Empowered lives.

Resilient nations.

PART A
Healthcare Waste Management Toolkit for
Global Fund Practitioners and Policy Makers

Rational for
Environmental
Safeguard Policies
and Strategies
Healthcare Waste Management Toolkit
for Global Fund Practitioners and Policy Makers

Part A
Rational for Environmental Safeguard Policies and Strategies

All rights reserved ©2015 UNDP

February 2015

Other parts of the Toolkit:

Authors:
Jan-Gerd Kühling, Environment & Hygiene Consultant
ETLog Health GmbH, [email protected]

Dr. Christoph Hamelmann, UNDP Regional Team Leader and Senior Advisor, HIV,
Health and Development (Europe and the CIS, Arab States); Coordinator, Secretariat
of the UN informal Interagency Task Team on Sustainable Procurement in the Health
Sector (iIATT-SPHS); [email protected]

This toolkit builds on lessons learned from a series of rapid assessments of

healthcare waste management components of Global Fund grants on country level.
Published are so far:

Disclaimer: The views expressed in the document are those of the authors and do
not necessarily reflect the official opinion of the UNDP. Neither the UNDP nor any
person acting on their behalf may be held responsible for the use which may be
made of the information contained therein.

Design & Layout: Phoenix Design Aid A/S, Denmark

Table of Contents

1 Executive Summary..........................................................................................................................6

2 About Environmental Safeguarding.............................................................................................8

2.1 What is environmental safeguarding...........................................................................................................................8
2.2 Why environmental safeguarding..................................................................................................................................8
2.3 Environmental safeguarding and risk assessment............................................................................................10
2.4 Waste and waste management for GF projects.................................................................................................10
2.5 Human rights-based approach to healthcare waste management......................................................11
2.6 Recommended further reading...................................................................................................................................12

3 Environmental Risks from Global Fund HIV, TB snd Malaria Projects...................................13

3.1 Environmental risks of health programmes..........................................................................................................13
3.1.1  Risks from the manufacturing of medical products...........................................................................13
3.1.2  Risks from the transport of materials...........................................................................................................13
3.1.3  Risks from the usage and disposal of supplied materials................................................................14
3.2 Risks from healthcare waste............................................................................................................................................14
3.2.1  Physical risks................................................................................................................................................................14
3.2.2  Chemical risks.............................................................................................................................................................14
3.2.3  Biological risks............................................................................................................................................................15
3.3 Specific risks from Global Fund grants.....................................................................................................................16
3.3.1  Examples of healthcare waste risks from HIV/AIDS Projects.........................................................16
3.3.2  Examples of healthcare waste risks from TB projects........................................................................17
3.3.3  Examples of healthcare waste risks from malaria projects.............................................................17
3.4 Groups of persons at risk...................................................................................................................................................18
3.5 Recommended further reading...................................................................................................................................18

4 Strategies to Control Environmental Risks of Global Fund Programmes.............................19

4.1 Integration into national waste management systems................................................................................19
4.2 Health systems strengthening aspects....................................................................................................................20
4.3 Applied healthcare waste management strategies.........................................................................................20
4.3.1  Waste prevention and reduction....................................................................................................................20
4.3.2  Logistic and disposal strategies.......................................................................................................................21
4.3.3  Waste stream concept development..........................................................................................................21
4.4 Healthcare waste management funding by GF grant projects................................................................21
4.5 Recommended further reading...................................................................................................................................22

5 Annex................................................................................................................................................24

HEALTHCARE WASTE MANAGEMENT TOOLKIT FOR GLOBAL FUND PRACTITIONERS AND POLICY MAKERS 3
 List of Figures

Figure 1: The three parts of the toolkit for environmental safeguarding of GF grants...... 6
Figure 2: Typical steps for a risk assessment............................................................... 10
Figure 3: The waste management hierarchy............................................................... 11
Figure 4: Steps for the development of waste stream concepts.................................... 21
Figure 5: Environmental safeguarding policy and strategy approach linked to a HCW
management concept integrated into the GF New Funding Model Cycle......... 22

List of Tables

Table 1: Waste categories expected from selected product categories of GF projects.....16

Abbreviations

ACT Artemisinin-based combination MSDS Material Safety Data Sheets

therapies NFM New funding model (of the GF)
ARV Antiretroviral (medicines) NSP National Strategic Plan
CCM Country Coordinating Mechanisms POPs Persistent organic pollutants
GAC Grant Approvals Committee PPE Personal Protection Equipment
GF Global Fund to Fight AIDS, PR Principal Recipient
Tuberculosis and Malaria PWID People who inject drugs
GHG Greenhouse gases QA/QI Quality assurance/quality improvement
HCW Healthcare waste RDT Rapid diagnostic test
HIV Human immunodeficiency virus SES Social and Environmental Standards
HSS Health Systems Strengthening SSI Small Scale Incinerators
iIATT-SPHS Informal Interagency Task Team for TB Tuberculosis
Sustainable Procurement in the Health TRP Technical Review Panel
Sector UN United Nation
IEC Information, education, UNDP United Nations Development
communication Programme
LCA Life-cycle assessment VPP Voluntary Pooled Procurement
LLIN Long-lasting insecticide-treated nets WEEE Waste Electrical and Electronic
MoH Ministry of Health Equipment

4 RATIONAL FOR ENVIRONMENTAL SAFEGUARD POLICIES AND STRATEGIES

Acknowledgements

We would like to acknowledge the valuable input of the following persons without whom this
document would not have been possible:

{ UNDP Istanbul Regional Hub: John Macauley.

{ UNDP country offices in Bosnia and Herzegovina: Yuri Afanasiev, Arijana Drinic, Jasmina
Islambegovic, Nesad Seremet and Armin Sirco.
{ UNDP country office in Tajikistan: Zebo Jalilova, Tedla Mezemir and Norimasa Shimomura.
{ UNDP country office in Uzbekistan: Abduvakkos Abdurahmanov, Jaco Cilliers, Zakir Kadirov and Flora
Salikhova.
{ UNDP Addis Ababa Regional Hub: Saleban Omar and Tilly Sellers
{ UNDP country office in Zimbabwe: Elliman Jagne and Adam Valois

This document is based on assessments which were carried out in Bosnia and Herzegovina, Tajikistan,
Uzbekistan and Zimbabwe. The assessment included several site visits and interviews with stakeholders
among sub-recipients, governmental authorities, CCM, environmental experts and from other UN
organizations. We would like to extend our gratitude to all the individuals and institutions that
contributed to the planning and execution of these assessments.

In addition we would like to thank Susan Wilburn (Sustainability Director, Global Green and Healthy
Hospitals) and Anne Woolridge (Chair of the Healthcare Waste Working Group, International Solid Waste
Association) who provided valuable comments and suggestions to this document as peer reviewers.

HEALTHCARE WASTE MANAGEMENT TOOLKIT FOR GLOBAL FUND PRACTITIONERS AND POLICY MAKERS 5
 1 Executive Summary

Patients, healthcare workers and the public are AIDS, Tuberculosis and Malaria (GF) and often acts
exposed to environmental and health risks during the as interim Principal Recipient (PR) of last resort for
implementation of health programmes. These risks countries in which the GF cannot identify a national
range from the direct exposure of staff to biological or PR for its grants. This partnership between UNDP and
chemical agents to public health risks from the burning GF has enabled the prevention and treatment of HIV,
of waste or the disposal of toxic materials. Following tuberculosis and malaria benefiting millions of people
the maxim of medical ethics primum non nocere in dozens of countries. However, GF programmes also
(first do no harm), these risks need to be addressed require the procurement and use of large volumes of
systematically on the policy, strategy and operational goods and services which have a potential negative
level. environmental and public health impact. In order to
minimize this impact, environmental safeguarding
The United Nations Development Programme (UNDP) should become an integral component of GF grants.
is a strategic partner of the Global Fund to Fight
Environmental safeguards for healthcare waste (HCW)
management as described in this document are pro-
Figure 1: The three parts of the toolkit for active precautionary measures preventing direct and
environmental safeguarding of GF grants indirect hazards of HCW including those caused by
greenhouse gases (GHG) emissions during waste
processing steps.

The GF strategy 2012-2016 Investing For Impact1

Environmental promotes the protection of human rights throughout
Safeguard the whole grant cycle as one of its five objectives. The
2011 report of the Special UN Rapporteur on the
adverse effects of unsound management and disposal
Waste Stream of medical waste2 highlighted the impact of improper
Concept HCW management on the enjoyment of human rights.
GF projects should therefore not only advocate for

Waste Management 1 Global Fund Strategy 2012-2016: Investing for Impact. Accessed
Planning Guide 03/02/2015
2 United Nations (2011): Report of the Special Rapporteur on the adverse
effects of the movement and dumping of toxic and dangerous products and
wastes on the enjoyment of human rights, Calin Georgescu. A/HRC/18/31.
Accessed 03/02/2015

6 RATIONAL FOR ENVIRONMENTAL SAFEGUARD POLICIES AND STRATEGIES

and ensure the basic rights to access to essential health It is hoped that the toolkit will help the Country
services but also the environmental safeguarding of Coordinating Mechanisms (CCMs) to play a leadership
these services following international and national role on environmental issues related to GF grants.
standards throughout the whole project cycle. It is further hoped that this toolkit will encourage
the GF executive and board to introduce a corporate
This document is the first part of a toolkit for environmental safeguarding policy and strategy, and
environmental safeguarding of GF grants. The toolkit will provide the tools to translate such policies into
is intended to help to reduce risks from the generation practice for all GF grants. Beyond that the HCW
and disposal of HCW, especially the disposal of management toolkit can serve all stakeholders
unwanted or unused pharmaceuticals, potentially in planning and implementation of global health
infectious waste and other hazardous waste. Part A of initiatives.
the toolkit will help decision makers to understand
why environmental safeguarding should be a standard Social and environmental sustainability are
in the planning and execution of any GF programme. fundamental to the achievement of development
Part B is intended to provide support in decision outcomes. Since the 1st January 2015, the formal
making on which waste stream concept and strategy procedures of corporate Social and Environmental
shall be applied, taking into account the country Standards (SES)4 have to be applied to all UNDP
context. Part C will provide support for the planning programmes and projects. Environmental and social
and implementation of safeguard strategies for GF screening and assessment processes for projects
grant practitioners including the budgeting for waste have become a standard practice in development
management as a standard component for each grant. programmes and are usually required by national
The findings of four country assessments of UNDP regulatory frameworks as well as by multilateral and
administered GF grants in Bosnia and Herzegovina, bilateral donors. The HCW management toolkit for GF
Tajikistan, Uzbekistan and Zimbabwe informed the grants aims to support such screening processes and
development of the toolkit3. the implementation of HCW management standards in
all grant operations.

3 Kuehling, J. Rapid Assessment: Healthcare waste component of Global

Fund Projects in Bosnia and Herzegovina. UNDP 2015; Pieper, U. Rapid
Assessment: Healthcare waste component of Global Fund HIV, TB and
malaria projects in Tajikistan. UNDP 2014; Kuehling, J. Rapid Assessment:
Healthcare waste component of Global Fund HIV/AIDS projects in
Uzbekistan. UNDP 2014. Kuehling, J. Rapid Assessment: Healthcare waste
component of Global Fund HIV, TB and malaria projects in Zimbabwe. 4 United Nations Development Programme: Social and Environmental
UNDP 2014. Standards Accessed 03/02/2015

HEALTHCARE WASTE MANAGEMENT TOOLKIT FOR GLOBAL FUND PRACTITIONERS AND POLICY MAKERS 7
 2 About Environmental Safeguarding

Key questions to be answered:

{ Can Global Fund projects create environmental risks?
{ What is the UNDP position with regard to environmental safeguarding?
{ Is environmental safeguarding optional or should it be a responsibility for grant makers and implementers?

{ Which principles should be followed to reduce the environmental impact?

{ What is the relation between human rights and healthcare waste?

{ And why is procurement the key for waste reduction?

2.1 What is environmental 2.2 Why environmental safeguarding

safeguarding Primum non nocere (first do no harm) is the guiding
Environmental safeguarding means the use of principle for any health programme considering both
precautionary measures to ward off impending dangers individual and the public well-being. While in the
or damage to the environment and human health past health interventions concentrated mainly on
which might be created during a project or programme. curative health services, today equal attention is given
Environmental safeguarding starts at the earliest to preventive services. Environmental safeguarding is
planning stage of a project and is continued until it itself a preventive service. Healthcare services without
ends. It can include different measures such as environmental safeguard are sub-standard care.

{ introduction of corporate environmental policies The execution of health programmes create risks for the
and strategies; environment and human health caused by HCW and
{ building adequate human and institutional capacity its management. Often these risks continue to exist at
to deal with environmental issues; the end of a project, some of them for many years.
{ carrying out environmental impact assessments
during the planning phase; Internationally financed projects such as the GF health
{ development of waste stream concepts for all health programmes have a special responsibility to follow
projects; international agreements and principles including the
{ including necessary financial resources for adherence to environmental standards. Safeguarding
environmental equipment and services; policies should also consider the internationally
{ monitoring and evaluation of environmental accepted polluter pays principle in the context of global
safeguarding measures for project operations; health initiatives.
{ environmental accountability through
dissemination of environmental information, Countries receiving support from global health
public consultation and information disclosure financing institutions are often parties to various
mechanisms. international conventions. During the implementation

8 RATIONAL FOR ENVIRONMENTAL SAFEGUARD POLICIES AND STRATEGIES

 About environmental safeguarding

{ The Minamata Convention on Mercury10 is

Best practice: the latest international treaty with relevance for
healthcare waste management and was designed to
The UN Environment Management Group protect human health and the environment from
is developing a framework for advancing mercury and mercury compounds. It aims that
environmental and social sustainability in mercury-added products such as thermometers or
the United Nations System5. This framework sphygmomanometers are not anymore procured or
should be considered during planning and imported latest until 2020.
implementation of projects
Another relevant convention is the United Nations
Framework Convention on Climate change11
(UNFCCC or FCCC). The 2010 Conference of Parties
of projects, compliance with these conventions (COP 16) in Cancún agreed on significant decisions
should be ensured. For health projects the following to address the long-term challenge of climate change
conventions are of particular relevance: collectively and comprehensively over time and to take
concrete action now to speed up the global response.
{ The Stockholm Convention on Persistent Organic In light of this, the UN launched Greening the Blue12
Pollutants6 aims to eliminate or restrict the in 2010 with the aim to measure and reduce the
production and use of POPs. These pollutions environmental impacts of the UN operations.13
such as carcinogenic dioxins or furans can be
unintentionally produced during the incineration of UNDP considers today environmental safeguard
waste products created by the project. processes as essential and experience showed that
{ The Vienna Convention for the Protection of the the ratio of benefits to costs in introducing safeguard
Ozone Layer7 and its accompanying Montreal processes are substantial. In 2015, UNDP issued
Protocol8 on Substances that Deplete the Ozone the Social and Environmental Standards (SES)
Layer is an international treaty designed to demonstrating UNDP’s commitment to mainstream
protect the ozone layer. For example, refrigerators social and environmental sustainability. The SES
and other equipment procured for health are embedded in the UNDP’s Quality Assurance
projects might contain the ozone depleting
hydrochlorofluorocarbons (HCFCs).
{ The Basel Convention on the Control of Did you know?
Transboundary Movements of Hazardous
Wastes and Their Disposal9 intends to reduce the The 63rd World Health Assembly stressed the
movements of hazardous waste and to minimize the importance of safe waste management and
amount and toxicity of wastes generated. Within a adopted the resolution: Improvement of health
GF project, pharmaceuticals and diagnostic items through safe and environmentally sound waste
might become toxic waste and their environmentally management14. The risks from healthcare waste
sound management must be ensured. were specially mentioned.

5 UN Environment Management Group: Advancing the Environmental and

Social Sustainability Framework in the United Nations System. Interim
Guide Accessed 03/02/2015 10 Minamata Convention on Mercury: Website. Accessed 03/02/2015
6 Stockholm Convention on Persistent Organic Pollutant: Website. Accessed 11 United Nations Framework Convention on Climate Change. Accessed
03/02/2015 03/02/2015
7 Vienna Convention for the Protection of the Ozone Layer: Website. 12 United Nations: UN Greening the Blue. Accessed 03/02/2015
Accessed 03/02/2015 13 UNDP (2013): Carbon footprint of UNDP administered Global Fund HIV/
8 Montreal Protocol on Substances that Deplete the Ozone Layer: Website. AIDS and Tuberculosis grants in Montenegro and Tajikistan. Accessed
Accessed 03/02/2015 03/02/2015
9 Basel Convention on the Control of Transboundary Movements of 14 WHO 2010: Improvement of health through safe and environmentally
Hazardous Wastes and Their Disposal: Website. Accessed 03/02/2015 sound waste management. Accessed 03/02/2015

HEALTHCARE WASTE MANAGEMENT TOOLKIT FOR GLOBAL FUND PRACTITIONERS AND POLICY MAKERS 9
 social review needed). When applied, all UNDP GF
Did you know? projects would fall either under category ‘Moderate’
or ‘High’.
UNDP recently carried out research on
measuring and reduction of GHG emissions of
its GF projects. It found that the social costs of
2.3 Environmental safeguarding and
carbon are at least 6% of the grant investment, risk assessment
and highlighted opportunities for emission
reduction.15 As for other projects, also in GF financed health
projects not all environmental risks can be avoided as
certain diagnostic and treatment procedures require
the use of potentially hazardous materials, but they can
Framework as one of 7 key quality criteria. SES will be reduced.
help UNDP programmes and projects to adhere to the
following objectives and requirements: Environmental risk assessment for health programmes
should aim to identify potential negative impacts
(i) strengthen the social and environmental outcomes already at the planning phase. The assessment
of programmes and projects; itself involves the identification of the hazard, the
(ii) avoid adverse impacts to people and the consequences and their likelihood, followed by the
environment; selection of risk control measures. They will depend on
(iii) minimize, mitigate, and manage adverse impacts the type of waste generated and the properties of the
where avoidance is not possible; waste which will render it hazardous. These properties
(iv) strengthen UNDP and partner capacities for are influenced by the substances of the components
managing social and environmental risks; of purchased products and the processes the products
(v) ensure full and effective stakeholder engagement. will go through during their life cycle. After the
identification of expected waste streams, the collection,
In 2012, UNDP launched a project-level environmental treatment and disposal strategy can be determined and
and social screening procedure which was revised the required resources calculated.
in 2014 to align with the SES. It requires the
environmental and social screening of all projects and
their assignment to one of three categories: ‘Low’ (no 2.4 Waste and waste management
action needed), ‘Moderate’ (environmental and social
elements needed) or ‘High’ (further environmental and
for GF projects
Nearly every country and organization has its own
definition of waste. In the European Union for
Figure 2: Typical steps for a risk assessment example, waste is understood as any substance or object
which the holder discards or intends or is required
Identification of the hazard to discard; waste management means the collection,
transport, recovery and disposal of waste, including
the supervision of such operations and the after-care of
Assessing the consequences disposal sites16. Currently a clear definition for waste and
waste management strategies is lacking in GF projects.
However if the polluter pays principle is applied, the
Assessing the likelihood
15 UNDP (2013): Carbon footprint of UNDP administered Global Fund HIV/
AIDS and Tuberculosis grants in Montenegro and Tajikistan. Accessed
Characterising the risk and 03/02/2015
possible uncertainty 16 European Commission (2008): Directive 2008/98/EC on waste (Waste
Framework Directive). Accessed 03/02/2015

10 RATIONAL FOR ENVIRONMENTAL SAFEGUARD POLICIES AND STRATEGIES

 About environmental safeguarding

Figure 3: The waste management hierarchy It is recommended that the waste management
hierarchy is followed and GF programmes should try
to prevent waste generation, or reuse or recycle the
Prevention waste, rather than just disposing all the waste. Life-
cycle assessments (LCAs) can be used to assess the
Low

Re-use
environmental impact associated with all the stages
er n
ega

Recycling of a product’s life from cradle-to-grave. This process

gs
avin
t ive

can help to identify energy and material inputs as

st s
Other recovery
env

r co
well as environmental releases from the production
iron

Disposal at e
me

of a product used in a project until the final disposal.

Gre
nt a

It can also help to make informed decisions for

l im
pac

procurements and the downstream components of

t

waste management.

GF and the PRs have responsibilities for the safe 2.5 Human rights-based approach to
management of the waste created through GF projects. healthcare waste management
Waste management does not start after the waste is A commitment to human rights is part of the GF’s
generated, but starts during the planning of activities. core values and reflected in the Global Fund Strategy
The waste hierarchy is a classification system for 2012–2016: Investing for Impact. The fourth strategic
waste management and options are ranked by their objective aims to promote and protect human rights,
environmental impact (figure 3). The most preferred calls for their integration in all aspects of the GF’s work
option is prevention of waste, particularly of hazardous and commits not to invest in programmes that infringe
waste. The introduction of environmental criteria human rights17.
for procurements of medical goods and services has
great potential for the prevention and minimization of In 2011, the Special Rapporteur of the UN focused on
hazardous HCW. Global health financing institutions the adverse effects that the improper management and
like the GF and their agents like GF PRs should disposal of HCW may have on the enjoyment of human
therefore use their market power and join many other rights. The report showed several examples how HCW
healthcare organizations, bilateral and multilateral impacts on human rights and highlighted that in most
development partners in the implementation of green developing countries, chemical and pharmaceutical
procurement in the health sector. wastes are disposed of with the rest of municipal
waste or in significant amounts through hospital
wastewater18.
Did you know?
The report concluded that the international community
has to date paid little attention to this issue, despite the
In May 2012 the UN Informal Interagency fact that a significant number of people – including
Task Team for Sustainable Procurement in the healthcare workers, patients, workers in support
Health Sector (IIATT-SPHS) was established. services linked to healthcare facilities, workers in waste
Its members (UNICEF, WHO, UNDP, UNOPS, disposal facilities, recyclers, scavengers and the general
UNHCR, UNEP, UNFPA and since 2014, the
Global Fund and UNITAID followed by Gavi
in 2015) procure products for global health 17 The Global fund Strategy 2012-2016: Investing for Impact. Accessed
initiatives at about US$ 6 billion annually and 03/02/2015
want to use their influence and market shaping 18 United Nations (2011): Report of the Special Rapporteur on the adverse
effects of the movement and dumping of toxic and dangerous products and
power for the greening of the health sector.
wastes on the enjoyment of human rights, Calin Georgescu. A/HRC/18/31,
p. 9 and p.12 Accessed 03/02/2015

HEALTHCARE WASTE MANAGEMENT TOOLKIT FOR GLOBAL FUND PRACTITIONERS AND POLICY MAKERS 11
 public – are at risk of injury and/or contamination { Website: The Vienna Convention for the Protection
through accidental exposure to HCW. of the Ozone Layer
{ Website: The Stockholm convention on Persistent
An environmental safeguard policy for the GF should Organic Pollutants
therefore address the rights of individuals and the { Website: The Basel Convention on the Control of
public to the provision of health services which follow Transboundary Movements of Hazardous Wastes
international environmental standards, and should and Their Disposal
provide guidance for the application of the safeguard { Website: The Minamata Convention for Mercury
policy in all grant making processes. { Website UN: Greening the Blue
{ World Bank: Environmental and Social Safeguard
Policies
2.6 Recommended further reading 19
{ UNDP: Social and Environmental Sustainability of
UNDP Programming and Operations
{ World Health Organization (2004): Policy Paper – { 63rd WHA – Item 11.18: Improvement of health
Safe health-care waste management through safe and environmentally sound waste
{ UN: Advancing the Environmental and Social management
Sustainability Framework in the United Nations { President’s Emergency Plan for AIDS Relief
System INTERIM GUIDE (PEPFAR) – Technical Considerations Provided by
{ UNDP (2015): UNDP’s Social and Environmental PEPFAR Technical Working Groups
Standards (SES) { Relevant links to environmental policies of selected
{ UNDP (2014): Social and Environmental Screening donor organizations:
Procedure P  Denmark: Sample environmental policy of
{ Asian Development Bank (2009): Safeguard Policy DANIDA
Statement P  Germany: Sample environmental policy of
{ Inter-American Development Bank(2006): BMZ
Environment and Safeguards Compliance Policy P  Japan: Sample environmental policy of JICA
{ OECD: Fact Sheet: Extended Producer Responsibility P  Norway: Sample environmental policy of
NORAD
P  Sweden: Sample environmental policy of SIDA
P  UK: Sample environmental policy of DFID
19 All Web-sites were accessed on 03/02/2015 P  US: Sample environmental policy of USAID

12 RATIONAL FOR ENVIRONMENTAL SAFEGUARD POLICIES AND STRATEGIES

3 Environmental Risks from Global Fund HIV,
TB and Malaria Projects

Key questions to be answered:

{ What are chemical, biological, physical risks from waste?
{ Who is at risk from healthcare waste?
{ What are the risks from the GF projects?

{ And who is in risk from GF projects?

3.1 Environmental risks of health Did you know?

programmes
The UN IATT-SPHS has initiated a Joint UN
The environmental risk of health programmes can Programme on green procurement in the
be defined as an actual or potential threat of adverse health sector. The strategic approaches include
effects on living organisms and the environment by engagement processes with manufacturers
effluents, emissions, wastes, resource depletion, arising aiming to improve the environmental footprint
from the implementation of the health programme. of medical products and their manufacturing
processes. Agreements about the feasibility
3.1.1 Risks from the manufacturing of of the introduction of environmental
medical products procurement criteria within defined
The manufacturing of medical products, especially timeframes will provide transparency and
those causing hazardous waste like pharmaceuticals incentives in a competitive market.
and diagnostic reagents, gives rise to a variety of
environmental risks. The global pharmaceutical,
medical equipment and commodity market continues
to grow year by year, and with it concerns about the
environmental standards of the production, especially burn or environmental damage. At the UN level, all
related to air, water and soil pollution, and GHG work related to the transport of dangerous goods is
emissions. By ensuring that the selected producer coordinated by the Economic and Social Council
complies with relevant environmental standards and by (ECOSOC) Committee of Experts on the Transport
applying green procurement strategies, the risks from of Dangerous Goods (TDG) and on the Globally
production can be reduced. Harmonized System of Classification and Labelling
(GHS), which produces the Recommendations on
3.1.2 Risks from the transport of materials the Transport of Dangerous Goods20 and the Globally
Transportation of goods by road, rail, air or sea involves Harmonized System of Classification and Labelling
the risk of traffic accidents. If the goods are dangerous,
there is also the risk of incidents, such as spillage, 20 UNECE: Recommendations on the Transport of Dangerous Goods –
leading to hazards such as fire, explosion, chemical Model Regulations. Accessed 03/02/2015

HEALTHCARE WASTE MANAGEMENT TOOLKIT FOR GLOBAL FUND PRACTITIONERS AND POLICY MAKERS 13
 of Chemicals21. Global health initiatives should follow into the atmosphere and chemicals and pesticides into
these recommendations through policies and standard the earth and groundwater. This, in turn, is harmful to
operating procedures for purchasers, implementers and human health, as well as to plants and animals. Burning
contract partners. of waste can result in emissions of dioxins and acid
gases such as nitrogen oxides (NOx), sulphur dioxides
Transporting goods will also create GHG emissions. (SO2), and hydrogen chlorides (HCL), which can be
Studies carried out in 2013 and 2014 on the carbon harmful to human health.
footprint of UNDP administered GF HIV/AIDS,
tuberculosis and malaria grants in Tajikistan and
Zimbabwe showed that international and in-country 3.2 Risks from healthcare waste
freight can contribute to up to 20% of the total GHG
emissions22. To reduce risks unnecessary transports The term HCW includes all the waste generated within
should be avoided and goods should be transported healthcare related activities and procedures. The
in a way which guarantees the minimization of GHG majority of waste is comparable to domestic waste and
emissions23. can be classified as non-hazardous or general HCW.
A smaller part may pose a variety of environmental
3.1.3 Risks from the usage and disposal of and health risks and is regarded as hazardous HCW.
supplied materials Hazardous HCW created by GF financed projects
Products supplied in health projects might be a might include:
potential source of harm or create adverse health effects
for patients, staff, the public and the environment. { Infectious waste: All waste which is suspected
Environmental risks are created in case of incidents to contain pathogens and that poses a risk of
and accidents during usage and from the disposal of transmission such as laboratory cultures from TB
discharged products. Unsafe disposal of waste can diagnosis
create environmental damage. Burying of waste not { Sharps waste: Used or unused sharps (e.g.
only takes up valuable land space, it also causes air, hypodermic, intravenous or other needles; auto-
water and soil pollution, discharging carbon dioxide disable syringes; syringes with attached needles)
(CO2), methane (CH4) and hydrofluorocarbons (HFCs) { Pharmaceutical waste: Medications that are expired
or no longer needed such as expired artemisinin-
based combination therapies;
{ Chemical waste: Waste containing chemical
Best practice: substances (e.g. deltamethrin or permethrin
from impregnated bed nets, mercury-containing
The UNDP managed GF HIV/AIDS commodities, silver from x-ray development,
programme in Uzbekistan introduced a system laboratory reagents such as formaldehyde and
to re-collect used syringes from people who xylene).
inject drugs. This reduces the risk that these { Electronic waste (WEEE): Waste from broken
hazardous items will end up in public places refrigerators, laboratory analysis equipments etc.
such as playgrounds.
3.2.1 Physical risks
Physical risks occur mostly from sharp items like
broken glass, syringes, disposable scalpels and blades,
21 UNECE: Globally Harmonized System of Classification and Labelling of etc. Cuts, stitches and other damage of the skin can
Chemicals (GHS): Accessed 03/02/2015 become entry points for pathogenic agents.
22 UNDP (2013): Carbon footprint of UNDP administered Global Fund HIV/
AIDS and Tuberculosis grants in Montenegro and Tajikistan. Accessed
3.2.2 Chemical risks
03/02/2015
23 UNDP (2014): Managing our climate change risk: An approach for
Chemical risks from HCW are often underestimated.
environmental safe guarding UNDP-Global Fund HIV/ AIDS, Tuberculosis Waste from health programmes often creates chemical
and Malaria programmes. Accessed 03/02/2015 risk as the materials are

14 RATIONAL FOR ENVIRONMENTAL SAFEGUARD POLICIES AND STRATEGIES

 ENVIRONMENTAL RISKS FROM GLOBAL FUND
HIV, TB AND MALARIA PROJECTS

Expired pharmaceuticals at hospitals from different sources

{ ignitable; waste can catch fire under certain

conditions. Examples are solvents, paints and Did you know?
certain degreasers;
{ corrosive; they corrode metals and may have a very WHO has estimated that, in 2000, injections
high or low pH. Examples are disinfectants, acids or with contaminated syringes caused:
alkaline cleaning fluids and battery acids;
{ reactive; they are unstable, and may produce toxic { 21 million hepatitis B virus (HBV)
fumes, gases and vapours when mixed with water infections (32% of all new infections);
or under other conditions such as heat or pressure. { 2 million hepatitis C virus (HCV)
Examples are certain cyanides or sulphide bearing infections (40% of all new infections);
waste; { 260 000 HIV infections (5% of all new
{ toxic; they are harmful or even fatal when ingested, infections)24.
inhaled or absorbed. Examples are pesticides
containing waste such as DDT or heavy metals such
as cadmium, lead or mercury.

Chemical risks are also caused by pharmaceutical waste 3.2.3 Biological risks

including pharmaceutical metabolites. Microbiological risks from HCW can be generated
from materials contaminated with pathogenic
agents. Typical examples are cultures and stocks of
infectious agents, waste from infected patients, waste
Best practice: contaminated with blood and body fluids, discarded
diagnostic samples, infected animals from laboratories,
contaminated materials like swabs, bandages or
In Tajikistan, expired pharmaceuticals are one contaminated equipment. This group is the largest
to two times per year collected and transported group of hazardous HCW and can represent up to 15 %
via a reverse logistic system from the oblasts to of the total waste stream of a healthcare facility.
Dushanbe. In Dushanbe they are packed and
transported to a landfill for safe disposal or
they are co-incinerated in a brick factory.
24 WHO (2011): Health-care waste management - Fact sheet N°281. Accessed
09/08/2014

HEALTHCARE WASTE MANAGEMENT TOOLKIT FOR GLOBAL FUND PRACTITIONERS AND POLICY MAKERS 15
 3.3 Specific risks from Global
Fund grants
The GF health programmes create different types of
HCW which can be divided into the following waste
categories:

Table 1: Waste categories expected from selected product categories of GF projects

Waste Categories

Pharma­ Infectious
Chemical ceutical waste Recyclables /
Selected Product Categories waste waste (after use) Sharps packaging Others

Pharmaceuticals (ARVs, ACTs, TB X X

medicines, etc.)

Test kits (for HIV, TB, malaria and X X X X

others)

Chemicals (reagents, X X
disinfectants, insecticides,
impregnated bed nets, etc.)

Disposable medical X X X
commodities (condoms, gloves,
swaps, syringe, sharp boxes etc.)

Reusable medical commodities X

(glass pipettes, etc.)

Lab equipment (analyzer, X Electronics

autoclaves, refrigerators, etc.) (WEEE)

Office equipment (Fluorescent X X Electronics

lamps, toner, computers, etc.) (WEEE)

Vehicle fleet (used oils, spare X X Used tyres

parts, etc.)

3.3.1 Examples of healthcare waste risks The waste assessment of the UNDP administered
from HIV/AIDS Projects GF HIV/AIDS projects in Bosnia and Herzegovina,
GF HIV/AIDS grants aim to close implementation gaps Uzbekistan, Tajikistan and Zimbabwe25 showed that a
of national HIV responses. This includes the provision wide spectrum of different waste streams is generated.
of HIV prevention, treatment, care and support The waste was ranging from non-hazardous office- and
services. Typical waste streams include non-hazardous warehouse waste to hazardous pharmaceutical and
waste (e.g. card-board, packing materials, office waste) chemical waste and bio-hazardous waste. One objective
and a variety of hazardous waste streams including of HIV grants is often the support of a needle exchange
infectious waste from HIV and STI testing, sharps waste programme. In that case the hazardous waste includes
(including syringes from PWID) and pharmaceuticals also collected sharp waste from PWID.
(such as ARVs or medicines for the treatment of
opportunistic infections). 25 See footnote 3

16 RATIONAL FOR ENVIRONMENTAL SAFEGUARD POLICIES AND STRATEGIES

 ENVIRONMENTAL RISKS FROM GLOBAL FUND
HIV, TB AND MALARIA PROJECTS

A finger prick – produces sharps waste and potentially infectious waste. Biosafety level 3 laboratory in Dushanbe, Tajikistan (GF TB and HIV grants)
GF grants perform millions of blood tests every year

3.3.2 Examples of healthcare waste risks waste must be guaranteed by specialized autoclave

from TB projects systems.
The prevention and treatment of TB requires the
usage of first- and second-line anti-TB medicines. 3.3.3 Examples of healthcare waste risks
Furthermore disposable medical equipment such as from malaria projects
syringes, syringes for tuberculin and also x-ray films are Indoor residual spraying activities are important
used during the treatment and prevention of TB which in malaria projects to reduce the risk of malaria
will result in the generation of sharp waste, infectious transmission by mosquito bites. As example in the
waste and chemical waste. Khatlon Province of Tajikistan, 24,000 households have
been sprayed using 75 g of insecticide per household.
Waste from the establishment and operation of a TB In total 1.8 tons of insecticides against mosquitos have
laboratory network results in all types of healthcare been applied and 5 tons in total in Tajikistan through
waste, including general waste, infectious waste and GF project activities, a country at the brink of malaria
sharps, pharmaceutical waste as well chemical waste. elimination.
Diagnosis for TB involves the testing of sputum
through microscopic methods, culture and gene Usage of insecticides in Sub-Saharan Africa results in
analysis. If a biosafety level 3 laboratory is planned to even higher waste management risks as more toxic
be operated, the onsite treatment of highly infectious pesticides are used. For example in Zimbabwe during
2009 to 2011, about 215 tons of DDT and 13 tons of
pyrethroids were used per year for indoor spraying in
GF projects.

Millions of bed nets have been distributed during the

past years by GF grant projects. The mosquito nets
are treated with lasting insecticides to avoid frequent
re-impregnation (long-lasting insecticide-treated nets -
LLINs). After 4-5 years these LLINs however need to be
exchanged with new LLINs and the old one need to be
safely disposed of.

Life-saving long-lasting insecticide-treated nets - produces 0,5 kg of waste

after use. The GF goal is to distribute 90 million LLINs annually26. 26 Global Fund Strategic Framework 2012-2016 ‘Investing for Impact’

HEALTHCARE WASTE MANAGEMENT TOOLKIT FOR GLOBAL FUND PRACTITIONERS AND POLICY MAKERS 17
 For the treatment of malaria, artemisinin-based
combination therapies (ACTs) are used. While
3.5 Recommended further reading27
artemisinin is not considered as a hazardous substance, { Kuehling, J. Rapid Assessment: Healthcare waste
the combination products usually are. component of Global Fund Projects in Bosnia and
Herzegovina. UNDP 2015
{ Pieper, U. Rapid assessment: Healthcare waste
3.4 Groups of persons at risk component of Global Fund HIV, TB and malaria
projects in Tajikistan. UNDP 2014.
Persons at risk from healthcare waste can be divided in { Kuehling, J. Rapid assessment: Healthcare waste
three main groups: component of Global Fund HIV/AIDS projects in
Uzbekistan. UNDP 2014.
{ Waste generators: All people that generate { Kuehling, J. Rapid assessment: Healthcare waste
hazardous and non-hazardous healthcare waste component of Global Fund HIV, TB and malaria
including clinical staff, patients and visitors projects in Zimbabwe. UNDP 2014
{ Waste workers: All people who handle hazardous { UNDP (2013): Carbon footprint of UNDP
and non-hazardous waste including the informal administered Global Fund HIV/AIDS and
waste sector such as scavengers Tuberculosis grants in Montenegro and Tajikistan.
{ General public. { UNDP (2014): Managing our climate change risk:
An approach for environmental safe guarding
The general public can be at risk through the direct UNDP-Global Fund HIV/ AIDS, Tuberculosis and
exposure to hazardous substances or indirectly Malaria programmes.
through the polluted environment: water, soil, and air. { UNECE: UN Recommendations on the Transport
Further, several toxic substances have the potential to of Dangerous Goods - Model Regulations Nature,
accumulate in the food chain. In addition, the emission Purpose and Significance of the Recommendations:
of GHG puts the global population at risk of global { WHO (2007): Core principles for achieving safe and
warming. sustainable management of health-care waste
{ EPA: Further reading on waste management in the
The ways of exposure include: US
{ European Union: Further reading on waste
{ Chronic, long-term direct or indirect exposure management
{ Acute direct or indirect exposure { Stockholm County Council (2014):
Environmentally Classified Pharmaceuticals

27 All Web-sites were accessed on 03/02/2015

18 RATIONAL FOR ENVIRONMENTAL SAFEGUARD POLICIES AND STRATEGIES

4 Strategies to Control Environmental Risks
of Global Fund Programmes

Key questions to be answered:

{ How to consider the existing legal framework of a country?
{ Are health systems strengthening aspects of relevance?
{ What is a waste stream strategy and how to develop it?

{ Which strategies can be used for GF grant projects?

{ How can HCW management for GF grants be financed?

{ What will be the next steps after finalizing the strategy?

4.1 Integration into national waste {

{
General environmental body of law
Law and regulations on public health and public
management systems hygiene
{ Specific laws on (hazardous) waste management, air
It is important to integrate all environmental safeguard pollution and sanitation
activities into the legal, regulatory and structural { Laws and provisions on occupational health and
waste management systems of recipient countries. The safety, and on transportation safety
starting point should be an assessment of policies, laws { Any other legal documents relevant to public
or guidelines. At least the following documents should health, hygiene and environment
be reviewed (if existent):
In addition, it should be established which of the
relevant international conventions the country is
Did you know? signatory of. All international environmental standards
should be respected by global health financing agencies
such as the GF and their agents like the GF PRs.
In several countries specific development plans
for the healthcare waste sector were developed In most countries, development plans for the
during the last years. These plans are often a environment sector exist which also address waste
good source of information on the national management systems. The health programmes of
policy and available systems. If such plans global health initiatives should build on and strengthen
do not exist consideration should be given to national strategies and avoid parallel structures. An
supporting the process of their development as assessment should provide the necessary information
health systems strengthening components of about the existing waste management infrastructure
GF grants project. in the country. The integration of the private sector for
waste service delivery should be considered.

HEALTHCARE WASTE MANAGEMENT TOOLKIT FOR GLOBAL FUND PRACTITIONERS AND POLICY MAKERS 19
 4.2 Health systems strengthening Best practice:
aspects
In Uzbekistan, the HIV/AIDS project included
According to the WHO28, HSS can be defined as Health Systems Strengthening aspects. To
improve healthcare waste management,
(i) the process of identifying and implementing the the development of new regulations, the
changes in policy and practice in a country’s health development and disseminating of SOPs for
system such that the country can respond better to healthcare waste segregation, handling and
its health and health system challenges and transportation and the training of staff was
(ii) any array of initiatives and strategies that improves included.
one or more of the functions of the health
system and that leads to better health through
improvements in access, coverage, quality, or
efficiency of health services. { Implementation of and operation of green
procurement and advanced supply chain
In the context of GF support, HSS refers to activities management systems
and initiatives that improve the underlying health { Environmental accountability through
systems of countries and/or manage interactions dissemination of environmental information,
between them in ways that achieve more equitable and public consultation and information disclosure
sustainable health services and health outcomes related mechanisms.
to the three diseases the GF is focusing on. An efficient
system for HCW management will be critical in order
to deliver global health initiatives in accordance to 4.3 Applied healthcare waste
international and national commitments and standards,
and in accordance with commitments to respect basic
management strategies
human rights.
4.3.1 Waste prevention and reduction
All GF health programmes should include a component Waste prevention and reduction can occur at three
for HCW management including HCW management levels: at the point of purchase or delivery, during the
system strengthening interventions as required in the period of product use and at the point of disposal. The
country context. This can include: most efficient point is the procurement process. For
example the avoidance of the purchase of mercury
{ Lead by example: Good governance and defined containing medical devices will result in the avoidance
responsibilities for HCW management of mercury containing waste in accordance with the
{ Strengthening national HCW management policies Minamata Convention. Less procurement of products
and strategies requiring waste incineration will reduce the production
{ Efficient and safe HCW management services and of POPs and thereby support the implementation of
their proper structural and functional maintenance the Stockholm Convention. Other typical strategies
{ Capacity building in occupational health and safety, to avoid the generation of waste are safer transport
injection safety, infection control, chemical safety mechanisms, improved storage management and
and HCW management efficient distribution strategies of products. Overall,
{ Monitoring and evaluation, QA/QI of HCW the environmental risk of HCW can be reduced by
management systems and operations selecting products with a lower eco-toxicity.
{ Sustainable financing of HCW management
systems Green public procurement has been identified
as a main driver for change towards reducing
environmental footprints and promoting green
28 WHO: Health Systems Strengthening Glossary. Accessed 03/02/2015 economies. The purchasing power of global

20 RATIONAL FOR ENVIRONMENTAL SAFEGUARD POLICIES AND STRATEGIES

 STRATEGIES TO CONTROL ENVIRONMENTAL RISKS
OF GLOBAL FUND PROGRAMMES

health financing institutions like the GF and of Figure 4: Steps for the development of waste stream
development partners should be systematically used concepts
to influence markets through engagement processes
with manufacturers and suppliers and the phased-
Waste identification and classification
in introduction of environmental procurement
criteria. The UN Informal Interagency Task Team on Risk assessment
Sustainable Procurement in the Health Sector (iIATT-
SPHS) was founded to promote green procurement Legal assessment
in the health sector29. Its recommendations should be
taken into consideration. Waste infrastructure & capacity assessment

Assessment of downstream options

4.3.2 Logistic and disposal strategies
The waste management, especially the HCW sector, Waste stream strategy development
underwent enormous changes during the last decade.
Out of sight, out of mind was the dominant way of Waste concept finalization & presentation
thinking in the past and waste was usually buried close
to the place of its generation. After the environmental
impact became evident, engineered disposal solutions
such as landfills and incinerators were introduced. for the environmental safeguarding of health
Today there is a strong trend away from this end-of- services and the waste generated during the project.
pipe solutions towards integrated solutions building on Interventions should build on waste stream concepts
developed during project planning at concept note
stage of the GF NFM and reviewed during project
Best practice: implementation following any significant change of
procurement plans or reprogramming of a grant.
During the execution of GF programmes
unwanted, unusable or expired products The development of waste stream concepts follows
will need to be returned. A proper system seven steps as shown in figure 5. It is further addressed
documenting all process steps will help in Part B of this Healthcare Waste Management
recipients to return hazardous items in a safe Toolkit30.
and organized way.
4.4 Healthcare waste management
waste stream concepts. Disposal is considered as part
funding by GF grant projects
of the life-cycle of a product like the production and As an essential part of every GF grant, the healthcare
the usage, and modern life-cycle strategies target the waste management component of concept notes and
reuse or the recycling of products after use. However proposals as outlined in this document will need a
some waste streams, especially hazardous waste streams dedicated results-oriented budget.
such as infectious waste, used chemicals or expired
pharmaceuticals, cannot be reused or recycled for Of special importance in waste management is not
technical or economic reasons and need a safe disposal. only to consider capital investment costs but to budget
also for capacity building, recurrent costs and systems
4.3.3 Waste stream concept development strengthening.
Each GF project should include a module on HCW
management to fulfil commitments and responsibilities
30 Kuehling, J., Hamelmann, C. Healthcare Waste Management Toolkit for
29 Hamelmann, C. Global consultation on environmentally friendly Global Fund Practitioners and Policy Makers, Part B: Waste stream concept
procurement in the health sector. Geneva 2014 Accessed 03/02/2015 development. UNDP 2015.

HEALTHCARE WASTE MANAGEMENT TOOLKIT FOR GLOBAL FUND PRACTITIONERS AND POLICY MAKERS 21
 Figure 5: Environmental safeguarding policy and strategy approach linked to a HCW management concept
integrated into the GF New Funding Model Cycle

International Environmental
Conventions, Treaties and Commitments

Environmental Safeguarding Policies, Laws & Regulations of

Board Members, Development Partners, Recipient Countries

Environmental Safeguarding Policy for the Global Fund

Ongoing Country Dialogue

National Concept TRP Grant 2nd GAC

Strategic Plan /
Note Making Grant Implementation
Investment Case GAC Board

Country Assessment
GF HCW Component
Waste Stream Concept
Development
HCW Management Module
Development (Disease and HSS
Component)
Review of Waste Stream
Concept
Review of HCW
Module
Compliance Review of
Environmental Safeguarding Policy
TA and Capacity Building for
HCW Management
QA/QI of HCW
management
Monitoring and Evaluation of
HCW Management Module

The Global Fund’s NFM is designed to enable strategic

investment for maximum impact. Within the new
4.5 Recommended further reading31
funding model, countries are strongly encouraged to GF: Procurement for Impact (P4i)
base funding requests on quality national strategic
plans. Environmental aspects including healthcare { UNDP: Healthcare Waste Management Toolkit for
waste management and GHG emissions caused by Global Fund Practitioners and Policy Makers, Part
health sector operations should be part of such strategic B and C
plans. { WHO (2014): Safe management of wastes from
health-care activities (Second edition)
Figure 5 summarizes graphically how a link between { WHO / UNEP (2008): Fundamentals of health-care
a GF environmental policy and strategy with national waste Management
legal and regulatory frameworks and international { WHO (2011): Health-care waste management Fact
conventions on the one hand, and with a HCW sheet N°281
management concept and operations integrated in the { NHS (2009): Sustainable Development Unit Waste
GF NFM on the other hand could look like. A checklist Guidance
for the integration of environmental safeguards into GF
grant making under the NFM is shown in the Annex. 31 All Web-sites were accessed on 03/02/2015

22 RATIONAL FOR ENVIRONMENTAL SAFEGUARD POLICIES AND STRATEGIES

 STRATEGIES TO CONTROL ENVIRONMENTAL RISKS
OF GLOBAL FUND PROGRAMMES

{ Basel Convention (2012): Technical guidelines

on the environmentally sound co-processing of
hazardous wastes in cement kilns
{ Holcim-NW-GIZ (2006): Guidelines on Co-
processing Waste Materials in Cement Production
{ UNFPA (2013): Safe disposal and management of
unused, unwanted contraceptives
{ Basel Convention (2003): Technical guidelines
on the environmentally sound management of
biomedical and healthcare wastes
{ UNEP (2012): Compendium of Technologies for
Treatment/Destruction of Healthcare Waste

HEALTHCARE WASTE MANAGEMENT TOOLKIT FOR GLOBAL FUND PRACTITIONERS AND POLICY MAKERS 23
 5 Annex

Checklist for the integration of environmental safeguards into the NFM of GF grants

Question Yes No

1.  Strengthening of national strategic plans (NSP)

1.1 Was an environmental assessment of the potential impact of the NSP carried out?

1.2 Are environmental safeguarding measures included in the NSP?

2.  Alignment of the Global Fund’s process to existing country dialogue

2.1 Was the potential environmental impact of the grant discussed during the country dialogue?

2.2 Were legal environmental requirements discussed by the CCM and reflected in the dialogues report

2.3 Were all concerned governmental and non-governmental organizations working on environmental
protection represented in the dialogue?

2.4 Were the long-term environmental cost impact discussed and an investment case to include cost
efficient measures discussed?

3.  Design and submission of a concept note

3.1 Was an environmental full cost analysis included in the concept note and did it consider long-term
environmental costs?

3.2 Does the concept note provide recommendations on how to reduce mitigate the environmental impact
from the grant?

3.3 Has special attention been paid on occupational health and safety aspects?

3.4 Were potential risks for the informal waste sector and for other vulnerable sectors from the discharge of
used products analysed?

3.5 Are the linkages between environmental health issues and HIV/Aids, Malaria and TB as causes and
consequences of each other addressed?

3.6 Are climate change aspects considered in the design of the concept note?

4. Independent review of concept notes by the Technical Review Panel (TRP) for recommendation by the Grant
Approvals Committee (GAC)

4.1 Did the TRP review the concept note in view of the environmental requirements from the different
international convention and agreements?

4.1 Did the TRP review the potential short-term and long-term environmental impact from the
implementation of the grants including climate change aspects?

24 RATIONAL FOR ENVIRONMENTAL SAFEGUARD POLICIES AND STRATEGIES

 Annex

Question Yes No

5.  Determination of upper budget ceilings by the GAC

5.1 Does the Fund Portfolio Managers have a good understanding on the potential environmental impacts
created by the grants?

5.2 The Fund Portfolio Managers integrated the “Duty of Care” and the “Polluter pays” principles?

6.  Grant making

6.1 Is a budget to enable the safe collection and disposal of to be discharged goods included?

6.2 Will technical support be provided to enable the environmental monitoring of the implementation of
the grant?

6.3 Do possibilities exits to compensate environmental impacts from the grant?

7.  Approval of grants by the GAC

7.1 Environmental safeguarding aspects are included in the grant agreement

8.  Approval of grants by the Global Fund’s Board.

8 Were all environmental aspects addressed, was an environmental classification of the potential impact
carried out and do channels exist to communicate the environmental aspects of a grant?

HEALTHCARE WASTE MANAGEMENT TOOLKIT FOR GLOBAL FUND PRACTITIONERS AND POLICY MAKERS 25
 Saving Lives Sustainably

Empowered lives.
Resilient nations.