 2002). Knowledge and awareness regarding proper waste man-
tion, steam and gas sterilization, thermal inactivation and agement remains low in the absence of trainings for hospital
chemical disinfection (Veiga, 2003). Hospital waste is autoclaved staff. Hence segregation procedures are not followed properly
and/or chemically disinfected before disposal (Abdulla et al., and the medical waste usually ends up with domestic waste in
2008). In certain cases, such disinfection is limited to only a landfill sites or open dumping grounds (Ullah et al., 2010). This
few hospitals (Longe and Williams, 2006; Manga et al., 2011),. exposes people living in the vicinity of these sites to public
In some cases, the waste is burned in open land fill sites health risks. In some instances, this waste is burned without any
(Sawalem et al., 2009) or thrown on the road sides (Zhang et al., safety mechanisms. This leads to environmental and occupa-
2013). Such sites are accessible to stray animals and sometimes tional safety risks. Moreover hospital sanitary workers, and
lie in close proximity to residential areas. In most cases pharma- scavengers in land fill sites, operate without the provision of
ceutical and chemical wastes are drained in the sewage systems, immunization or safety equipment (Kumar et al., 2015). This
which can end up in natural eco systems and cause environmen- exposes them to infections as well as injuries from needles and
tal pollution (Al-Khatib et al., 2009; Mbongwe et al., 2008; sharps. Stray animals and drug addicts are also found near land-
Phengxay, 2005). Illegal sale and recycling of hospital waste is fill sites, leading to further epidemiological risks. Illegal sale of
another issue (Bashir, 2012; Gupta and Boojh, 2006). Poor qual- medical waste for recycling and reuse has been reported in the
ity of incinerators has been noted in many studies across develop- media. These wastes are being recycled into toys and drinking
ing countries (Bazrafshan and Mostafapoor, 2011; Israel Deneke straws(Jaffery, 2013). Liquid and chemical wastes from the lab-
et al., 2011). Incineration is the most widely used method of hos- oratories are usually drained in public sewers without any treat-
pital waste disposal; however, it has been criticized as it causes ment. Blocked drains during flooding and monsoons expose the
environmental pollution (Salkin et al., 2000) thus requiring public to further healthcare hazards.
additional expenditure on emission control devices. Novel tech- Issues regarding management of healthcare waste may also
niques such as pyrolysis have been mentioned as relatively inex- exist in some developed countries. The case of developing coun-
pensive waste disposal technologies which significantly reduce tries merits special attention due to their relatively large popula-
waste by volume and also result in energy recovery (Salkin, tion, high rates of urbanization and lack of resources (Bank,
2003). Further research is needed to explore relatively inexpen- 2005; Bank, 2010–2014). Many developing countries lack the
sive and environment-friendly waste disposal solutions. technology and the skills required to implement and monitor hos-
pital waste management programs. However, precautions such as
waste reduction, minimization and source segregation can help
Discussion reduce the footprint of such wastes. Figure 2 outlines the steps
HWM is a serious concern in many developing countries of the that can be taken towards sound hospital waste management.
world. Shortcomings in HWM can lead to health, safety and The first step involves training of all hospital staff regarding
environmental risks for all the stakeholders in such societies safe and efficient waste management. Waste minimization and
(Yves Chartier, 2013). To resolve the issue a comprehensive avoidance should be translated as resulting in a decreased work
assessment of their current HWM practices in resource con- burden on the staff. The staff should be made to realize that they
strained countries is essential. This can help identify gaps and are the primary stakeholders in the creation of a clean and
prioritize available options. These options can be standardized hygienic work environment. Where possible, the sanitary staff
and used for subsequent monitoring and evaluation. This issue is should be screened and vaccinated against infectious diseases
especially important in developing countries. A majority of these and infected staff should be relocated away from the patient
countries lies in Asia, Africa and Latin America and such coun- wards (Raggam et al., 2009). Source segregation using PPEs
tries usually have high rates of urbanization and population should be emphasized during the training (Makajic-Nikolic et al.,
growth (2010–2014). For instance, in Pakistan 35% of the popu- 2016). Paramedic staff, especially the nurses, should be trained to
lation lives in the cities and this figure will rise to about half of avoid waste mixing and spillage. For efficient waste disposal,
the population within a decade (Murtaza Haider, 2014). non-risk waste items such as kitchen waste can be composted,
Infrastructure in cities in the developing world is deficient to whereas paper and cardboard and empty plastic bottles can be
meet the requirements of mounting urbanization. In spite of sold to recyclers (Unger and Landis, 2016; Yay, 2015). Revenue
8 Waste Management & Research

Figure 2.  Outline of hospital waste management. Adapted from Hossain et al. (2011), Twinch (2011) and
Yves Chartier (2013).

from these can, partly, cover the cost of waste collection at the cost required to completely disinfect and recycle them can be
facility. Risk waste items should be stored separately, away from prohibitive. However, instead of incineration an environmentally
the wards/patients. Each component of risk waste should be han- friendly technique such as pyrolysis with energy recovery can be
dled and disposed of in the most appropriate manner. For instance, used for disposal (Salkin, 2003). Waste water from hospitals
in some developing countries human body parts are given ritual should also be filtered before it is released into general sewers.
burial. However if the body tissue has been affected with Prion, Conventional techniques and equipment include reverse osmosis,
there is a need to treat it with chemicals such as sodium hydrox- membrane bioreactors, etc. (Kovalova et al., 2013). However,
ide under pressure (Salkin et al., 2000) or a novel technique such most of these are quite expensive and cannot be implemented in
as pyrolysis. Cytotoxic wastes including drugs and exposed items most of the hospitals in the developing world. Nevertheless, pre-
such as beddings, gloves, clothes, etc. should be incinerated cautions such as disinfection can help minimize the risk from
(Askarian et al., 2013). Hazardous pharmaceuticals should also pharmaceutical and chemical waste in the waste water. Table 5
be incinerated. Non-hazardous pharmaceuticals can be drained in summarizes the different treatment technologies for each of the
general sewers in limited quantities each month. Ideally, such different hospital waste categories.
wastes should be returned to the pharmacies and manufacturers Quality improvement is an iterative process that requires
for proper treatment and disposal (Dias-Ferreira et al., 2016; some trial and error. Owing to the hazardous nature of hospital
Smith, 2002). Sharp items consisting of needles, syringes, broken wastes, the room for experimentation is limited here. A careful
glass, etc. can be steam sterilized and subsequently recycled. investigation of the local conditions is necessary before any
However, sharps infected with cytotoxic, radioactive items waste management improvement plan is put in place. For this, the
or Prion should be dealt with relevant treatment mechanisms general outline given in Figure 2. can be customized with the aid
(Askarian et al., 2004a). Chemical wastes usually consist of of the alternatives provided in Table 5. Each of the alternatives
items from diagnostic work, housekeeping procedures, mercury provided in Table 5 has its advantages as well as disadvantages.
waste, discarded batteries, etc. These items can either be treated This points towards the need for continuous research and devel-
onsite through dilution or collected by original equipment manu- opment in this field to find an optimal solution in a local setting.
facturers (OEMs) or recyclers (Williams, 2013). Radioactive HWM is a niche that requires special attention due to its sig-
waste includes items contaminated with radionuclides. These nificance. The issues outlined in this paper can be analyzed from
items should be stored in lead containers and collected by appro- different angles. Most of the existing studies on the topic of hos-
priate government agency for treatments using deep underground pital waste management in developing countries are qualitative
burial (Krauskopf, 2013) or membrane technology (Sancho et al., (Ali et al., 2016c; Kumar et al., 2015), and they are usually con-
2013), etc. Finally, mixed items such as cotton dressings, clothes ducted from a public health perspective. There have been rela-
and equipment covered in patient refuse should be burned as the tively fewer periodic studies to quantify waste generation across
Ali et al. 9

Table 5.  Waste disposal alternatives for different waste types.

Waste types Waste disposal alternatives

Non-risk waste Recovery of plastic, paper, Kitchen & yard waste to be Inseparable items to be landfilled
cardboard, metals, glass, composted or used as feed stock or incinerated or treated by
etc. for biogas production. Pyrolysis
Sharps Autoclaving/microwave Surgical equipment to be Prion infected sharps must be
treatment and recycling of autoclaved and reused. incinerated under high pressure
needles, syringes, etc. after chemical treatment or
treated by Pyrolysis
Pathological/ Human body parts buried Human/animal body tissues Prion infected tissues must be
tissue waste according to religious/ incinerated or treated by Pyrolysis incinerated under high pressure
cultural rites. or autoclaved & landfilled. Body after chemical treatment or
fluids to be disinfected & drained. treated by Pyrolysis.
Pharmaceutical & Cytotoxic drugs and Expired pharmaceuticals returned Unused hazardous
cytotoxic waste exposed items such as to pharmacies or manufacturer. pharmaceuticals and their
bedding, sharps, gloves, Testing kits, dialysis equipment, containers should be returned to
etc. must be incinerated. etc. can be recycled. Illegal drugs the manufacturer. Nonhazardous
treated by appropriate govt. agency. pharmaceuticals can be drained in
limited quantities periodically.
Radioactive waste Treated by appropriate Must be sealed in concrete and  
government agency. buried.
Chemical waste Batteries can be recycled. Housekeeping chemicals to be Toxics like Mercury can be
treated by dilution. reclaimed. Volatile chemicals
should be neutralized.
Mixed waste Items exposed to infectious Items exposed to radioactive or Sludge from wastewater filtration
waste to be treated by volatile chemical waste to be can be incinerated or composted
Pyrolysis or shredded, treated as radioactive and chemical or treated by anaerobic digestion
autoclaved & landfilled. waste respectively. or treated by Pyrolysis.

hospitals in such countries (Ali et al., 2016d). Moreover, existing disposal. Proper training of the waste management personnel can
studies only give a broad overview of the existing waste manage- assist this undertaking (Ali et al., 2016c). Similarly, waste stor-
ment scenario without a detailed analysis. For instance, data age, transportation and disposal activities can be systematized
regarding ward-wise waste generation rates at a hospital are usu- through the development of a management information system.
ally missing from the results, thus making it difficult to compare Waste disposal activities can also be outsourced to third-party
findings with other studies. Hence periodic assessments are nec- specialists, leading to job growth and reduction in poverty. In
essary to quantify these wastes and to assess onsite waste conclusion, cleaner and safer healthcare waste management in
management practices for any shortcomings such countries. developing countries requires dynamic policy making. The issue
Researchers can review different techniques used to evaluate and has hitherto received little attention and needs to be highlighted
improve waste management practices such as life cycle analysis to create greater awareness.
(Ali et al., 2016a), system dynamics, Total Quality Management
(TQM), social network analysis, etc. Non-economic factors to
Limitations
motivate sound hospital waste management can also be studied
using multi criteria decision-making techniques. Finally socio- A limitation of this study is that it mainly focused on studies
economic interactions between stakeholders involved in HWM accounting for waste management practices in hospitals and
can be studied using techniques such as social network analysis studies on institutions such as clinics, maternity centers, etc. have
(Ali et al., 2016b). The goal of all of these studies should be to not been included here. Moreover, few comparisons have been
find novel ways for HWM improvement in countries and regions made with the situation in developed countries. This is mainly
facing resource constraints. because our focus here was to ascertain the challenges and issues
faced in developing countries. Finally, we mainly relied on arti-
cles appearing on Web of Science database and hence some stud-
Conclusions ies were not accounted for.
We conclude that HWM faces many challenges across the devel-
oping countries of the world. This translates as an acute need for
Future studies
assessment and expansion of local health care infrastructure. In
the absence of financial and technological resources, precautions In the future, the researchers should not only focus on conducting
such as source segregation of the waste can help reduce the envi- situation analyses of hospital waste management in a developing
ronmental footprint of hospital wastes as well as the cost of waste country. They should also discover loopholes, if any, in the
10 Waste Management & Research

administrative/organizational structure of hospital waste man- Arena U, Mastellone ML and Perugini F (2003) The environmental perfor-
mance of alternative solid waste management options: A life cycle assess-
agement at hospitals. Moreover, they should discover if poor
ment study. Chemical Engineering Journal 96: 207–222.
waste management practices have a bearing on the health of hos- Askarian M, Momeni M and Danaei M (2013) The management of cytotoxic
pital staff. Suggestion of behavioral solutions may encourage drug wastes in Shiraz, Iran: An overview of all government and private
better waste management practices at the hospitals. Finally, sus- chemotherapy settings, and comparison with national and international
guidelines. Waste Management & Research 31: 541–548.
tainable and environment friendly solutions for hospital waste Askarian M, Vakili M and Kabir G (2004a) Results of a hospital waste sur-
disposal should also be researched in more detail. vey in private hospitals in Fars province, Iran. Waste Management 24:
347–352.
Declaration of conflicting interests Askarian M, Vakili M and Kabir G (2004b) Results of a hospital waste sur-
vey in private hospitals in Fars province, Iran. Waste Management 24:
The authors declared no potential conflicts of interest with respect to 347–352.
the research, authorship and/or publication of this article. Bank TW (2005) World development indicators. Available at: http://data.
worldbank.org/country/pakistan (accessed 22 November 2015).
Funding Bank TW (2010-2014) Population growth (annual %). Available at: http://
data.worldbank.org/indicator/SP.POP.GROW (accessed 22 November
The authors disclosed receipt of the following financial support for 2015).
the research, authorship, and/or publication of this article: China Bashir S (2012) Most hospitals sell waste to recycling units. Available at:
Specialized Research Fund for Doctoral Program of Higher http://www.thenews.com.pk/Todays-News-5-148738-Most-hospitals-
Education (grant number 20120092110039); National Natural sell-waste-to-recycling-units (accessed 22 November 2015).
Science Foundation of China (grant numbers 71325006, 71690241, Bazrafshan E and Mostafapoor FK (2011) Survey of medical waste character-
71461137008); National Natural Science Foundation of China (grant ization and management in Iran: A case study of Sistan and Baluchestan
Province. Waste Management & Research 29: 442–450.
numbers 71172044 and 71273047) and Major Program of National
Bdour A, Altrabsheh B, Hadadin N, et al. (2007) Assessment of medical
Social Science Foundation of China (grant number 12&ZD207).
wastes management practice: A case study of the northern part of Jordan.
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