Strategic Management Accounting

¥rl:k 2698475
njhiyNgrp
uf.a wxlh
Telephone 2698507
vdJ ,y
My No:
*elaia 2692913 Tfns wxlh
ngf;]; 2694860 ckJ ,y
Fax Your No:
úoaHq;a ;emE,
kpd;dQ;ry; Kfthp postmaster@health.gov.lk oskh
e-mail jpfjp
fjí wvúh
Date 08 / 11/ 2012
,izaj;jsk; www.health.gov.lk
iqjisrsmdh
website Rtrphpgha
SUWASIRIPAYA
fi!LH wud;HdxYh
Rfhjhu mikr;R
Ministry of Health
Environmental management framework for healthcare waste &

infrastructure development.
In the health sector, environmental issues creating adverse impacts vary widely in nature. Of them
Health Care Waste Management (HCWM) is considered to be one of the significant issues, although
some other important issues like food safety, occupational health and safety, management of industrial
carcinogens, indoor air pollution etc also deserve due attention. Over the program period, support
will be provided to expand/improve the services of health care facilities throughout the country. This
is likely to generate more HCW which in the absence of safe management and disposal practices can
greatly increase the risks to people and the environment through exposure of infectious and hazardous
substances contained in it. Apart from health care waste, other environmental impacts directly caused
by program implementation are likely to be triggered by the construction of Health Care Facilities
(HCFs) which is likely to be relatively small scale, spread in different locations of the country and
most likely confined to existing premises of the medical institutions and with localized impacts.
The objective of this report is to present a framework for improving HCWM in the country.
the policy and legislative framework for HCWM in the country and related technical guidelines,
evaluate HCWM practices, treatment and disposal technologies in use, provide an update of the
achievements and gaps in the implementation of HCW systems (especially in view of the policy and
national action plan prepared in 2001), present level of compliance with legal requirements and the
presentation of an action plan for improving HCWM based on identified gaps. In addition, the report
also provides safeguard requirements for managing impacts from civil works construction under the
proposed 2nd HSDP.
We greatly appreciate the comments made by you on this draft document. Please provide your
feedback to Director(Environmental and Occupational Health), Ministry of Health, 385, Baddegama
Wimalawanse Thero Mw, Colombo 10 on or before 10th December 2012.
Dr. Y.D. Nihal Jayathilake,

Secretary,
Ministry of Health
385" mQcH noafoa.u jsu,jxY ysus udj;" fld<U 10" 385, tzf;fj;Jf;Fhpa gj;Njfk tpkytq;r NjNuh khtj;ij, nfhOk;G 10.
385, Rev. Baddegama Wimalawansa Thero Mawatha, Colombo 10, Sri Lanka.
Draft Environmental Management Framework 2012
THE GOVERNMENT OF SRI LANKA
Environmental Management Framework

for
Health Care Waste
&
Infrastructure Development
Second Health Sector Development Program
Draft
Ministry of Health
June 2012
Second Health Sector Development Program Page 1

Abbreviations
CEA : Central Environmental Authority

CFE : Caring for the Environment
DLI : Disbursement Linked Indicator
DEOH: Directorate of Environmental and Occupational Health
EIA : Environmental Impact Assessment
EPL : Environmental Protection License
E&OH : Environment and Occupational Health Unit
GCA : Greater Colombo Area
GOSL : Government of Sri Lanka
HCF : Health Care Facility
HCW : Health Care Waste
HCWM: Health Care Waste Management
HSDP : Health Sector Development Project
IDA : International Development Association
MoH : Ministry of Health
MOH : Medical Officer of Health
NAP : National Action Plan
NCCWM : National Committee for Clinical Waste Management
NCD : Non-Communicable Disease
NEA : National Environmental Act
NHDP : National Health Development Plan
PAD : Project Appraisal Document
PHS : Provincial Health Services
PMS : Project Management Secretariat
PSC : Project Steering Committee
PU : Peripheral Unit
RE : Regional Epidemiologist
SA : Situation Analysis

Table of Contents
Chapter 1: Overview of the Second Health Sector Development Program
1.1: Program objectives and proposed activities ... .. .. .. .. .. 6
1.2 Development Objectives of the 2nd HSDP ... .. .. .. .. .. 6
1.3 Project Description ... .. .. .. .. .. .. .. .. 6
1.4: Objectives of the framework and the intended audience ... .. .. .. .. 12
1.5 Structure of the report ... .. .. .. .. .. .. .. .. 13
1.6 Sources of information .. .. .. .. .. .. .. .. .. 14
Chapter 2: Existing policy/regulatory framework for HCWM in Sri Lanka

2.1: Overview of the organization of the Health sector in the country … .. .. .. 15
2.2: Health care waste management in Sri Lanka .. .. .. .. .. .. 18
2.2.1: General Background .. .. .. .. .. .. .. .. .. 18
2.3 Existing health care waste management framework in the country .. .. .. 19
2.3.1: National Policy .. .. .. .. .. .. .. .. .. 19
2.3.2: National Guidelines .. .. .. .. .. .. .. .. 20
2.3.3: Code of Hygiene .. .. .. .. .. .. .. .. .. 21
2.3.4: National Color code .. .. .. .. .. .. .. .. 21
2.3.5: Legislation and regulation .. .. .. .. .. .. .. .. 22
2.3.6: Other sectoral strategies addressing HCW .. .. .. .. .. 23
2.3.7: Recommended institutional and monitoring framework .. .. .. .. 24
Chapter 3: Review of the present scenario of HCWM in Sri Lanka
3.1: Types of HCW generated .. .. .. .. .. .. .. .. 25

3.2: Baseline information on HCW production in different HCFs .. .. .. .. 26
3.3: Characterization of HCWM in the country .. .. .. .. .. .. 34
3.4: Summary of treatment technologies and infrastructure employed in the country for .. 36
3.5 Achievements and gaps in the implementation of the policy/national action
plan and lessons learnt .. .. .. .. .. .. .. .. .. 37
3.6 Financial resources available for HCWM in the country .. .. .. .. .. .. .. .. .. 39
Chapter 4: Strategy for scaling up HCWM under HSDP II

4.1: Summary of HCWM strategies addressed in the National Health Development Plan .. 40
4.2: Priority areas selected for implementation under HSDP II .. .. .. .. 42
4.3 Description of result indicators to be monitored under 2 nd HSDP .. .. .. .. .. 47

Chapter 5: Implementation and monitoring arrangements for HCWM under the

Second HSDP
5.1 : Project Institutional and Implementation Arrangements .. .. .. .. 49
5.2 Implementation of HCWM under 2nd HSDP .. .. .. .. .. .. 50
Chapter 6: Technologies available for HCWM and comparison of alternatives

6.1 Treatment Technologies .. .. .. .. .. .. .. .. .. 52
6.2: Incineration .. .. .. .. .. .. .. .. .. .. .. .. 53
6.3: Autoclaving .. .. .. .. .. .. .. .. .. .. .. 55
6.4: Microwave irradiation .. .. .. .. .. .. .. .. .. 55
6.5: Chemical Disinfection .. .. .. .. .. .. .. .. .. 56
6.6: Land disposal .. .. .. .. .. .. .. .. .. .. 57
Chapter 7: Safeguard requirements for infrastructure development under 2nd HSDP..

7.1 Environmental Clearance under national laws .. .. .. .. .. .. .. 59
7.2 Incorporation of safeguards into plan, design and contract .. .. .. .. 59
Annexes
Healthcare Waste Management –Rapid Assessment Tool .. .. .. .. 63
Assessment of Healthcare Waste Management in Major Health Institutions.. .. 70

List of Tables
Table 1: Health Institutions and bed strength by District .. .. .. .. 16
Table 2: Overview of the administration of Health Services and classification of
medical institutes .. .. .. .. .. .. .. .. 17
Table 3: National Colour Code for segregation of HCW .. .. .. .. 22
Table 4: Production of non-risk and hazardous HCW per district .. .. .. 26
Table 5: Average production of HCW in different categories of HCFs .. .. 27
Table 6: The daily generation of healthcare waste in government-owned hospitals
in Sri Lanka, calculated using bed capacities in year 2000 .. .. 28
Table 7: Estimates of hazardous waste generation in government hospitals of Sri Lanka
in 2000 .. .. .. .. .. .. .. .. .. 28
Table 8: Quantities of HCW generation in selected HCFs in the Galle District .. 29
Table 9: Quantities of hazardous HCW generated in selected hospitals in the
country (results of the rapid assessment done in 2011) .. .. .. 32
Table 10: Current practices in handling HCW in 33 major hospitals evaluated .. .. 34
Table 11: Description of current practices in handling HCW in 33 major
hospitals evaluated .. .. .. .. .. .. .. .. 35
Table 12: Treatment technologies and infrastructure employed in the country for
HCWM treatment .. .. .. .. .. .. .. .. 36
Table 13: Suitable treatment and disposal technologies according to the different
categories of HCW .. .. .. .. .. .. .. .. 53

Chapter 1: Overview of the Second Health Sector Development Program
1.1: Program objectives and proposed activities
For the country’s vision as reflected in the Mahinda Chintana to be realized, investing in the
modernization of the health system would be a critical pre-requisite. A more modern health
system of international standards, commensurate with the aspirations of a middle-income country
population would not only help achieve the objective of improving living standards and social
inclusion; rather it would contribute to all the objectives set out in the vision document, including
sustained economic growth, and shifting toward a knowledge-based and competitive economy.
Without a healthier population and a system that is geared to handle the health challenges thrown
up by the rapid demographic and epidemiological transitions facing Sri Lanka, the quantum leaps
needed in the availability of highly skilled and more productive labor force would remain an
unrealized dream. The Bank’s Country Partnership Strategy seeks to deepen the World Bank
Group’s support to Sri Lanka in addressing its emerging middle-income country agenda. The
Second Health Sector Development Program (2nd HSDP) would be an important contributor to
all three sub-areas under the area 3 (Improving Living Standards and Social Inclusion) of the
Country Partnership Strategy. Thus, its higher level objective would be to enable the health
system to play its critical part in helping Sri Lanka actualize its aspirations of economic growth,
overall development and improved quality of life of all Sri Lankans.
1.2: Development Objectives of the 2nd HSDP

The Project Development Objective is to enable the Government of Sri Lanka to modernize the
health system to respond to the challenges of Non-Communicable Diseases (NCDs), while
sustaining and enhancing past achievements on Maternal Care Health (MCH), nutrition and
communicable diseases.
The Project disbursement will be linked to 8-10 Disbursement Linked Indicators (DLIs)
identified from the focus areas of the National Health Development Plan (NHDP); in close
collaboration with the MoH and the 9 Provincial Health Ministries.
1.3: Project Description

The Program will support the National Health Development Plan, with the following thematic
areas of focus: (a) malnutrition; (b) non-communicable diseases; (c) systemic modernization.
Malnutrition:
The Government of Sri Lanka has been committed to ensuring optimal nutrition for all Sri
Lankans irrespective of their geographical locations, socio-economic status, or physiological
status. The Mahinda Chintana underscores the importance of specifically targeting health and
nutrition interventions to vulnerable populations (and especially the estate populations) in
addition to strengthening the delivery of effective national nutrition interventions.

However, decades of nutrition programming have yielded less than expected results in Sri Lanka,
and hence there needs to be a fundamentally different approach to prevention and control of
malnutrition. The facts that under-five children of even the richest quintiles show 10-12%
underweight prevalence and that over-nutrition and under-nutrition are present side by side,
sometimes in the same family, show that absence of food alone is not the primary determinant of
under-nutrition in Sri Lanka. Rather, it is the feeding and caring practices among pregnant and
lactating women, and for the under-two children that need to be modified. For such behavior
change to occur at the household level, community-based interventions are required,
demonstrating to the care-givers the impact of appropriate feeding and caring practices.
Achieving sustainable improvements in nutrition results is fundamentally a multi-sectoral cross-

cutting challenge. The National Nutrition Policy of Sri Lanka does provide a platform for inter-
sectoral coordination in order to accelerate efforts to achieve optimum nutrition for all. In
addition, the policy provides the overall guidance for the development of national strategic plans
of action for nutrition activities. One of the strategies under this policy is to reduce maternal and
child under-nutrition, by a special focus on the first 1000 days of the life cycle (from conception
to 24 months). Therefore, even though HSDP II will support Sri Lanka holistic nutrition program
of ensuring optimal nutrition throughout the lifecycle, the project will particularly focus on those
nutrition activities that will enable as well as ensure the acceleration in the reduction of maternal
and child malnutrition during the first 1000 days of life.
Implementation of “1000 days” interventions and with a focus on the under-served areas:
Nutrition interventions specifically targeted at: Pregnant Women (monitoring and promotion of
weight gain during pregnancy; iron/folate and calcium supplementation; deworming); Children
0-2 years of life (Bevioural Change and Communication related to breastfeeding, timely
introduction of safe and nutritionally adequate complementary foods, appropriate nutritional care
for sick children and hygiene practices; zinc supplementation during treatment/management of
diarrhoea; integrated management of severe acute malnutrition through facility- and community-
based interventions; de-worming) will be supported/monitored by the project. The project will
also ensure targeting of these interventions to underserved areas, plantation communities and the
urban poor. The use of community groups/mobilizers will be promoted for the implementation
community-based nutrition activities.
Capacity Enhancement/Worker Empowerment: The project will support the Government of Sri
Lanka to build capacity - through various forms of training, monitoring and supervision – to
deliver effective and appropriate nutrition interventions at facility and community levels, since
weak capacity could also weaken Sri Lanka’s nutrition program. Enhancing the capacity of, as
well as empowering community organizations to plan, implement and monitor relevant nutrition
interventions will be prioritized.

Nutrition Surveillance / Monitoring and Evaluation: The availability and use of quality data is
essential for evidence-based decision making to improve nutrition programming. The project
will support the GoSL to; establish and island-wide indicator-based M&E and Nutrition
Surveillance (NS) systems to monitor the implementation of the key nutrition (1000 day)
interventions; strengthen the utilization of NS reports for decision making at national and
divisional levels; link the NS data to the National Nutrition Information System and to existing
HIS tools and systems of the Government of Sri Lanka.
Non-communicable diseases
The recently completed joint Bank-GOSL study of NCDs in Sri Lanka confirmed that in addition
to the maternal and child health and infectious diseases, there is now a growing burden of
chronic NCDs, resulting in what is commonly called the double burden of diseases. The study
shows that during the past half-century the proportion of deaths due to circulatory disease (such
as heart disease and stroke) has increased from 3 percent to 24 percent while that due to
infectious diseases has decreased from 42 percent to 20 percent. This epidemiologic transition in
the country is compounded by a demographic transition with the proportion of people 60 years
and older is likely to more than double by 2040 to above 24 percent. Because NCDs are
commoner with aging, timely actions to address NCDs could result in benefits such as healthy
aging, lower disability, and longer, more productive lives.
In addition to the demographic and epidemiologic transitions, economic development along with
changing life styles, urbanization and increased motorization are increasing the burden due to
acute injuries such as road traffic injuries, falls, suicides, violence and mental health disorders.
The proportion of deaths due to injuries is approximately 15% of total deaths and the proportion
of mental health disorders is also known to be high.
The GOSL has prepared a policy (1996), a Master plan upto 2017 and a National Health
Development Plan for 2013 to 2017. The proposed program of support to the GOSL will provide
resources for implementing the following aspects of acute and chronic NCD control and
prevention.
The priority diseases supported for primary prevention include cardio-vascular diseases (CVD),
(includes strokes and hypertension), diabetes mellitus, cervical, breast and few other selected
cancers, asthma, thalassemia, mental diseases, injuries, cataracts, and chronic kidney disease of
unknown etiology.
Strengthening primary prevention program for NCDs: The primary prevention activities
considered and agreed with the GOSL include strengthening the implementation of and
institutionalizing legislation for better implementation of Framework Convention for Tobacco
control (FCTC) and the Tobacco control act and introducing legislation for the control of indoor
air pollution, pesticides, alcohol, salt, sugar and ‘trans’ fat usage. In addition, appropriate and

targeted communication strategies through mass media, work places, schools, youth clubs etc.
for targeted populations is required. These communication messages are expected to improve the
knowledge, attitudes, practices with regard to the risk factors that can be controlled with
legislation (salt, fat, sugar, tobacco, alcohol use, restriction on pesticide use and control at sales
outlets, vehicle seat belt and child restraint use, helmet use, etc) and for reducing risk factors like
physical inactivity, low fruit and vegetable usage and road traffic injuries and suicides.
Furthermore, initiatives to support pilots and a subsequent scaling up of elderly care services and
community based interventions for safety promotion and NCD related risk reduction approaches
through the preventive and primary care levels will be implemented.
Secondary prevention interventions: The secondary prevention strategies include introduction,

scaling up of and quality improvement of early detection interventions and screening programs
for cardio vascular, diabetes, chronic respiratory diseases including asthma and selected cancers.
Some of the strategies discussed and agreed include institutionalizing methods for identifying
high risk groups through the use of risk charts, expansion and use of mobile health screening
system for screening workplace (informal and formal) populations and strengthening the on-site
screening facilities at primary and secondary care level hospitals (provincial level hospitals
including divisional hospitals). In addition, quality improvement of the services provided at
hospital clinics (long term) for management of diagnosed NCD patients will be strengthened.
The strategies include establishing essential screening and diagnostic laboratory and other
investigative facilities for above NCDs at all secondary level and primary facilities, creating
networks with divisional level facilities for follow up care for NCDs, improving the physical
facilities and services for patients seeking care at the clinics, establishing methods to reduce
waiting times for clinic care, strengthening information system for managing NCD patients and
piloting a referral – back referral system for NCD patient care.
Tertiary prevention: At the tertiary level, specialized hospitals will improve the ICU services
available and increase the ratio of ICU beds to general beds in the facilities. Furthermore, based
on a needs assessment, required expansion of services including strengthening the laboratory
services, investigative services and other ancillary services required to manage cases will be
introduced. Furthermore, initiatives will be taken to establish at least one comprehensive
rehabilitation unit in the most advanced health facility in every province. It is planned that these
units will be linked with a forward and back referral arrangement with the secondary and
primary care levels for follow up care. Opportunities for public private collaboration for the
establishment of advanced centres on cord blood, stem cells and other centres will be explored.
A better coordination between preventive and curative programs at various levels is needed for a
more efficient approach to deal with the NCD burden. In addition, improving the availability of
drugs and supplies in the health facilities at all levels, improving the infrastructure to manage the

increasing number of NCDs patients will be supported. Moreover, a pre hospital emergency
service will be supported.
Systemic improvements
Improved planning and management of health infrastructure
Health infrastructure development by careful planning and management is very much required as
it is the backbone of the health services. Such improvements are vital to achieve the expected
results from the proposed project
Modernized health management information system (HMIS):

A robust HMIS is critical for evidence-based planning, policy-making, programming and
management (both patient management and facility management); perhaps this would be the
single most important pre-requisite for an efficient, effective and equitable health service
delivery. While there is a wealth of data currently being collected (more diligently maintained
than most developing countries) by Sri Lanka’s health sector, the analysis and interpretation of
these data into meaningful information, and subsequent use of such information for policy-
making, planning, programming and management need considerable improvement.
Sri Lanka’s HMIS is largely paper-based and its various components (e.g., preventive services,
patient records, inventory and supplies, human resources information, and financial data
systems) are not integrated into an inter-connected system. Two other lacunae in the health
information system are: the absence of out-patient data in the public sector and little linkage with
the private providers. HMIS is in urgent need of modernization, in line with the country’s
overall vision of promoting e-governance, information and communication technologies and
turning Sri Lanka into a “knowledge economy”. Apart from making data collection, reporting
and analysis easier, faster, and more accurate, computerization and e-solutions have great
potential to increase efficiency in hospital management and facilitate smoother patient flow, e.g.,
by linking clinical examination information with laboratory results and prescriptions, which
could be sent through the computer network to the respective service stations. Planning and
management at the facility level could also be greatly enhanced by electronic management
information systems, linking the data on patients, human resources, supplies and inventory
management (including the calculation of pharmaceutical requirements based on disease
burden), equipment maintenance and financial information. Several isolated pilot initiatives to
computerize health information have been undertaken in Sri Lanka. While the fact that such
pilots have been tested in Sri Lanka holds the promise of national scale-up, their uncoordinated
implementation runs the risk of developing incompatible systems in various parts of the country.
The program will assess the gaps in the system, review the experience with automation of HMIS
in-country and outside Sri Lanka and initiate the modernization of HMIS nationally. Specific

results have been identified for achievement in this area, which are disbursement linked
monitored through disbursement indicators.:
An effective health care quality assurance system

HSDP had supported several interventions aimed at improving health services quality in Sri
Lanka, including the adoption of the Japanese 5S concepts of total quality improvement in many
health facilities towards the betterment of physical facilities, cleanliness, orderliness, and
organizational behaviors, the development of 93 clinical care guidelines, and the establishment
of a quality secretariat. HSDP inputs for the health care waste management system, the
promotion of emergency treatment units and the experimental idea of best-practice immunization
clinics were also steps in the direction of quality improvement. Building on those steps, and the
standards in medical education and other health-related professional standards that are set by the
Sri Lanka Medical Council, there is a need to develop a comprehensive health care quality
assurance system, which should apply equally to public and private sectors. The program will
support the establishment of an effective national board of accreditation for hospitals (under the
already existing Quality Secretariat), laboratories (including the improvement of the National
Quality Assurance Laboratory) and pharmacies. While several quality-related indicators are part
of the results framework
Better skilled human resources for health, matching sector needs

The human resource pool in the sector includes administrators to highly specialized medical
cadres, laboratory staff, general medical officers, nurses and support staff. The human resource
pool is more than 100,000 and except for medical officers, all other categories of non
administrative staff are trained by the central Ministry of Health. The proposed program will
support strengthening basic, in service and continuing medical education programs to all levels
of staff. In addition, it will support carrying out a detailed assessment of human resource skills
analysis to meet the future sector needs and thereafter support a further discussion and way
forward on cadre creation if required. Furthermore, this component will support strengthening
the regional and central training centers providing basic and in service training to the human
resource categories managed under the health sector.
(Reference: Draft Project Appraisal Document, June 25 2012)

1.4 Objectives of the framework and the intended audience

Projects and Programs financed with IDA resources need to comply with World Bank
Operational Policies. Therefore, components eligible for funding under the 2nd HSDP will be
required to satisfy the World Bank‘s safeguard policies, in addition to conformity with
environmental legislation of the Government of Sri Lanka (GOSL). The 2nd HSDP is categorized
as Environment Category B and will trigger the safeguard policy on Environmental
Assessment (OP/BP 4.01).
When OP 4.01 is triggered the borrower is required to carry out an assessment of potential issues
triggered by the project/program and to prepare necessary mitigation plans. The 2nd HSDP being
a sector support will supplement the national health budget and monitor performance in selected
strategic areas. As such, the exact activities funded by IDA resources may not be earmarked and
hence what is possible is to look at the key environmental issues in the health sector and come up
with a framework of actions to be supported during program implementation.
In the health sector, environmental issues creating adverse impacts vary widely in nature. Of
them Health Care Waste Management (HCWM) is considered to be one of the significant issues,
although some other important issues like food safety, occupational health and safety,
management of industrial carcinogens, indoor air pollution etc also deserve due attention. Over
the program period, support will be provided to expand/improve the services of health care
facilities throughout the country. This is likely to generate more HCW which in the absence of
safe management and disposal practices can greatly increase the risks to people and the
environment through exposure of infectious and hazardous substances contained in it. Apart
from health care waste, other environmental impacts directly caused by program implementation
are likely to be triggered by the construction of Health Care Facilities (HCFs) which is likely to
be relatively small scale, spread in different locations of the country and most likely confined to
existing premises of the medical institutions and with localized impacts.
The objective of this report is to present a framework for improving HCWM in the country.
the policy and legislative framework for HCWM in the country and related technical guidelines,
evaluate HCWM practices, treatment and disposal technologies in use, provide an update of the
achievements and gaps in the implementation of HCW systems (especially in view of the policy
and national action plan prepared in 2001), present level of compliance with legal requirements
and the presentation of an action plan for improving HCWM based on identified gaps. In
addition, the report also provides safeguard requirements for managing impacts from civil works
construction under the 2nd HSDP.

1.5: Structure of the report

The structure of the report is as follows.
Chapter Focus
Chapter 1  Introduction to 2nd HSDP

 Objectives of the report
Chapter 2  Overview of the organization of the health

sector in the country
 Policy and regulatory framework, related
guidelines and institutional set up for
standardizing HCWM
Chapter 3  HCW generation in the country
 Overview of present HCW handling and
management practices
 Treatment technologies and infrastructure
employed by various HCFs
 Implementation progress of the policy and
national action plan prepared in 2001
 Achievements, gaps and lessons learnt
 Financial resources available for HCWM
Chapter 4  National Health Development Plan and HCWM

activities
 Strategies and action plan for improving
HCWM in the next 5 years
 Indicators to monitor performance and progress
in the identified priority areas
 Time bound implementation plan and resource
requirements
Chapter 5  Institutional arrangements for implementing and

monitoring HCWM activities
Chapter 6  Technologies available for HCWM and

comparison of alternatives
Chapter 7  Safeguard requirements for civil works

 Occupational health and safety guidelines
 Environmental provisions for inclusion in the
contractor agreements

1.6 Sources of information

 Situation Analysis and National Action Plan, 2001, Ministry of Health and Indigenous
Medicine
 Draft Health Care Waste Management – National Guidelines, October 2001, Ministry of
Health and Indigenous Medicine
 Draft National Policy for HCWM, October 2001, Ministry of Health and Indigenous
Medicine
 Situation Analysis and Action Plan for Chest Clinics, STD Clinics and Blood Banks,
2002, Ministry of Health and Indigenous Medicine
 Program of Action for Health Care Waste Management, November 2005, Health Sector
Development Project
 Draft Report on Situation Analysis of the Waste Generation and Existing HCWM
Systems in Hospitals, October 2006, Health Sector Development Project
 Infection Control Handbook, 2008, Ministry of Health
 Caring for the Environment 2008-2012, 2008, Ministry of Environment and Natural
Resources
 Health Budget 2012, Ministry of Health
 National Health Development Plan 2013-2017, Ministry of Health
 Draft Project Appraisal Document for the 2nd Health Sector Development Program, June
2012, World Bank
 Annual Health Bulletin, 2007, Ministry of Health
 Guidance Manual for the Preparation of National Health Care Waste Management Plans
in Sub-Saharan Countries, World Health Organization and the Secretariat of the Basel
Convention
 Health Care Waste Management in Sri Lanka, 2007, CORDAID
 Guidelines for the Management of Scheduled Waste in Sri Lanka, 2009, Central
Environmental Authority
 Rapid Assessment of HCWM practices in 40 Hospitals in the Country – carried out by
the Ministry of Health in support of the preparation of this report

Chapter 2: Existing policy/regulatory framework for HCWM in Sri Lanka
2.1 Overview of the organization of the Health sector in the country

In Sri Lanka, both public and private sectors provide health care services. The public health care
sector is larger and has a wide coverage that provides accessible care throughout the country. It
is estimated that the public sector provides health care for nearly 60% of the population and 95%
of the total in-patient care. It consists of a hospital based curative care system and a preventive
community health care system which are administered by the ministry of health and the Deleted:
Provincial Health Services1.
Curative services
For curative services, the government has a well established referral system that functions
through an extensive network of HCFs situated across the country. As such, it has been estimated
that a majority of the population has easy access to free western type government health care
services within an average 4.8 Km of a patient’s home2.
The network of HCFs comprises of, hierarchically, Peripheral Units (PU) at the village level,
District Hospitals at the district level, Base Hospitals which act as referral units with Medical,
Surgical, Paediatrics and Obstetrics and Gynaecology (OBG) specialties, District General
Hospitals in each district with specialties like ENT/Ophthalmology, Dermatology, Radiology
apart from Medical, Surgical/Paediatrics and OBG, Provincial General Hospitals in each
province and one National Hospital in Colombo which has all the specialties, and super
specialties, and which is the apex referral centre in the health system. In addition, there are
Teaching Hospitals attached to Medical Colleges with all the specialties. Table 1 provides details
of the different HCFs available and the total bed strength by district.
Preventive services
For preventive services, each Divisional Secretariat has a Medical Officer of Health (MOH) in
charge who is responsible for an average population of 60,000 people. The Medical Officers of
Health are assisted by Public Health Mid Wives (PHMs) and Public Health Inspectors who are
responsible for the Mother & Child Health programme and the Environmental and Occupational
health programme including food safety respectively. In addition, preventive health care services
are overseen at the district level by a Deputy Provincial Director of Health Services (DPDHS)
and at the provincial level by a Provincial Director of Health Services (PDHS). At the national
level, all health care services come under the purview of the Director General of Health Services
(DGHS).
1
Annual Health Bulletin, (2003), Ministry of Health
2

Private health care service sector

The private sector provides mainly curative care, which is estimated to be nearly 50% of the
outpatient care of the population and is largely concentrated in the urban and semi-urban areas3.
It consists of a number of large hospitals, private general practitioners, laboratories, blood banks,
and dental clinics.
4
3
4
Annual Health Budget, 2012, Ministry of Health

Table 1 – Health Institutions and bed strength by District
Administratively, the national health system which comprises of a network of curative and
preventive health care facilities as described above is divided into three levels – Central,
provincial and district. While the MOH administers the major hospital categories such as the
National Hospital, Teaching Hospitals and the Central Blood Bank at the central level, the
provincial services are administered through the Provincial Directors of Health Services (PDHS)
offices which in turn deliver services through Provincial General Hospitals, General Hospitals,
Base Hospitals, District General Hospitals and Peripheral Units. They generate all sorts of HCW
in significant quantities. Rural Hospitals, Central Dispensaries and Maternity Homes come under
the direct supervision of the MOH units. They do not have surgery units and mostly generate
only general medical wastes and sharps.
Health Administration HCF category Type of Medical Type of HCW

Activity generated
Central level
 Ministry of Health  National Hospital All kinds of medical All categories of
 Director General of  Teaching Hospitals care activity, including medical wastes are
Health Services  Central blood Bank specialized treatment generated including
and surgery specific medical waste
in some facilities such
as cytotoxic waste
Provincial Level
 Provincial Ministry of  Provincial General All kinds of medical Same as above
Health Hospitals activity including
 Provincial Secretary  Provincial Blood surgery
 Provincial Director Banks
of HS  General Hospitals
 Base Hospitals
District Level  District General Curative health care and Same as Base
 Deputy Provincial Hospitals only small surgery that hospitals but small
Director of HS  Regional Blood do not require general quantities
Banks anesthesia
 Peripheral Units Disposable syringes in
small quantities and
 Divisional Director  Rural Hospitals Mainly outpatients small quantities of
or MOH  Maternity Homes and Primary health care general medical waste
Central Dispensaries including vaccinations.
 Central Dispensaries
(Primary Care Units)
Table 2 - Overview of the administration of Health Services and classification of medical

institutes5
5
Adopted from the Situation Analysis and National Action Plan, 2001, Ministry of Health

2.2: Health care waste management in Sri Lanka
2.2.1: General Background
With health care waste gaining greater importance as a significant public health and
environmental risk, the GOSL has, over the last decade or so, taken several positive steps to set
up better standards of HCWM in the country and to consider HCWM as an integral part of the
delivery of health care services. The background to this was paved when between 1994 and 1997
the Colombo Environmental Improvement Project published findings of a study on solid waste
management in the city of Colombo, which indicated that prevailing HCW disposal practices
posed a huge threat to the public and hence needed drastic improvement. Subsequently, when the
CMC defined a 25 year plan to treat municipal waste in a composting plan with private sector
participation, it stipulated that no medical waste should be present in the waste collected. As a
result, an urgent need arose to find a satisfactory alternative solution for the disposal of HCW
generated from the hospitals in the Greater Colombo Area (GCA).
In 2000, the GOSL requested external support to assist the Ministry of Health (MOH) to develop
an integrated Health Care Waste Management system for the country. As a result, within the
framework of the HIV/AIDS Prevention Program initiated by the GOSL and funded by the
World Bank, a three phased program was launched under the direct supervision of the National
Steering Committee for Clinical Waste Management (NCCWM). Initially, an assessment was
carried out in analyzing HCWM practices in HCFs around the country with a specific focus on
hospitals located in the GCA. In the subsequent phase, National Guidelines and the National
Policy for HCWM were drafted and a National Action Plan was prepared aimed at gradually
expanding improved HCWM practices throughout the country in a systematic way over a period
of 5 years including a specific system for the hospitals in the GCA. It was intended that with the
implementation framework in place, the final phase would to be dedicated to implementation of
the recommendations provided in the first two phases. In addition, under the HIV/AIDS
Prevention Project, it was also determined that specific and immediate action needed to be taken
to reduce biological hazards associated with HCW generated from chest clinics, STD clinics and
the blood banks within the country6. As such, a situation analysis and an action plan were
prepared targeting this specific sector of the health services. Equipment was supplied and
training programmes were conducted.
Over the past several years the MOH has successfully implemented a number of programs in
support of the key recommendations made above to improve HCWM in the country. A system to
treat all infectious waste generated from public hospitals within the GCA, which was estimated
to be about 25% of the total generated in 2001, was commissioned and is currently operating.
Several more treatment equipment has been commissioned in various major HCFs across the
6
Situation Analysis and National Action Plan, 2001, Ministry of Health
Situation Analysis and Action Plan for Chest Clinics, STD Clinics and Blood Banks, 2002, Ministry of Health

country with external as well as government funding support. Despite such achievements (which
are highlighted in greater detail later in this chapter as well as the next), safety from HCW is still
a challenge for Sri Lanka given its total national generation and the resources available for
treatment/disposal. Addressing these challenges in order to have a standardized HCWM system
covering the whole island with sustainable solutions that suit local requirements and conditions
would certainly require current efforts to be stepped up both qualitatively and quantitatively.
The package of enforcement and backstopping documents which were developed by the MOH
between years 2001–2002, referred to above, basically form the implementation framework for
HCWM in the country. Although a decade has passed, these documents still provide a sound
basis on which better HCW planning can be enforced and hence should be strongly considered in
deciding the way forward for future HCWM activities/programs. The sections below provide
greater detail of the policy and legislative framework.
2.3 Existing health care waste management framework in the country
2.3.1: National Policy
Policies, guidelines, procedures and codes of practice are essential to support any health care
waste management system. In 2001, the Government of Sri Lanka drafted a comprehensive
national policy on health care waste management. It was divided into three main sections:
 General considerations on Healthcare Waste Management (HCWM) and the institutional
mechanism for policy implementation that should be set up at national level.
 Provisions for the safe management of HCW in medical Institutions, including
regulations and HCWM plans.
 Provisions for the implementation of and the monitoring of HCWM plans at national and
provincial levels including legislation, provision of human and financial resources,
training and awareness and participation of private sector7.
Some salient features of the draft policy are discussed here below.
 The draft National Policy for Healthcare Waste Management states that all healthcare
waste generated by the medical institutions of the public and private sector must be safely
handled and disposed of. It states that every hospital is legally responsible for the proper
management of waste that it generates until its final disposal and considers HCW as an
integral part of hospital hygiene and infection control. It refers to the legal responsibilities
of HCFs under the NEA and other regulatory needs, internal hospital rules etc for
creating the legal and regulatory framework for HCWM at the national, provincial and
institutional levels.
7
Draft National Policy on Health Care Waste Management, 2001, Ministry of Health

 Another important feature of the draft policy is that it requires major hospitals to prepare
specific HCWM plans outlining needs, objectives, strategies, procedures for approved
management and disposal of HCW and timeframe for implementation and submit to
Central or Provincial Health Services for validation and support. At the provincial level,
the draft policy requires PHS to set up annual Provincial and District HCWM plans
presenting the strategy for HCM that should be developed at the regional level. This plan
shall compile all the HCWM plans of the HCFs they are responsible and approved by the
Central Health Services before implementation.
 The policy recommends specific budget lines to be developed relating to hospital hygiene
and HCW management in the National Accountancy of the Health System in order to
ensure sufficient human and financial resources are allocated to implement the HCWM
plans in medical institutions.
 It also states that policy implementation needs to be monitored on the basis of the specific
objectives defined in the National Action Plan (the plan developed to implement the
policy country wide - see section below) and that institutionally, the National Steering
Committee on Clinical Waste Management will be responsible for the overall monitoring
and evaluation and the PHS for the implementation of monitoring procedures in HCFs
within their area of jurisdiction.
 Approved HCWM practices, equipment for treatment and disposal, training and
awareness, involvement of civil society, private sector participation are some of the other
key aspects reviewed in the draft policy.
Though the draft policy was submitted to the Cabinet of Ministers and referred to different
agencies for their feedback, official approval was not granted as before the process could be
completed a cabinet reshuffle took place and the process was interrupted and remain as it is up to
date.
2.3.2: National Guidelines
In 2001, the GOSL drafted national guidelines for health care waste management with an aim to
providing a better understanding of the fundamentals of HCWM planning and directing HCFs in
setting necessary procedures and standards to comply with policy and legislative requirements.
These were drafted in a form that attempts to provide fundamental elements that should be
integrated into future legislation specific to HCW. Although guidelines were reviewed by the
National Committee for Clinical Waste Management as well as the Ministry of Health it did not
receive formal endorsement by the government.
The draft national guidelines contained both practical and conceptual information on HCWM
covering four main sections:

 Definition and categorization of HCW including potential harmful effects that can result
from its harmful management
 Procedures for segregation, packaging, labeling, collection, storage, transportation and
disposal of HCW that should be applied and followed in all HCFs in the country and for
selection of appropriate treatment and disposal technologies and facilities
 Instructions for the implementation of health care waste management plans including
detail description of duties and responsibilities of health care provider at various levels
 Instruction for personnel of Central and Provincial Health Services that should deal with
HCWM to ensure smooth implementation of the guidelines and to set up regular
monitoring mechanisms
In 2007, concise guidelines for HCWM were prepared under the Hospital Efficiency and Quality
component of the Sri Lanka Health Sector Development Project based on the detailed draft
guidelines prepared in 2001. The concise guidelines which mainly contain sections in waste
categorization and health care waste management procedures, have been formally adopted and
incorporated into the Handbook of Infection Control.
2.3.3: Code of Hygiene
Management of HCW is an integral part of hospital hygiene and infection control that must be
reinforced with internal rules. As such the GOSL developed a Code of Hygiene for STD/TB
clinics in 2008. The national code of hygiene contains HCWM procedures and is seen as part of
an overall set of actions to control the hygiene conditions within the hospital. It sets out duties
and responsibilities of medical and non-medical staff regarding hygiene procedures to be
applied, recommended practices to maintain high level of hygiene and on-going management
and managerial activities to be carried out in the hospital.
The code of practice has to be implemented along with the HCWM guidelines.
2.3.4: National Color code
Separating different waste streams based on the type of treatment and disposal practices is a key
step in the HCW management cycle. To implement a uniform system of segregation throughout
the country, the Ministry of Health developed a National colour code for health care waste, dated
March 2006 and circulated to all the government health care institutions, which is presently being
implemented. With a view to streamlining the collection of waste, technical specifications for bags
and bins to be used for different waste types were also made available for all hospitals. The national
colour code identifies 7 specific categories.

Colour Category Contents

Yellow Infectious Cultures or stocks from microbiology, tissues
from surgeries/autopsies, material or
equipment in contact with blood or body
fluids soiled linen, dialysis equipments such
as tubing and filters.
Yellow with red stripes Sharp waste Sharps, needles and IV sets contaminated
with body fluids
Black General waste General or municipal waste that is
uncontaminated
Green Biodegradable Garden, kitchen and food waste
waste
Red Glass waste Uncontaminated bottles, pieces of glass
Blue Paper waste Paper, cardboard and office stationary
Organge Plastic waste Uncontaminated plastic medicine bottles,
saline bottles without IV sets, plastic bags
Table 3 – National Colour Code for segregation of HCW
2.3.5: Legislation and regulation
National legislation is the backbone for planning HCWM in any country and provides the legal
basis for establishing controls and permits. It is vital in making medical and non medical staff in
hospitals for being responsible at their own level and in securing the HCW disposal process.
In Sri Lanka the NEA No 47 of 1980 and its amendments (No 56 1988 and No 53 of 2000) are
the basic legal documents that regulate hazardous waste and consequently HCWM in the
country. Although it’s a comprehensive document and specific regulations on hazardous waste
has been in force since 2002, medical institutions were not included in the list of
institutions/activities for which an Environmental Protection License (EPL) must be requested
from the Central Environmental Authority (CEA) until 2008.
The comprehensive analysis of the situation regarding HCWM in the country conducted in 2001
highlighted that the lack of a legislative framework for HCWM as one of the main shortcomings
and recommended that the government consolidated existing legislation by editing a specific
regulatory document most appropriate for the management and disposal of HCW. In 2008, the
GOSL consolidated the NEA by incorporating medical institutions in the list of
institutions/activities that require an EPL.
 Part II of the National Environmental (Protection & Quality) regulation No. 01 of 2008
includes “Health care service centers generating infectious wastes, including medical
laboratories and research centers” as a prescribed activity that requires a license.

 Schedule VIII lists Healthcare waste as a scheduled waste from specific sources that no
person shall generate, collect, transport, store, recover, recycle or dispose except under
the licence issued by the Authority and in accordance with standards and other criteria as
may be specified by the Authority.
Source - Guidelines for the management of scheduled waste in Sri Lanka (2009)
Accordingly, every HCF is legally responsible for the proper management of health care waste
from the point of generation until its final disposal to ensure minimum environmental and public
health impacts.
However, the regulations on HCWM classifiy all categories of HCW and emphasizes the
importance of safe disposal of all categories of hazardous waste.
2.3.6: Other sectoral strategies addressing HCW
Caring for the Environment (CFE) 2008-2012, which is the second successive sectoral
environmental action plan prepared by the Ministry of Environment and Natural Resources to
implement the National Environmental Policy of 2003, recognizes HCWM as a significant
public health issue in the country that needs intervention, The CFE, which has been focused on 6
key sectors and addresses clinical waste under the waste management sector, has been prepared
with close consultation with the relevant sector agencies including the MOH. With regard to
clinical waste, the CFE broadly identifies the related public health and environmental issues and
refers to the draft national policy and other initiatives that were planned and on-going at the time
with the support of the MOH. Given below in the table are the key strategic actions
recommended in the CFE in order to achieve better institutional and administrative mechanism
for HCWM.

Source – Caring for the Environment 2008-2012
2.3.7: Recommended institutional and monitoring framework
The institutional mechanism for implementing the national policy was broadly envisaged under
three levels of management:
 At the central level, co-ordination and development of strategies and mechanisms to
implement policy commitments, in accordance with national requirements, has been
vested with the NCCWM. In addition, development of training and capacity building
packages, training implementation supervision, setting up of HCW monitoring protocols,
overall monitoring and evaluation has been assigned to the NCCWM. The Central Health
Services are responsible for technically backstopping HCFs under its management
purview.
 At the provincial level, implementation of the policy has been vested with the Provincial
Councils. In particular the PHS is responsible for setting up provincial HCWM plans,
synthesized from individual hospital HCWM plans coming under its area of jurisdiction,
development of financial resources and for the implementation of HCW
monitoring/auditing procedures.
 At the local level, setting up of HCWM plans that outline needs, objectives, strategies,
procedures and timeframes for medical institutions has been vested with the hospital
management.

Chapter 3: Review of the present scenario of HCWM in Sri Lanka
3.1: Types of HCW generated
The WHO classifies hazardous waste into the following categories. The major hospitals in which
all the ranges of medical activities are performed, produce the following HCW categories
 Infectious waste, suspected to contain pathogens (bacteria, viruses, parasites, or fungi) in

sufficient concentration or quantity to cause disease in susceptible hosts.
 Pathological waste, consisting of tissues, organs, body parts, human foetuses and animal
carcasses, blood, and body fluids.
 Sharps, items that could cause cuts or puncture wounds, including needles, hypodermic
needles, scalpel and other blades, knives, infusion sets, saws, broken glass, and nails.
Whether or not they are infected, such items are usually considered as hazardous health
care waste.
 Pharmaceutical waste, includes expired, unused, spilt, and contaminated pharmaceutical
products, drugs, vaccines, and sera that are no longer required and need to be disposed off
appropriately. It also includes discarded items used in the handling of pharmaceuticals,
such as bottles or boxes with residues, gloves, masks, connecting tubing, and drug vials.
 Genotoxic waste, includes certain cytotoxic drugs, vomit, urine, or faeces from patients
treated with cytotoxic drugs, chemicals, and radioactive material. Cytotoxic or
antineoplastic drugs are the principal substance in this category. These drugs are used in
highly specialized units.
 Chemical waste, consists of discarded solid, liquid, and gaseous chemicals, used for
diagnostic and experimental work and for cleaning, housekeeping, and disinfecting
procedures. These are considered hazardous if at least one of following properties is
present; toxic, corrosive (pH<2 or pH>12), flammable, reactive (explosive, water-
reactive, shock sensitive) or genotoxic.
 Waste with high content of heavy metals.
 Pressurized containers. Many types of gases used in health care are often stored in
pressurized cylinders, cartridges, and aerosol cans. Many of these, once empty or of no
further use (although they may still contain residues), must be disposed off.
 Radioactive waste.
In addition to the above, waste generated in hospitals include non-risk HCW or domestic waste
that include waste that are not contaminated with infectious or pathogenic agents and includes
food residues, paper, cardboard, plastic wrappings etc

3.2: Baseline information on HCW production in different HCFs
A comprehensive national survey to measure types and related quantities of HCW generated in
different HCFs across the country has never been undertaken in Sri Lanka due to practical
reasons. However, various research papers and situation analysis have attempted to estimate the
national generation using different calculations and methodologies. Of these, the most
comprehensive baseline values estimated on HCW quantities generated in Sri Lanka so far is the
situation analysis undertaken by the MOH in 2001 with funding support from the World Bank.
The following section attempts to furnish and discuss findings on HCW generation quoted in
various surveys and investigations reported in the last decade or so including the rapid survey
conducted in a sample of major HCFs in support of the preparation of this framework. In general
a wide variation in the reported rates of HCW generation is observed in the various sources
reviewed. This is primarily due to the fact that different methodologies, calculations and
observations have been used in different investigations. Therefore, it is difficult to carry out a
proper comparative analysis or to establish patterns of HCW production associated with different
levels of HCFs over time.
1. Draft Report on Situation Analysis and National Action Plan, 2001
The following table has been extracted from the draft SA and NAP, and presents the results of an
initial assessment undertaken in the various medical institutes in support of the preparation of the
NAP in 2001. As stated earlier, this was not a national survey but a comprehensive calculation
using direct measurement methods in a sample of different levels of HCFs. The methodology
used for the estimation of HCW quantities has been based on the number of containers used for
medical waste collection during a defined period of time, subjected to volume adjustments based
on a filling rate used for each category of container and finally adjusted applying a volumetric
mass ratio according to the type of waste thrown into the container and their humidity rates.
District TH PH BH DH PU RH Total ton/day HCW %

No of Beds Non-risk Hazardous
Colombo 9436 571 226 302 22 11.84 3.28 26.8%
Gampaha 2259 1212 777 137 139 4.15 1.28 10.5%
Kandy 2293 586 842 364 755 2.98 0.91 7.5%
Kurunegala 1123 528 1421 578 212 2.28 0.76 6.2%
Galle 1592 911 340 95 2.45 0.74 6.0%
Anuradhapura 1052 524 392 611 2.31 0.63 5.2%
Ratnapura 957 465 779 278 161 1.73 0.53 4.4%
Badulla 859 346 848 35 326 1.89 0.53 4.3%
Kalutara 666 716 605 189 159 1.50 0.48 3.9%
Jaffna 927 241 413 265 59 1.36 0.41 3.4%
Matara 897 580 250 222 1.24 0.34 2.8%
Kegalle 613 921 57 207 0.69 0.29 2.4%
Matale 670 229 207 133 0.63 0.28 2.3%

District TH PH BH DH PU RH Total ton/day HCW %

No of Beds Non-risk Hazardous
Puttalam 668 434 183 127 0.55 0.24 2.0%
Batticaloa 618 394 60 36 0.91 0.26 2.1%
Ampara 765 485 135 54 0.48 0.21 1.7%
Polonnaruwa 405 256 232 186 0.35 0.16 1.3%
Nuwara Eliya 237 1050 81 138 0.38 0.16 1.3%
Hambantota 303 586 219 219 0.34 0.16 1.3%
Moneragala 256 693 20 161 0.37 0.16 1.3%
Trincomalee 337 247 140 110 0.34 0.15 1.2%
Vavuniya 193 48 0.25 0.11 0.9%
Mullaitivu 110 135 0.14 0.07 0.6%
Mannar 180 90 31 0.09 0.04 0.3%
Killinochchi 125 67 0.06 0.04 0.3%
Safe Margin (15%) 5.9 1.8
National Daily Production (tons/day) 45.22 14.06
Table 4 - Production of non-risk and hazardous HCW per district
The Situation Analysis estimated overall production of hazardous HCW at the national level to
be about 15 tons/day. As can be noted in the table above, important disparities in waste
generation were highlighted between districts with Colombo responsible approximately for 25%
of the generation. In Colombo, it was found that HCW generation is concentrated within the
Greater Colombo Area with an estimated 4.2 tons/day (including private hospitals) justifying the
fact that a specific solution had to be found for the district. In addition, 30%of the national
estimate of HCW generation came from Gampaha, Kandy, Kurunegala, Galle and Anuradhapura
and were recommended as priority districts for the application of the NAP.
Institution Average Production Kg per bed per day

Non-risk HCW Hazardous HCW Sharps
Teaching Hospitals 1.38 0.37 0.02
Provincial Hospitals 1.52 0.36 0.01
Base Hospitals 0.75 0.32 <0.01
District Hospitals 0.5 0.20
Peripheral Units 0.5 0.20
Rural Hospitals <0.15 <0.10
Private institutions 1.5 0.28 0.01
(Colombo)
Table 5 - Average production of HCW in different categories of HCFs. The figures do not
include production of blood and anatomical waste due to their specific disposal.
2. Caring for the Environment 2008-2012
The national strategy and action plan for the implementation of the Environmental Policy, Caring
for the Environment 2008-1012, reports that a study conducted jointly by the MENR, CEA and
the BOI in 2003 on Hazardous Waste Management estimated clinical waste generated to be
5,643.8 tons per year which is in line with the daily generation estimated by the SA in 2001.

It also presents the following estimates relating to daily generation of HCW in different
categories of hospitals as indicated in the table below. The data has been sourced from an article
published in the Ceylon Medical Journal in September 2004 which uses international daily waste
generation rates from high income countries as a comparative scale to estimate HCW generated
in Sri Lanka. The study does not include the private sector hospitals and assumes that its
exclusion will compensate for the over-estimation that would result in using data from high-
income countries.
According to the study, estimates from global arena suggests that the University hospitals
generate higher quantities of healthcare waste at 4.1-8.7 kg/bed/day and that General hospitals,
district hospitals and primary healthcare units generate much lower quantities viz. 2.1-4.2
kg/bed/day, 0.5-1.8 kg/bed/day, and 0.05-0.2 kg/bed/day, respectively. Using these rates and the
bed capacities in year 2000, the daily HCW generation in the government sector hospitals of Sri
Lanka has been given as below.
Hospital category No. of Total number of Estimated daily waste generation

hospitals beds (kg/day)
Lower estimate Upper
estimate
University /Teaching 15 14,659 60,102 127,533
hospitals
General/Provincial 6 4,966 10,429 20,857
hospitals
Base hospitals 36 9,865 4,933 17.757
Primary healthcare units* 868 23,212 1,161 4,624
(DH, PU, RH, MH and CD)
Total 925 52,702 76,624 170,790
Table 6 -The daily generation of healthcare waste in government-owned hospitals in Sri Lanka,
calculated using bed capacities in year 2000.
According to this analysis the total HCW produced by listed government sector hospitals is
between 76,624 and 170,790 Kg daily. Out of the total healthcare waste generated, the WHO
estimates that only 10-25% falls into the hazardous category. In line with this, the estimated
daily hazardous waste generation in Sri Lanka has been estimated as given in the table below.
Total Health Care Hazardous waste (Kg/day)

Waste (kg/day) At 10% of total HCW At 25% of total HCW
Lower estimate 76,623 7,662 19,155
Upper estimate 170,789 17,078 42,697
Table 7 - Estimates of hazardous waste generation in government hospitals of Sri Lanka in 2000

Even at the lower estimate of 10% of total healthcare waste being hazardous, the figure is
significantly higher that what has been reported in study by the MENR on hazardous waste
generation (2003) but significantly lower than the figure reported in the Situation Analysis
undertaken by the MOH (2001).
3. Situation Analysis in a selected district of the southern province
In 2006, the University of Ruhuna carried out a Situation Analysis in the Galle District of the
Southern Province, with funding from the World Bank supported Health Sector Development
Project (HSDP), in order to complete a needs assessment and subsequently a prioritized action
plan for HCWM for the district. This activity was started as a pilot project under HSDP in order
to implement HCWM island wide. During the study 29 hospitals of different categories in the
district were investigated using a survey questionnaire and site visits supported by discussions
with hospital staff and quantities of HCW generated were calculated. The table below present the
results of a sample of hospitals investigated for which detailed results were presented in the
report.
Name of Hospital Bed Total waste Non-risk Hazardous Total Waste Haz Waste
Strength generation Waste Waste 8 Generation Generation
(Kg/day) (Kg/day) (Kg/day) (Kg/bed/day) (Kg/bed/day)
Peripheral Units
Induruwa 33 14.95 11.96 2.99 0.45 0.09
District Hospitals
Udugama 148 177.5 166.85 10.65 1.19 0.07
Unawatuna 68 40.4 39.18 1.21 0.59 0.02
Baddegama 98 30.2 21.14 9.06 0.31 0.09
Base Hospitals
Balapitiya 275 681.7 613.53 68.17 2.4 0.25
Elpitiya 171 134.6 122.48 12.11 0.79 0.07
Hiniduma 102 140.5 139.09 1.4 1.38 0.01
Teaching Hospitals
Karapitya 1410 1559 1057.5 352.5 1.11 0.25
Mahamodara 406 442.9 252.45 190.44 1.09 0.47
Table 8 – Quantities of HCW generation in selected HCFs in the Galle District
According to the analysis above, the two teaching hospitals in the district produce hazardous
waste in the range of 0.25-0.47 kg/bed/day which is close to the average production rate of 0.37
kg/bed/day reported in the Situation Analysis of 2001. However, the rates reported for Base
Hospitals, District Hospitals and Peripheral Units is show a significant variation from the
average figures reported in the Situation Analysis 2001.
8
Mainly sharps and infectious waste

4. Rapid assessment of HCW management in a sample of HCFs across the country

conducted by the MOH in 2011.
In November 2011 the MOH conducted a rapid assessment of a selected sample of medical
institutions belonging to major HCFs in order to briefly assess the current levels of waste
generation and HCWM practices employed using a survey questionnaire. The questionnaire is
attached as Annex 1. Out of 40 hospitals targeted, 35 responded. Feedback on estimated waste
quantities in different waste categories reported by the hospital authorities has been summarized
in the table below.

Name Bed Bed Quantity of hazardous solid waste generated

Strength Occupancy
rate
Infectious Sharps Anatomical Chemical Radioactive Cytotoxic Pharmaceutical
(Kg) (Kg) (l) (l) (Kg) (Kg)
(Kg)
Teaching Hospitals
1.National
1 Hospital of 3300 82% 500 100 25 2
Sri 1Lanka
1
2 Castle Street 485 89% 160 9 7.5
Hospital for Women
3 Lady Ridgeway 901 78% 140 15
4 Colombo South 1093 83% 200 100 50
5 Peradeniya 954 72% 125 50 0.6
6 De Soyza Maternity 343 87% 100 5

Hospital
7 National Cancer 876 113% 177 74 1000
Institute
8 Karapitiya 1606 85% 450 30
9 Chest Hospital 671 80% 80 6 5
10 Sirimavo 115 89% 10 5

Bandarnaike CH
11 Jaffna 1228 90% 1000 150 1800
12 Kurunegala 1650 87% 2000 79
13 National Institute of 1514 63% 13 2

Mental Health
14 Sri Jayawardenapura 1046 66% 100 15

GH
15 Kandy 2286 81% 470 71 60 600
16 Mahamodara – 252 95% 55 4

Galle

17 Colombo North 1405 90% 120 24

18 Kegalle 746 83% 327 76
19 Infectious Diseases 200 56% 10 1

Hospital
District General Hospitals
20 Gampaha 708 74% 90 10
21 Rehabilitation 259 72% 20 4

Hospital _ Ragama
22 Kalutara 300 83% 300 10
23 Ratnapura 1010 78% 1000 50 30
24 Badualla 1375 78% 1500 75 10
25 Ampara 530 80% 200 50
26 Negambo 676 75% 400 300
27 Nuwara eliya 427 90% 50 5
28 Nawalapitiya 526 69% 30 12
29 Trincomalee 435 70% 62 7
30 Polonnaruwa 747 72% 130 13
31 Matale 737 60% 250 10

Base Hospitals
32 Gampola 352 83% 25 10
33 Teldeniya 87 50% 05 0.5

34 Kantale 231 43% 20 10
35 Dehiattakandiya 135 100% 50 1
Table 9 – Quantities of hazardous HCW generated in selected hospitals in the country (results of the rapid assessment done in 2011)

It is difficult to calculate the daily average production of hazardous HCW per medical institution
from the results above as the information is not complete. Most hospitals have provided only
estimated quantities for infectious waste and sharps generated while other types of wastes are not
properly accounted for. With regard to infectious and sharp wastes, the daily average production
indicates a wide variation even within the same category of hospital. For example, for infectious
waste the values range from 0.05 – 0.8 kg per bed for Teaching Hospitals, 0.05 to 1 kg/bed for
District General Hospitals and 0.02 to 0.37 kg/bed for Base Hospitals. The lowest generation of
infectious waste for Teaching Hospitals is recorded from the Infectious Diseases Hospital.
Similarly, the daily average production of sharp waste range from 0.008 to 0.1 kg/bed for
Teaching Hospitals (as opposed to 0.02 calculated in the SA, 2001), 0.03 to .0.4 kg/bed for
District General Hospitals and 0.005 to 0.04 kg/bed for Base Hospitals.
A proper estimation of the quantities of HCW produced should be made over a period of time to
arrive at average figures while taking into account potential slack periods or other unusual
circumstances that may cause significant variations in the waste quantities. While this type of
rapid surveys itself have a number of limitations, it is doubtful if hospitals possess accurate data
with regard to HCW generation.
Observations
Reasonably accurate data and information on waste production and waste management practices
are essential for planning an effective waste management programme. As such, it is important for
medical institutions to properly record current levels of waste production and document waste
management practices as it forms the basis for formulating a suitable HCWM strategy for the
institution and consequently at the regional and national levels. As mentioned earlier, although
there have been various attempts to estimate the national HCW generation in the last decade or
so, as outlined above, of which the Situation Analysis conducted in 2001 could be considered as
the best estimate, no comprehensive national survey has been undertaken.
As can be seen from the above, even the various attempts made so far to estimate baseline HCW
generation levels in different years show wide variations which makes it difficult to carry out a
comparative analysis over time or to project future levels based on established historical patterns.
According to yet another study conducted by the AIT on health care waste management in South
Asia in 2008, medical waste generation in Sri Lanka was presented as 0.36Kg/bed/day 9. This
figure is in line with the average production of medical waste reported for the major HCF under
the Situation Analysis (2001). Using this rate, assuming there has been no change in the demand
for health services and given the total bed strength of 69,501, the current level of hazardous
HCW production in the state sector hospitals would be around 25 tons per day. However, this is
a very rough estimate (on the upper side) which does not take into account the various factors
that would influence the total quantity of hazardous waste generated such as the size and
9
Visvanathan, C., 2008, Medical Waste Management in Asia, Asian Institute of Technology

functions of different HCFs (smaller facilities generate small quantities of hazardous wastes),
occupancy rates, the increased quality of segregation in the larger facilities and the consequent
reduction of infectious waste etc.
3.3: Characterization of HCWM in the country
The handling of health-care waste is critical in minimizing risks associated with human health
and the environment. As such, implementation of safe HCWM procedures aimed at minimizing
potential risks should be practiced at every stage of the waste management cycle starting from
segregation and identification of hazardous and non-risk HCW, packaging, storage, treatment
and disposal. The rapid assessment conducted by the MOH in 2011 investigated some activities
relating to the handling of HCW in the selected HCFs surveyed. Presented here below is a
general picture obtained from the survey outcome as well as information available with the
MOH.
Description Responses
Yes No No Response
Segregation of waste according to national 35 None None
colour code
Waste collection and on-site transportation 35 None None
Waste storage 35 None None
Waste Storage Space 30 4 1
(2 not
satisfactory)
Off-site transportation 1
Waste treatment 24 8 1
Open
burning
Waste disposal No clear response
Table 10: Current practices in handling HCW in 33 major hospitals evaluated
The table below provides a narrative to the figures presented above.

Description Remarks
Segregation The survey responses show that there is a good attempt in all
the range of medical institutions to segregate waste at the
source according to the national colour code. This is a very
positive aspect of the current HCWM practices which should
be maintained and reinforced as this is the starting point in an
effective waste management system and helps reduce cost of
final disposal that must be borne by the HCFs as well as
protect public health.
Waste Collection Generally, the handling of infectious waste at source by

doctors, nurses and para-medical staff is relatively acceptable.
partly because generators are trained personnel who
understand potential risks involved. It is the collection beyond

ward level that has a relatively higher possibility of causing

injury or infection. Only a few hospitals have shredders that
can destroy the used syringes at the treatment site. On-site
transportation is mainly done by hand carts and trolleys.
On-site storage Most of the hospitals evaluated have dedicated space for on-
site storage of HCW excepting 4. However, standards of
hygiene of these storage rooms may considerably vary from
one place to another and it’s not clear from the feedback
whether these sites are adequate (excepting two which have
highlighted inadequate storage space) for the purpose with
restricted access and enough protection from the effects of
weather, scavenging by animals etc.
Waste Transportation In most situations final disposal sites are situated quite a
distance from the point of generation and with low technology
used during transportation, spills can easily take place which
can be a potential source of infection transfer. In most of the
hospitals waste is transported to the on-site storage facility by
sanitary laborers using carts and trolleys or by hand. These
laborers do not wear adequate protective gear. Off-site
transportation to treatment facilities is carried out by a few
hospitals which are part of the integrated HCWM system
implemented in the GCA.
Waste treatment and disposal Of the 33 hospitals evaluated, 3 hospitals use steam sterilizers,
13 use incinerators (type and capacity not mentioned), 5
outsource to a private sector service provider, 8 open burn.
The hospital in Nuwera Eliya is making use of the semi-
engineered landfill operated by the Municipal Council to
dispose of the hazardous waste. In addition, a few hospitals
operate sharp pits and placenta pits to dispose of sharps and
placentas in a safe way.
Current treatment and disposal practices employed by HCFs

who manage their own waste are varied and depend on the
type and quantity of the HCF produced and the resources
available.
In Sri Lanka, finding sustainable solutions for the treatment
and disposal of HCW is one of the main challenges
encountered, given it requires high technological and capital
input. While some of the major hospitals either own and
operate modern treatment facilities or outsource to a private
service provider, many other facilities lack sustainable options
to dispose of the HCW generated within their institutions.
Table 11 – Description of current practices in handling HCW in 33 major hospitals evaluated

3.4: Summary of treatment technologies and infrastructure employed in the country for
HCWM
1. Burial – Infectious and general waste are being buried in some of the health institutions
where land space is available.
2. Open burning - Mixed waste or infectious waste separated are being burnt
3. Barrel incinerators – Infectious waste are being put to a barrel placed on bricks and a
mesh and then burnt
4. Sharp pits- Deposit sharps in a pit layer wise covering with lime
5. Needle burners - burning of infected part (metal) of the syringes.
6. Incineration – Some institutions use low temperature (below 1000’c) single chamber
incinerators and some use dual chamber high temperature (above 1000’c) incinerators for
incinerating infectious waste and sharps.
7. Steam Sterilization
Autoclaving ; laboratory cultures and some infectious waste are autoclaved before
disposal
Indirect Steam Sterilization – Few hospitals (04) use indirect steam sterilizers for waste
treatment.
8. Chemical disinfection - Some infectious waste are chemically disinfected. (Sodium
hyperchloride)
9. Placenta pits – Placenta are put in to a series of pits alternatively for natural digestion.
Name of Hospital Treatment Technology Funding Assistance

NHSL Steam sterilization WB
LRH Do WB
CSHW Do WB
GH Ampara Incineration UNOPs
Bu Kalmunai north Do UNOPS
BH – Kalnumai South Do UNOPS
BH Pottuwil Do UNOPS
BH Akkaraipaattu Do UNOPS
BH samanthurai Do UNOPS
TH- Mahamodara Steam sterilization Swedish government
TH- Batticaloa Incineration USAID
GH – Nuwara eliya Sharp pit JAICA
Table 12 – Treatment technologies and infrastructure available in some of the health institutions
funded under different agencies.

3.5 Achievements and gaps in the implementation of the policy/national action plan and
lessons learnt
In 2001, a National Action Plan (NAP) was prepared by the MOH, under a consultancy
assignment, to translate the national policy and guidelines into action as part of the government’s
long-term goal to upgrade and standardize HCWM procedures throughout the country, and there
by ensure the safe, environmentally friendly and cost effective management of HCW. The NAP
was broadly made up of seven packages of actions that were grouped thematically and was
complete with defined institutional responsibilities and potential indicators for each action, a
rough cost estimate for implementation and a timeframe which recapitulates each specific action
recommended for implementation within each package. The overall duration of the NAP was
intended to be 5 years.
Implementation of the NAP has been selective. While some important specific actions have been
implemented, the overall implementation success of the NAP has been limited and as a result the
desired outcomes in standardizing HCWM in the country have not been fully realized. The
section below elaborates on the gaps, achievements and lessons learnt from the last 10 years of
implementation experience.
Key Achievements
 Consolidation of the National Environmental Act by gazetting disposal of HCW as a
prescribed activity that needs to be carried out under an environmental protection license.
 Development and the implementation of the national colour code
 Development of national guidelines on HCWM and code of hygiene and instructions
booklet for STD/TB clinics
 Creation of a budget line for HCWM in the national budget for the health services.
 Establishment of a health care waste management system for the public hospitals within
the Greater Colombo Area with two semi-centralised autoclaves and related
administrative/management arrangements for continued operation.
 Provision of infrastructure and equipment to improve HCW disposal practices in a
number of major hospitals in the provinces with government and donor funding (see table
above).
 Provision of training on HCWM for healthcare workers and other personnel in several
state hospitals under the HIV/AIDS Prevention Project, Health Sector Development
Project and WHO sponsored programs. A HCWM cell was established in the Department
of Community Medicine (Colombo Medical Faculty) which conducts training programs
on HCWM on an annual basis to about 60 hospital staff in collaboration with the MOH.
 Inclusion of HCWM in the academic curricular for several post graduate courses
conducted by the Medical Faculty of the University of Colombo.( M. Sc in Medical
Administration/ Community Medicine)

 Development of guidelines for transportation of cytotoxic waste for treatment & disposal
 Post graduate research has been carried out on HCWM
Key Gaps
 Formal adoption of the draft national policy and detailed guidelines on HCWM (note:
HCWM guidelines included in the National Guidelines on Infection Control are very
concise and do not carry details on institutional responsibilities, detail procedures etc for
waste handling). Cabinet approval for these documents has been long overdue.
 Lack of validation and formal adoption of the NAP, setting up of working groups and
evaluation criteria to monitor progress
 An officially recognized and dedicated institutional arrangement to co-ordinate, assist
and monitor implementation of the NAP. The NAP proposed the official designation of a
national project coordinator, officers within the PHS and HCWM officers at the major
hospital categories to oversee implementation of the recommended actions.
Subsequently, the establishment of a HCWM unit at the MOH was proposed and
initiated. Neither of these materialized.
 Specific technical guidelines and format for the preparation of hospital HCWM plans
 A protocol for the monitoring and auditing of HCWM plans
 Although a specific budget line for HCWM is identified for each medical institution, it
may not relate to the actual costs associated with implementation of a proper HCWM
plan
 Lack of research on HCWM or number and type of accidents associated with the
mishandling of HCW.
Key Lessons learnt

 It is important that proper HCWM plans are established at the hospital/provinces as it will
provide a realistic indication to the MOH/PHS as to waste quantities generated,
characterization, need for management, appropriate equipment/technology and associated
costs. Without such a basis progress in HCWM will be difficult to assess or monitor.
 Selection of the most appropriate equipment and technology for waste treatment is the
most critical aspect in the management of HCW. The technology suitable for each HCF
or cluster of HCFs should be selected based on careful consideration of local conditions
including sitting of such facilities. After nearly 1.5 years of operation, it has been
proposed and canvassed that the steam sterilizer installed at the NHSL under the HCWM
program for hospitals in the CMC area, has to be shifted to a location in the outskirts of
Colombo. This is mainly because of the limited space and ad hoc expansion of the
hospitals. The financial implications of such subsequent changes to the hospital
authorities could potentially be making the HCWM program cost ineffective.
 Experience has shown that even when hazardous HCW is treated, disposal could still be a
problem in Sri Lanka. The CMC’s refusal to collect treated HCW owing to certain local

government regulations has been a stumbling block in the smooth functioning of the
HCWM system implemented within the GCA.
 Hospitals may not be maintaining a proper information system on waste generation which
is amply shown in the rapid questionnaire survey conduced by the MOH in 2011 in
support of this framework. Information on waste generation is the basis on which the
management system should be decided upon; as such this is an important area the
hospital authorities should pay attention to.
3.6 Financial resources available for HCWM in the country
The MOH allocates around Rs 50 million (0.067 % of the health budget) to the HCFs under the
central government for HCWM. Provincial Authorities also allocate some funds to HCWM,
however, data not readily available on this due to various reasons. Some of the deficiencies
found in the rapid appraisal 2011 can be directly linked to the inadequate funding. GOSL and
MOH find it difficult to increase the allocation due to budgetary constraints.
Hospital HCWM plans or provincial HCWM plans should be the basis on which financial
allocations should be decided upon for inclusion in the health budget. However, having said that,
given the multiple demands placed on health services and the limited resources available,
government funding for the health sector may not be able to provide the needed injection of
capital finance for installing sustainable technology for the management and disposal of HCW.
Thus, it is important for designated officers of the MOH and the PHS to work closely with other
sectoral government agencies, donor agencies etc to source necessary support for the
implementation of HCWM plans. So far, external funding in the management of HCW has been
a huge impetus in Sri Lanka and should be further collaborated with to continue taking HCWM
forward to better levels.

Chapter 4: Strategy for scaling up HCWM under HSDP II
4.1: Summary of HCWM strategies addressed in the National Health Development Plan
1. Establish healthcare waste treatment facilities island wide

2. Develop required guidelines and standards for healthcare waste management
3. Obtain Environmental Protection License and Hazardous Waste License for healthcare
institutions
Environmental & Occupational Health Unit has identified the following objectives and strategies
under HCWM.
Objectives
1. To develop a national policy on healthcare waste management ( HCWM)
2. To develop a national plan on HCWM .
3. To implement HCWM plan in hospitals
4. To harmonize the HCWM plan in all institutions
5. To build capacity among health staff on HCWM at all levels
Strategies
1. To review and update institutional capacities
2. To improve the infrastructure facilities
3. To improve the competencies of staff
4. To transfer the ownership of HCWM to respective institutions
5. To build inter-sectoral coordination securing the intra sectoral coordination
6. To promote the usage of appropriate technology for HCW treatment.
Based on the above objectives and strategies the following national action plan has been
constructed for implementation.

National Action Plan on HCWM (2013 – 2017)
Activities 2013 2014 2015 2016 2017

1. Update the draft policy on HCWM
and obtain cabinet approval
2. Strengthen Environmental &
Occupational Health Unit to develop
standards, guidelines, and facilitate
Healthcare waste management
activities in health institutions
3. Carryout situational analysis and
needs assessment of HCF
4. Develop Action Plans for HCWM in
the Healthcare Institutions.
5. Training to Health staff at all levels
on HCWM
6. Establish HCWM teams in hospitals
7. Supply of HCWM equipment to

Health Institutions
8. Develop HCWM infrastructure

facilities
9. Establish HCWM treatment options

at HCF
10. Develop waste water guideline
11. Develop Waste water and sewerage

treatment plant at HCF
12. Develop solid waste management

options as resource recovery
processes
13. Develop HCWM monitoring formats

and systems
14. Facilitate obtaining EPL and SWL

for health institutions
15. Inter-sectoral Collaboration on

HCWM

4.2: Priority areas selected for implementation under HSDP II
Although HCWM has increasingly gained recognition as an area of critical importance over the
last decade and many steps have taken towards establishing better management, it still remains a
significant environmental and public health issue in the health sector. Reaching complete safety
from the risks of HCW produced in the country requires current efforts to be extended both
quantitatively and qualitatively in a progressive manner.
With support from the Second Health Sector Development Project funded by the World Bank,
the following key actions are recommended for implementation during the lifetime of the project.
Actions Indicators of Lead Responsibility

Achievement (please also refer
page 50)
1. Strengthening the national implementation framework for HCWM in the country
1. Establishing policy commitment and Draft National Policy on NSCHCW & MOH
responsibility for HCWM HCWM updated and
formally endorsed and
approved.
It is important that a formal commitment to a national policy is made before any action plan for
improving HCWM can be undertaken. While a comprehensive national policy was developed in
2001, the objectives and underlying principals of which are detailed on page 19, it was not
formally endorsed by the government. Therefore it remains to be a draft policy to this date
pending approval.
As more than a decade has passed since the policy was drafted, it is recommended that the
National Committee on Clinical Waste Management review the policy and update it as
necessary to suit current challenges and demands in HCWM. Following the review and
agreement to its content by the MOH, the draft policy should be re-submitted for cabinet
approval subsequent to which a stakeholder consultation should be conducted and finally
approved with parliamentary endorsement.


page 50)
2 Strengthen Environmental and Strengthen E&OH Unit MOH
Occupational Health Unit within the with necessary staffing and
MOH to facilitate HCWM activities. budgetary allocations
established.
Strengthening the Directorate of Environment and Occupational Health of the MOH is essential
in managing a HCWM program at the national level and ensuring continued efforts in
implementing a national HCWM program and its long-term sustainability. HCWM is a
specialized service requiring technical skill and know-how. As such, a strengthening the unit
staffed with suitable expertise can play a vital role in strategically directing the sector,
technically backstopping HCFs to improve the management of HCW within their institutions
and providing monitoring oversight at the national level.
Although the creation of a specialized unit for HCWM was initiated under HSDP long delays
were experienced in getting the necessary management clearances and as a result administrative
formalities could not be completed prior to project closure. The Management Services
Department, which is responsible for creating cadre had several discussions with the MoH but
could not get the approval for cadre during the project period. Therefore it is recommended that
the Environmental & Occupational Health Unit be strengthened providing technical oversight
and co-ordinating and guiding hospital authorities on HCWM issues.
A formal institutional arrangement that links the E&OH unit to the health institutions be agreed
upon.
2. Operationalizing Health Care Waste Management in HCFs
1 Develop a standard template/form for Template for institutional Directorate of

H CWM plans for medical and provincial HCWM Environment and
institutions and for PHS. If plans. Occupational
necessary, prepare additional Health/MOH in
technical guidelines consisting of Technical guidelines for collaboration with
basic steps in the preparation of preparing HCWM plan. NCCWM
HCWM plans to supplement the draft
National Guidelines.
While draft national policy/guidelines may provide the framework for standardizing HCWM
procedures across the country, translating recommended practices at the HCF level by either
improving or initiating HCWM systems is unlikely to be sustainable unless a process of
planning is introduced and established.
It is important that the major HCFs introduce a process of planning for HCWM that culminates
in the preparation of HCWM plan specific to each institution, which can be updated on a yearly


page 50)
basis or periodically as necessary. The HCWM plan is the basic document which will
summarize the (i) generation of hazardous HCW (type and quantity), (ii) designation of
responsibilities of the hospital waste management team, (iii) waste management procedures to
be set up/improved, (iv) choice of treatment and disposal technology, (v) financial resources
required, (vi) monitoring/evaluation protocol of plan implementation etc.
The draft national guidelines prepared in 2001 include guidance on some of the key steps
involved in preparing a HCWM plan. However, if required, the MOH could supplement this
with a practical guide for developing a hospital HCWM plan. Several useful sources 10 are
available on the internet from which a supplementary guide could be developed for the use by
hospital management.
2 All Teaching Hospitals to prepare EPL status obtained by 22 Hospital

HCWM plans and to obtain Teaching Hospitals Management and
Environmental Protection License MOH
within 3 years
Teaching hospitals are the largest type of HCF in the country and generate all sorts of hazardous
health care wastes in significant quantities. Given that the overall capital and operational costs
for implementing and standardizing HCWM measures remains high, it makes sense to first start
improvement in HCWM in the larger hospitals and then extends to smaller health-care
establishments.
Of the 22 Teaching Hospitals in the country, only 06 are in possession of an Environmental

Protection License where around 08 more institutions are pending the licenses. Others are in the
process upgrading the HCWM system and obtaining the EPL and SWL.
It is recommended that the MOH review current HCWM practices employed in all THs and
assist them in setting up specific HCWM plans, which can be updated periodically, and which
will progressively lead the institutions to comply or improve compliance with legislative
requirements. The establishment of HCWM plans and monitoring its implementation will
oblige medical institutions and administrative authorities to consider HCWM as an integral
issue of health care services and progressively reinforce organizational capacities to achieve
better standards.
10
WHO, 2002, Basic Steps in the Preparation of Health Care Waste Management Plans for Health Care
Establishments (Health Care Waste Practical Information Series No 2)


page 50)
3 Other selected major hospitals to Hospital specific HCWM Hospital
develop comprehensive HCWM plans developed and Management
plans. financed
Apart from Teaching Hospitals, Provincial General Hospitals, District General Hospitals and
Base Hospitals are the other major HCFs that offer a range of specialized health care services
and consequently produce significant quantities of hazardous HCW. According to the National
Health Budget of 2012 there are 87 major HCFs spread across the country.
As it may not be possible to cover all of the 87 major hospitals under the 2nd HSDP, it will focus
on the major facilities in those provinces that rank high in terms of the quantity of HCW
produced.
4 Selected provinces to prepare Provincial/regional PHS

provincial HCWM plans HCWM plans established
Based on HCWM plans of medical institutions under its purview, it is recommended that the
PHS set up annual provincial HCWM for the selected provinces which will present the strategy
for HCWM at the regional level. It will provide the PHS a clear analysis of the prevailing
situation in the province/region and help set up short, medium and long term objectives and
associated expenditure.
An officially nominated focal point in the PHS (recommended – RE) should be in charge of
developing the provincial HCWM plan with technical backstopping from the proposed HCWM
unit within the MOH.
3.Training and awareness
1 Prepare and implement a national Training program MOH

training programme developed.
Under the HIV/AIDS Prevention and Health Sector Development Projects, the MOH carried out
numerous training programs to train health care workers in the proper management of HCW.
Currently, the MOH in collaboration with the University of Colombo conducts a HCWM
training program annually for a small selected group. In order to achieve acceptable practices in
health-care waste management and compliance with regulations, it is essential to continue
training specifically targeting managers and other personnel primarily involved in the waste
stream management in different HCFs across the country. Also, it may be important for hospital
waste management teams and focal points in the PHS to receive technical training on the
development of HCWM plans.
It is recommended that the Division of Environment and Occupational Health/MOH develops


page 50)
and implements a national HCWM training program, based on current needs and emerging
challenges, identified training gaps and capacity constraints etc to build the skill/knowledge
base that will facilitate an optimal outcome from HCWM investments made.
4. Monitoring of HCWM activities
1 Establishment of a monitoring National HCWM NCCWM & MOH

framework to review and audit monitoring framework
HCWM plans implemented at all developed.
levels.
A national programme for the management of health-care waste should be viewed as a

continuous process which requires periodic monitoring and assessment by the responsible
government agency. Such periodic reviews are important in ensuring sustainability of the
process. A monitoring framework is, thus, needed to be set up which will establish monitoring
protocols, institutional mechanisms, data storage and reporting procedures etc to follow up on
the implementation of HCWM plans at the institutional and provincial levels.
It is essential that the monitoring framework provide the necessary tools to measure if the
objectives of a HCWM program have been achieved. They would broadly include;
 The set-up of adequate indicators of achievement or performance. Qualitative should

always be coupled with quantitative indicators in order to monitor and evaluate the
outcome of the HCWM plan.
 A simple, regular reporting system to keep the appropriate authorities constantly
informed with sufficiently accurate and relevant information that can be easily verified,
enabling decision makers to change the implementation strategy if necessary based on
the practices encountered in the HCFs;

4.3 Description of result indicators to be monitored under 2nd HSDP
Result Outcome Indicators Baseline Time

Frame
1 Review and formally i. Draft policy reviewed by the NCCWM 2013
endorse the draft national ii. Draft policy re-submit for cabinet approval 2013
policy on HCWM iii. Stakeholder views sought on cabinet 2014
approved policy
iv. Policy approved by the Parliament 2014
v. National policy on HCWM approved and 2015
formally adopted
2 Strengthen E&OH Unit i. Formal mandate for the unit with detail job 2015
descriptions for recommended cadre
positions developed.
ii. Separate budget line for HCWM under 2014
Environmental & Occupational Health
Unit
iii. Infra- Structure developed for 2016
Environmental & Occupational Health
Unit
3 Develop a standard i. Standard template for hospital specific 2014
template/form for HCWM HCWM plan developed.
plans for medical institutes ii. Standard template for Provincial HCWM
and for PHS. If plan developed
necessary, prepare
iii. Technical guidelines developed and
additional guidelines
adopted
consisting of basic steps
for the preparation of
HCWM plans.
4 All Teaching & Provincial i. EPL status obtained – 8 Teaching 3 2013

Hospitals to prepare Hospitals
HCWM plans and to ii. EPL status obtained – 8 Teaching 2014
obtain Environmental Hospitals
Protection License within iii. EPL status obtained – 6 Teaching 2015
3 years Hospitals
5 District General Hospitals i. HCWM plans developed for – 04 2013
and Base Hospitals A& B hospitals
to prepare comprehensive ii. HCWM plans developed for - 20 2014
HCWM plans Hospitals
iii. HCWM plans developed for - 20 2015
Hospitals
iv. HCWM plans developed for - 20 2016
Hospitals
v. HCWM plans developed for- 20 2017
Hospitals
6 Selected provinces to i. Provincial HCWM plan developed for – 2015
prepare provincial HCWM 04 provinces

plans ii. Provincial HCWM plan developed for -05 2015

provinces
7 Prepare and implement a i. Training program developed 2014
national training ii. No of training programs conducted – 3 2015
programme iii. No of training programs conducted – 5 2016
iv. No of training programs conducted - 5 2017
8 Establishment of a
monitoring framework to i. Monitoring framework developed and 2015
review and audit HCWM endorsed by the MOH
plans implemented at all
levels.

Chapter 5: Implementation and monitoring arrangements for HCWM under the Second
HSDP
5.1 : Project Institutional and Implementation Arrangements
As a sector assistance program, the implementation of the 2nd HSDP will be the
responsibility of regular implementing divisions/units in charge of the subject matter under
the leadership of the MOH and the PHS. The actual project implementation will involve
central and district level administrative and technical staff, health workers and technicians.
Directorate of Environmental Health and Occupational Health (EOHD) of the ministry of

health will oversee and coordinate the implementation of the HCWM project. In order to
achieve this objective a strengthening of the present EOHD will be done as discussed in the
National action plan.
The project Management team of the D E & OH unit will be responsible for the following key
tasks:
i. Operating the Project Account;
ii. Reviewing the DHPs and the plans and budgets for approval by the PCT;
iii. coordinating the elaboration of operational documents, including:
iv. Preparing TORs and contracts for technical assistance (e.g. capacity building of
PMUs, Health Forum organization, annual audits);
v. Consolidating reports necessary for documenting use of IDA funds and
implementation progress and results;
vi. Reporting on procurement documents for large items;
vii. Managing capacity building activities. In particular, with the support of
consultancy firms, it will develop training programs in the areas of
planning/monitoring and procurement/financial reporting for the districts;
viii. Coordinating monitoring and evaluation activities;
ix. Communicating to key stakeholders the nature, progress and outcome of the
Program;
x. Liaise with international agencies such as IDA, JICA, WHO, and other partners to
ensure that all sector activities are well coordinated.
The project management team will also be supported by a Project Steering Committee
(PSC) appointed by the MOH who will oversee implementation of program activities.
More specifically, the role of the PSC will be to (i) monitor the achievements of project
objectives, (ii) provide policy direction, general project oversight and take necessary
decisions to address implementation issues which may arise during the life of the project.

The relevant division of the MOH and the will ensure that the PSC recommendations to
resolve project implementation issues are satisfactorily implemented.
With technical assistance, the project management team will set up a management
information system, for all project activities (provincially and centrally managed
components), that links financial and procurement management information to the
physical progress of the project. With this tool, the project management team will
supervise, monitor, and report on project activities to the PCT and to the Bank, and will
ensure that implementation of the various project components are implemented in
accordance with the rules set out in the Operations Manual, and that annual audits are
carried out as stipulated in the Grant Agreement.
At the Provincial level, under the technical and policy guidance of the MoH, the Local
Government and the Provincial Councils will serve as the coordinating and monitoring
agencies responsible for overseeing the implementation of the district programs. Actual
implementation of project activities will be the responsibility of the District health
authorities (2 to 3 Districts in each Province) and their divisional staff responsible for
planning, executing and monitoring their District Health Plan. Districts will continue to
receive considerable technical assistance and on-the-job training to strengthen Program
Management Centers (PMCs) capacity to implement the project, the core operational
body to implement the Program under a Performance Based approach.
5.2 Implementation of HCWM under 2nd HSDP
 The Second Health Sector Development Project will basically support the
implementation of the National Health Development Plan through the programs of the
MOH and the 9 provincial MOHs. As the program is designed to be implemented
through the regular health institutional structure, responsibility of implementing and
monitoring results related to HCWM will lie with the relevant divisions/units of the
MOH, PHS and the medical institutions.
Institutional Division/Unit Responsibility in implementing the action plan for HCWM

Level
Central Environment  The mandate of implementing environmental health program
Level and including HCWM within the Central MOH lies with the Directorate
Occupational of Occupational Health and Environment Division (OHED) which
Health Division comes under the purview of DDG – Public Health Services 1
(EOHD) of the  Therefore, under the 2nd HSDP it will take the lead in co-ordinating
MOH. with higher levels of the Ministry and the NCCWM to re-establish
the process to formalize a policy framework for HCWM and
technical guidelines that support the implementation of the
approved national policy.

Institutional Division/Unit Responsibility in implementing the action plan for HCWM

Level
 Develop incentives and mechanism to help facilitate HCFs to
comply with the legal requirements. In particular, the EOHD will
be responsible for providing technical assistance for the
implementation of the HCWM policy, particularly developing
necessary guidelines and templates for the development of HCWM
plans.
 Identify capacity constraints for HCWM and developing a national
training program targeting areas lagging in proper HCWM and to
train major HCFs and PHS to develop comprehensive HCWM
plans.
MOH  Lead responsibility in establishing a dedicated institutional unit

under the purview of the EOHD for HCWM. The structure, cadre,
detail mandate, dedicated budget etc for the unit will need to be
discussed and finalized during program implementation.
NSCCWM  Review and update the draft policy on HCWM

 Develop a national monitoring framework to monitor and audit
HCWM plans; the introduction of a protocol will lead the HCFs to
regularly follow up on HCWM plan implementation.
 Overall monitoring and evaluation of HCWM activities under the
2nd HSDP
Provincial PHS  Ensure establishment of Provincial HCWM plans presenting the

Level strategy for the region and update periodically. This plan should be
compiled from all the individual HCWM plans of the HCFs they
are responsible for, provide a clear picture of the status of HCWM
in the region, and set up short and long term objectives.
Hospital Major HCFs  Every hospital is legally responsible for the proper management of
Level the waste that it generates until final disposal. Directors of every
HCF will take the responsibility to implement safe HCW
procedures in their institutions. Therefore, all major hospitals will
take the responsibility of establishing HCWM plans for the
institution and implement accordingly.
MOH/PHS  The EOHD of MOH and the PHS should (i) co-ordinate efforts to
ensure that HCWM plans are annually set up in the entire major
hospitals, (ii) provide technical services and (iii) supply adequate
resources.

Chapter 6: Technologies available for HCWM and comparison of alternatives

6.1 Treatment Technologies
Several alternative technologies have been developed and are in use to treat and dispose of
hazardous HCW. Broadly, they include incineration in rotary kilns or double chamber
incinerators, incineration in single chamber incinerators, autoclaving, hydroclaving which is an
improved derivative technology of the traditional autoclaving, chemical disinfection, microwave
irradiation and sanitary landfilling. In Sri Lanka, the two most popularly used technologies are
autoclaving and incineration The final choice of treatment technology for a HCF will depend on
various factors, many of which are specific to local conditions, but should be fundamentally
driven by the objective of minimizing negative impacts on public health and the environment.
Certain treatment options while effectively reducing infection hazards and preventing scavenging
may contribute to other health and environmental concerns, such as emission of toxic material
into the atmosphere of waste containing high contents of heavy metals or chlorine compounds
when incinerated below recommended temperatures. Therefore, the selection of treatment
technology has to be a carefully evaluated one in light of local circumstances and the overall
waste management strategy of the country.
As there is ample literature produced by various organizations11 including the WHO on guiding
medical institutions in selecting the most appropriate treatment and disposal technology,
depending on the types and quantities of waste produced and other specific local conditions, this
chapter will be limited to providing a broad technical overview of the options only. The table
below presents suitable treatment and disposal technologies according to the different categories
of HCW and has been sourced from the Guidance Manual for Preparing a National Health Care
Waste Management published by the WHO12.
Waste Rotary Two Single Auto/Hydroclave Chemical Microwave Sanitary

Category Kiln Chamber Chamber Disinfection Irradiation Landfill
Incinerators Incinerator
Non-rsik HCW In all HCFs, the non-risk HCW which constitute of food residues, plastic/polythene containers,
waste paper etc should always be segregated from hazardous waste and disposed of with general
municipal waste and/or removed to a recycling facility, as appropriate.
Human Yes Yes No No No No

Anatomical
waste
Waste sharps Yes Yes Yes Yes Yes For small
11
The “Technical Guidelines on Environmentally Sound Management of Biomedical and Healthcare waste” (2002) adopted by
the Conference of the Parties to the Basel Convention;
• Safe management of wastes from health-care activities, WHO (1999);
• Teacher’s Guide: Safe management of wastes from health-care activities, WHO (1998);
• (Draft) Guidance for the development of National Action Plans, WHO (2002);“Basic Steps in the Preparation of Health Care
Waste Management Plans for Health Care Establishments”, WHORegional Office for the Eastern Mediterranean (CEHA) (2002).
12
Guidance Manual for the Preparation of National Health Care Waste Management Plans in Sub-Saharan Countries, World
Health Organization and the Secretariat of the Basel Convention

quantities
with
encapsulation
Pharmaceutical Yes Small No No No No No
waste amounts
Cytotoxic Yes No No No No No Small
waste Yes for quantities
modern with
ones inertization
Infectious Yes Yes Yes Yes Yes Yes
waste
Highly Yes Yes Yes Yes Yes Yes but only
Infectious after pre-
waste treatment
Radioactive No No No No No No Yes but need
waste to be
specially
designed
Other Yes No No No No No No
hazardous Yes if
waste specially
designed
Table 13 - suitable treatment and disposal technologies according to the different categories of
HCW
The section below is a comparison of the alternative technologies available to treat hazardous
HCW and has been adopted from the Situation Analysis report of 2001 (MOH) and relevant
Who guidelines13.
6.2: Incineration
Incineration is the only technology that can effectively treat most types of health care waste. It
involves a high-temperature dry oxidation process that reduces organic combustible waste to
inorganic incombustible matter with a resultant significant reduction in the waste volume and
weight. Incinerators can range from extremely sophisticated high-temperature operating plants to
very basic combustion units that operate at much lower temperatures. Broadly, they can be
categorized as (i) Double chamber pyrolotic incinerators (ii) single chamber incinerators and (iii)
rotary kilns. One of the main drawbacks of this technology is the gaseous emissions the process
yields, particularly toxic substances if the waste material contains cytotoxic drugs, chemicals,
halogenated material or waste with high contents of heavy metals (such as batteries and broken
mercury thermometers etc). Higher operating temperatures and treatment of flue gases limit
potential for atmospheric pollution and odors caused by the incineration process.
Therefore, selection of the incineration equipment is important and should be carefully evaluated
on the basis of available resources, local conditions and of public health benefits against the
potential risks of air and groundwater pollution caused by inadequate destruction of certain toxic
13

wastes. It is recommended that incinerators designed especially to treat HCW should operate at
temperatures between 900°C – 1200°C. To achieve optimal results from incineration, the waste
should meet certain criteria such as having a low heating value, high content of combustible
matter, very low content of incombustible matter , low moisture content etc.
Description  Pyrolotic double chamber incinerators (incineration at 900°C – 1900°C)

 Rotary kiln (incineration at 1200 °C)
 Single chamber incinerators (incineration at low temperatures 300°C –
400°C)
Advantages Pyrolotic incinerators and rotary kilns

 Complete destruction and sterilization of waste/sharps and hence
elimination of health risks
 Significant reduction in waste volume and weight
 Very high disinfection efficiency
 Destroys all types of liquid, pharmaceutical and other organic waste
 Large quantities of waste can be treated
Single chamber incinerators

 Good disinfection efficiency
 Reduces waste volume and weight significantly
 No need for highly trained operators
Disadvantages Pyrolotic incinerators and rotary kilns

 High investment costs
 Emits toxic flue gases and hence need extensive flue gas emission control
systems
 Depending on the treatment of flue gases, discharge of wastewater
containing toxic metals can occur
 Well trained staff is required for operation
 Expensive to operate and maintain
 Generates ash residues that needs safe disposal (about 1% of unburnt
material)
Single chamber incinerators

 Needs frequent de-ashing and removal of soot and slag
 Contributes to significant atmospheric pollution due to low operating
temperatures and lack of emission control systems
 Inefficient in destroying thermally resistant chemicals and drugs
 No destruction of sharps
Capacity (per hour) 50Kg to several metric tons or 200Kg – 10 tons per day
High-temperature incineration of chemical and pharmaceutical waste in industrial cement or

steel kilns is commonly practiced by many countries as In Sri Lanka, waste from hospitals is sent
to the only licensed industrial kiln operated by Holicm Lanka in Puttalam.

6.3: Autoclaving
Autoclaving is the process of exposing infectious waste to high temperature, high pressure steam
in an enclosed container, similar to the autoclave sterilization of medical equipment. It
inactivates most types of micro-organisms, if properly operated with sufficient temperatures and
contact time, and once disinfected the output can be considered non-hazardous which can be
land-filled with general municipal waste. Autoclaving requires shredding of wastes and sharps
prior to loading to the equipment in order to increase disinfection efficiency. This method is most
appropriate for infectious and sharp wastes and not for certain types of wastes such as
anatomical, pharmaceutical, chemical wastes. The equipment requires to be operated and
maintained by adequately trained technicians and the effectiveness of the disinfection process
has to be routinely checked using a bacterialogical test.
Description Minimum contact times and temperatures will depend on several factors such
as the moisture content of the waste and ease of penetration of the steam.
Research has shown that effective inactivation of all vegetative
microorganisms and most bacterial spores in a small amount of waste (about
5– 8kg) requires a 60-minute cycle at 121°C (minimum) and 1 bar (100kPa);
this allows for full steam penetration of the waste material.
Advantages  Relatively simple to operate
 Low environmental impact
Disadvantages  Relatively expensive to install and operate

 Large autoclaves may need boiler with stack emission control systems
 Shredder is liable to mechanical failures and breakdown requiring regular
maintenance
 Efficiency of disinfection is very sensitive to the operational conditions.
 Generates wastewater
 Large quantities of disinfected waste needs final disposal to a landfill
Capacity (per hour) From 10 to 1500 Kg
Autoclaving is commonly used technology in the country for sterilizing medical equipment as
well as infectious HCW. The HCWM system implemented for the public hospitals in the GCA
comprises of two semi-centralized steam sterilizers located in two strategic locations which
disinfects waste generated in 3 major HCFs in the said area.
6.4: Microwave irradiation

In this type of treatment, health care waste is exposed to a high energy electromagnetic field in
an enclosed chamber which rapidly heats up the liquids contained in the waste and consequently
destroys the infectious components. Prior to being irradiated the HCW has to pass through a
preparative process which includes segregation to remove undesirable material, shredding and
humidification and once disinfected the waste is compacted before being disposed of. Similar to
the autoclaving technique, the output from a microwave facility is considered non-hazardous and
is suitable to be land-filled with municipal waste. The efficiency of microwave disinfection will
depend on the operating conditions and should be checked routinely through bacteriological

tests. As the process is powered by electricity and does not involve the application of steam,
generation of gaseous emissions and wastewater are minimal compared to incineration and even
autoclaving, which can require combustion of fuel for the generation of steam.
Description It is reported that most microorganisms are destroyed by the action of

microwaves with a frequency of about 2450 MHz and a wavelength of
12.24cm.
Advantages  Good reduction in waste volume due to shredding and compacting

involved
 Good infection efficiency under optimal operating conditions
 Environmentally sound
Disadvantages  High investment and operation cost

 Sophisticated and complex technology, hence require highly skilled
operators
 Cannot treat certain categories of waste such as pharmaceutical waste,
cytotoxic waste etc
 Only solids can be treated and that too only once shredded
 No reduction in the weight of waste treated
 Potential high maintenance as shredders are subjected to frequent
breakdowns and poor functioning
Capacity (per hour) 22 – 1100 Kg
The microwave process is widely used in many developed countries. However, it’s not very
popular in developing countries due to the high initial cost and maintenance involve. At the
moment the technology is not popular in Sri Lanka as a suitable solution for treating HCW.
6.5: Chemical Disinfection

In this method, chemical disinfection that is used routinely to kill microorganisms on medical
equipment and on floors has been extended to treat HCW. Chemicals are added to HCW to kill
or inactivate pathogens it contains and is most suitable for treating liquid waste such as blood,
urine,. However, solid HCW such as sharps and microbial cultures may also be treated but
requires to be shredded to ensure that a maximum surface area comes into contact with the
disinfectant. Once treated, HCW is considered non-risk HCW and can be disposed with
municipal waste but the chemical disinfectant may create significant environmental problems if
not disposed securely. Hence, in planning the use of chemical disinfection it is important to
carefully consider the requirements for the eventual disposal of the chemical residues. It is
recommended that thermal sterilization be considered with preference over this method of
treatment for reasons of efficiency and environmental pollution. Chemical disinfection is usually
carried out on hospital premises, however, commercial, self-contained, and fully automatic
systems have been developed for health-care waste treatment and are being used mostly in
developed countries.

Description Chemicals that are used are mostly strong oxidants such as chlorine
compounds, ammonium slats, aldehydes, phenolic compounds etc)
Advantages  Shredding, when carried out, reduces the volume of waste

 High disinfection efficiency
 Effective for highly infectious liquid wastes
Disadvantages  Use of hazardous chemicals has the potential to cause environmental

contamination
 Polluted wastewater produced in the process (as water is usually
added during shredding to prevent excessive warming and to
facilitate better contact with the disinfectant)
 Require highly trained technicians to operate and maintain
automated systems
 Inadequate for pharmaceutical, chemical and some types of
infectious waste
Capacity (per hour) 22 to 1100 Kg
6.6: Land disposal

Disposal of HCW in municipal landfills is not advisable if it is untreated, however, it could be
regarded as an acceptable disposal route if the medical authority genuinely lacks the means to
treat waste prior to disposal. Allowing HCW to accumulate in hospital premises or elsewhere
constitute a far greater risk of infection transmission than disposal in a landfill. When this
solution has to be used, it is important that HCW be disposed of in a sanitary landfill and rapidly
covered. As sanitary landfills are designed to geologically isolate waste from the environment
and are managed with controlled operation, contamination of soil and water, air pollution, smell
ad direct contact with people can be significantly prevented. However, HCW should not be
deposited on or around open dumps which could lead not only to acute pollution problems but a
great risk of subsequent disease transmission.
In the absence of sanitary landfills, a controlled dump site which fulfills minimum requirements,
such having certain engineering work completed to effectively retain waste and an established
system for rational and organized deposit of waste, could be used. It is further recommended that
HCW be deposited using one of the following techniques; (i) bury in a shallow hollow excavated
in mature municipal waste at the base of the working face and cover with a fresh layer of
municipal waste (ii) bury in a excavate deep pit in mature municipal waste and backfill with the
removed municipal waste or (iii) design and dedicate a special cell in the landfill where only
HCW will be received.
In smaller HCFs with means for minimal HCW management programs, especially in remote
areas or areas with severe hardships, safe burial in a specially constructed burial pit may be the

only viable option. As a minimum, the hospital should follow certain basic rules in managing the
burial pit such as lining the pit with a material of low permeability, restricting access to the site
to authorized personnel only, covering HCW with a layer of soil after each load and with lime if
ordour has to be suppressed, bringing only hazardous waste to the site to optimize the space
available in the pit etc,. Once filled, the pit should be sealed off.
Advantages  Simple and inexpensive to operate

 No specific construction cost is involved if operated within available
landfill systems
 Protected from scavengers gaining access to HCW
Disadvantages  HCW is not treated and remains hazardous

 Strong co-ordination between waste collector and landfill operator
required
 Reduces awareness among health care workers of the need to
segregate waste categories
 Potentially high transport cost that may be involved
 Disposal in special HCW cells need conscientious operation
according to specific guidelines
Sri Lanka does not operate fully engineered sanitary landfills. However, the Nuwera Eliya
Municipal Council operates a semi-engineered small landfill which is used by the Nuwera Eliya
General Hospital to dispose of its hazardous HCW. Ampara has land fill sites developed by
UNOPS. All other landfills used by local authorities are unsafe dump sites and hence is not safe
for the disposal of infectious HCW.

Chapter 7: Safeguard requirements for infrastructure development work under 2nd HSDP
The second HSDP may invest in the development of health infrastructure, mainly buildings to
improve/expand health care services. Environmental impacts of such construction, which would
in most cases take place within the existing premises, are likely to be localized, relatively small
scale, spread in different locations of the country and confined to the construction site. However,
the hospital management and health authorities should take precautions to minimize any
potential adverse impacts caused by civil works and also to ensure that environmental friendly
practices are employed when planning and designing the sub-project.
7.1 Environmental Clearance under national laws

Under EIA regulations of the NEA, development of hospital infrastructure that may involve the
following will need to obtain environmental clearance from the Central Environmental
Authority.
 Clearing of land area exceeding 50 hectares

 Reclamation of land, wetland area exceeding 4 hectares
 Construction of waste treatment plants treating toxic or hazardous wastes
 Construction of buildings/structures within any of the sensitive areas defined in Part III of
the EIA regulations
It is very unlikely that infrastructure development undertakings of the project would belong to
any of the prescribed categories mentioned above, however, in the unlikely event it does an
application need to be submitted to the CEA using the Basic Information Questionnaire available
on its website. Based on the application the CEA will make a determination on the level of
assessment required and instruct the relevant authorities of the requirements that need to be met
in obtaining EIA clearance.
7.2 Incorporation of safeguards into plan, design and contract

Irrespective of the outcome of environmental screening under the NEA, construction of HCFs
under the 2nd HSDP will adopt the following broad guidelines in planning, designing and
construction of the facilities.
Planning and Siting

 Good area planning should precede any construction design work in existing or new
premises. If the proposed new health premises are part of a long-term plan for developing
the area, the project should support the preparation of a vision plan for the premises in
order to provide a future development perspective and enable the optimal utilization of
space and energy.

 When new sites are developed, the project should give strong consideration to proper site
selection criteria such as (i) accessibility (ii) availability of services such as water supply
and other infrastructure essential for development of a health care service (iii) availability
of space for waste management activities (iv) proximity to ecologically sensitive areas (v)
minimum interference with local hydrology (vi) minimum potential impact on the
surroundings of the health premises (vii) areas known to be vulnerable to natural disasters
etc
 Spatial planning within the health premises should also give priority to potential for
creating green areas and other facilities for visitor/resident comfort.
Designing
 The design of health facilities should give due consideration to the comfort of users and
needs of patients, children, disabled and the old.
 The design of the buildings should also ensure adequate ventilation and lights and should
give priority to making the most of the potential of natural systems and renewable energy
sources.
 The health facility should have adequate safe water supply and sewage/wastewater
disposal systems.
 The building design also should make ample spaces and provisions for collection,
storage, transfer, treatment and disposal of HCW generated by the facility during the
operational phase. If the type of treatment facility (such as incineration) is determined the
design should incorporate the infrastructure needed to support its functioning.
Construction
Protection of Ground Cover and Vegetation
 Removal of existing green cover including trees should be limited to the bare minimum.
Disposal of solid waste and debris

 All construction debris and residual spoil material including any left earth should be
disposed by the contractor at a location approved by the Local Authority for such a
purpose.
 The debris and spoil should be disposed in such a manner that (i) waterways and drainage
paths are not blocked; (ii) the disposed material should not be washed away by floods and
(iii) should not be a nuisance to the public.
Soil Erosion
 The contractor should be instructed to take all steps necessary to ensure the stability of
slopes including those related to temporary works.
 Work that will lead to heavy erosion shall be avoided during the raining season. If such
activities need to be continued during rainy season prior approval must be obtained from

the hospital authority by submitting a proposal on actions that will be undertaken by the
contractor to prevent erosion.
 The work, permanent or temporary shall consist of measures as per design or as directed
by the Engineer to control soil erosion, sedimentation and water pollution to the
satisfaction of the Engineer. Typical measures would include grass cover, slope drains,
retaining walls etc.
Noise
 All noise generating machinery used during construction should be fitted with noise
control devises and comply with the standards stipulated by the CEA for sensitive
environments. The use of noise generating machinery should be limited to day time hours
and cause minimum disturbance to patients if in-patient care facilities already exist within
the premises.
Labour Camps
 If labour camps are established, they should be provided with adequate and appropriate
facilities for disposal of sewerage and solid waste. The sewage systems shall be properly
designed, built and operated so that no pollution to ground or adjacent water
bodies/watercourses takes place. Garbage bins should be provided in the camps,
regularly emptied and disposed off in a hygienic manner, to a designated site by the Local
Authority.
 The labour camps should be monitored for cleanliness and hygiene and necessary
measures should be taken to prevent any breeding of vectors.
 The labour camps must be removed from the site after its need is over along with septic
tanks, garbage and other construction debris and clean. The area should be restored back
to its former condition before handing the site over.
Dust Management
 To prevent dust pollution during the construction period, regular watering of the
construction site must be carried out and all material stocks onsite must be covered to
prevent dust and other particles getting airborne.
 All vehicles delivering materials shall be covered to avoid spillage and dust emission.
Health and Safety

 Prevention of breeding of mosquitoes at places of work, labour camps, material stores etc
should be given top priority. Stagnation of water in all areas including gutters, used and
empty cans, containers, tyres, etc must be monitored.
 Contractor’s places of work, labour camps, plus office and store buildings must be kept
clean and devoid of garbage to prevent breeding of rats and other vectors such as flies.

 Construction vehicles, machinery and equipment must be stationed only in designated

areas of the work site and should not pose any danger to the public or hospital users.
 Material stockpiles should be located sufficiently away from the areas frequently used by
hospital workers and visitors.
 If possible, construction sites should be fenced out temporarily in order to avoid any risk
posed to hospital workers and users.
 Vehicle speed limits must be enforced for construction vehicles in areas near and inside
hospital premises.
Sourcing of Raw Material

 The contractor must ensure that all raw material such as sand, rubble, metal, timber etc
required for the construction of the building are sources from licensed sources. If the
contractor himself pans to operate his own quarry/sand pit, all necessary approvals from
the relevant authorities must be obtained. Copies of such approvals should be submitted
to the hospital authority.

Annexes
Healthcare Waste Management –Rapid Assessment Tool
1. Hospital Information
a) Name of the Hospital :………………………………………
b) Bed Strength:………………………………………………...
c) Bed Occupancy Rate:……………………………………….
d) Number of wards:……………………………………………
e) Number of Staff:…………………………………………….
f) Doctors/ Nurses/ / Paramedics/ Minor Staff ………………..
2. Does the hospital have a approved Health Care Waste Management Plan? Yes
No
…………………………………………………………………………………………………
………………
3. Amount of Healthcare Waste Generated per day:
Waste type Quantity
Infectious waste
Chemical waste
Pharmaceutical waste
Sharps
Radio-active waste
Bio degradable Waste
Plastic/ polythene
Paper

Electronic waste / mercury

waste
Other
4. Details on waste handling and disposal (solid waste)
4.1 Details on waste segregation – into which categories are HCW separated?
No Segregation Non-risk HCW Hazardous HCW
Sharps Radioactive HCW Other
4.2 What type of containers are used to segregate waste (bags, cardboard boxes,
plastic/metal containers)
………………………………………………………………………………………………
………………………
………………………………………………………………………………………………
………………………
4.3 What type of labeling and color coding is used for marking segregated waste?
………………………………………………………………………………………………
………………………
………………………………………………………………………………………………
……………………
4.4 What is the method of waste collection and on-site transportation
Manual Cart/Trolley Other

4.5 Do sanitary laborers use protective clothing like masks, boots, gloves and aprons?
Yes No
4.6 What types of containers are used for collection and internal transport of waste?
(Bins, bags, boxes, trolleys, wheelbarrows etc)
………………………………………………………………………………………………
………………………
………………………………………………………………………………………………
………………………
4.7 Where is segregated waste stored while awaiting removal from the hospital or
disposal? Is this area secure?
………………………………………………………………………………………………
………………………
………………………………………………………………………………………………
………………………
4.8 Is there off-site transportation of HCW involved prior to disposal? If yes, please
provide details of the following:
Does the hospital have an approved off-site transportation plan?
………………………………………………………………………………………………
………………………
Who does the transportation?
………………………………………………………………………………………………
………………………
How often is waste removed?
………………………………………………………………………………………………
………………………
What are the control methods practiced?

………………………………………………………………………………………………
………………………
………………………………………………………………………………………………
………………………
4.9 How is HCW treated prior to disposal?
………………………………………………………………………………………………
………………………
………………………………………………………………………………………………
………………………
………………………………………………………………………………………………
………………………
………………………………………………………………………………………………
………………………
4.10 Is there a waste treatment facility available within the hospital? (incinerator/steam
sterilizer)
…………………………………………………………………………………………………
……………………
…………………………………………………………………………………………………
……………………
or
4.11 Has the hospital outsourced HCW treatment to third party? If so, does the
organization offer satisfactory services?
…………………………………………………………………………………………………
………………
…………………………………………………………………………………………………
…………………

4.12 Where is the treated waste finally disposed to?
…………………………………………………………………………………………………
……………………
…………………………………………………………………………………………………
……………………
5. Waste water generation, treatment and disposal
5.1 What is the quantity of

(i) Waste water generated per
day……………………………………………………………………
(ii) Water usage per

day…………………………………………………………………………
……
5.2 Methodology of waste water treatment and disposal
…………………………………………………………………………………………………
……………………
…………………………………………………………………………………………………
……………………
6. Staff responsible for HCW management
6.1 Is there a waste management team in the hospital with designated responsibilities?
Please provide a brief overview of how duties and responsibilities for HCWM is
organized.

…………………………………………………………………………………………………
……………………
…………………………………………………………………………………………………
…………………
…………………………………………………………………………………………………
……………………
…………………………………………………………………………………………………
……………………
6.2 Who is the focal point for HCWM in your hospital?
…………………………………………………………………………………………………
……………………
7 Has the hospital obtained the services of a cleaning service
Yes No
8 Status of obtaining Environmental Protection License and Scheduled Waste License from
the Central Environmental Authority
…………………………………………………………………………………………………
……………………
…………………………………………………………………………………………………
……………………

9 Do you think the current practices of waste handling, storage and disposal offer sufficient
security and protection against risks posed by hazardous HCW
…………………………………………………………………………………………………
………………
…………………………………………………………………………………………………
…………………
10 Issues / comments related to Healthcare Waste Management in your institution
…………………………………………………………………………………………………
……………………
…………………………………………………………………………………………………
……………………
…………………………………………………………………………………………………
……………………
…………………………………………………………………………………………………
……………………

Assessment of Healthcare Waste Management in Major Health Institutions
Name Bed Bed No of Quantity of solid Quantity Method Method of Method of Method Method of Traini EPL/H
Streng Occupanc Staff waste generated of Waste of Waste Waste of Sewerage ng on WL
th y rate ( Category wise) Water Waste Transportati Treatment Waste Treatment HCW obtained
generated segrega on and & Disposal water M
-tion Storage treatme
nt
1. 3300 82% 6750 Infectious 500 Used – NCC Storage Steam Connect - Trainin Pending
NHSL Kg 3750 units available Sterilization ed to g licenses
Sharps 100 Kg Disposal by main conduc
Chemical 25liters CMC sewer ted
Pharmaceutical
waste 10Kg
Radio active – 2
Kg
E waste 100Kg
per year
Mercury – 5Kg
per year
2.TH- 485 89.66% 1042 Infectious – 50m3 – As per Carts, storage Steam Chemic No Trainin Yes
CSHW 160Kg 100m3 the available sterilization al –( treatment g
Sharps – 9Kg Nationa & shredding TCL) conduc
Chemical – 7.5l l Colour ted
Code CMC –
recycling
paper, plastic
general
waste
3..Lady 901 78.4 2220 Infectious waste – Water NCC Waste Steam No No yes Applicati
Ridgeway 125Kg usage transportation sterilization ons
Hospital Sharps – 15 Kg 675.6 m3 –by Carts and submitted
Storage shredding at
08 Kg per 2 available CSHW
weeks
10 tube light
bulbs
4TH- 1093 83% 1990 Infectious- 200kg 791.40 NCC Storage Treatment – No - yes Applicati
Colombo Sharps – 100Kg litres available outsourced ons
South Placenta body Bio submitted

nt
parts( 350kg per degradable-
week) local
authority
Other
recycled.
5.TH- 954 72% 1789 Infectious – 180000 l NCC Storage room Out sourced Connect Sewerage yes
Peradeniy 125Kg ed to treatment
a Sharps – 50% sewer plant
Chemical – 65
litres Chlorination
Radio active
600ml
6.De 343 86.67% 850 Infectious – 100 100 m3 NCC Storage Room Out sourced no No yes Applicati
Soyza Kg ons
Maternity Sharps – 5Kg prepared
Hospital
7. 876 1199 Infectious – - NCC No Out sourced No Sewerage yes Applicati
National 177Kg treatment on
Cancer Sharps – 74Kg plant Submitte
Institute Plastic Cytotoxic d
75Kg
Glass Cytotoxic –
25Kg
8.T H - 1606 85.7% 2571 Infectious – 25 liters NCC Storage Incinerator yes Applicati
Karapitiya 175Kg Rooms available – ons to be
Sharps 30Kg not adequate submitted
.
9.TH – 671 - 423 Infectious – 80 275 m3 NCC Storage – not Incineration Waste yes NO
Chest Kg satisfactory – not water
Hospital Sharps – 6kg adequate treatme
Chemical – 5Kg nt plant
10.TH- 115 89.15% 355 Infectious -08 Kg - NCC No - storage Open Waste yes Not No

nt
Sirimavo Sharps – 5Kg burning water adequa
Bandarnai connect te
ke CH ed to
sewer
11.TH _ 1228 90& 1104 Infectious 165,000 NO Waste yes Not Preparati
Jaffna 1000Kg gallons Disposed by water adequa on for
Local connect te Submissi
Sharps 150Kg authority ed to on
Cytotoxic 1800Lg sewer
per year
12.TH – 1650 87% 2725 Infectious – 250m3 NCC Under Incineration No No yes No
Kurunegal 2000Kg ???? construction Not adequate
a Sharps – 79.5%
13.Nation 1514 62.81% 1052 Infectious – 13 - NCC Storage area Out sourced No Available yes Applicati
al Institute Kg available not ons
of Mental Sharps – 1.5 Kg functioning submitted
Health
14. Sri 1046 66% 1608 Infectious – - NCC Storage Incineration yes yes yes Licenses
Jayawarde 100Kg Available obtained
napura G Sharps – 15Kg
H Chemical –
100Kg
15.TH - 2286 81% 4672 Infectious – NCC Storage Out Sourced No Yes Yes Licenses
Kandy 470Kg Available Obtained
Sharps – 71Kg
Placenta – 60Kg
Cytotoxic Waste –
600Kg
16.TH – 252 95.54% 758 Infectious – 55Kg 20m3 NCC Demarcated Steam No No No Applicati
Mahamod Sharps – 4-5 storage area Sterilizer ons
ara - Galle boxes submitted
17.TH- 1405 2103 Infectious – - NCC Demarcated Incinerator No No yes
Colombo 120Kg Area +
North Sharps -24Kg Out Sourced

nt
18.TH - 746 83% 1405 Infectious – - NCC yes Burning and Connect yes yes No
Kegalle 327Kg buring ed to
sewer
Sharps – 76.5Kg
Chemical Waste -
54 liters
19.IDH 200 220 Infectious – 8 – NCC Secure Area
10 Kg
Sharps - 01Kg
Chemical 1-2Kg
20. DGH- 708 73.83% 979 Infectious – 90Kg 03m3 NCC Separate Huts Incineration Drafted NO
Gampaha Sharps – 10Kg Available a
project
prposal
21 259 72.5% 322 Infectious – 20Kg 240m3 NCC No Clinical Collecte No Applicati
Rehabilitat Waste – d in a ons
ion Sharps – 4Kg transported closed Submitte
Hospital _ to NCTH - pit d
Ragama Ragama
22. DGH - 300 1367 Infectious – 30 000 NCC Storage room Open Connect Yes Applicati
Kalutara 300Kg liters available not burning of ed to ons
Sharps -10Kg adequate infectious Sewera submitted
waste ge
System
Sharps – out
sourced
23.PGH 1010 78% 1847 Infectious – 500000L NCC Storage and Incinerator. No Sewerage yes No
Ratnapura 1000Kg demarcated method system
Sharps – 50Kg Water area available.
Pharmaceutical usage- available.
waste – 20Kg 1200000L
Cytotoxic waste –
30Kg per year

nt
Mercury waste –
50 l x12 per year.
24..PGH 1375 78% 1807 Infectious – 1,10,000l NCC Storage incineration Adding Sewerage yes Applicati
Badulla 1500Kg available TCLfilt system ons
Sharps -75Kg eration available. submitted
Chemical 90 100 l Connect
Cytotoxic 10Kg ed to
per year sewerag
e
25. DGH 530 80% 930 Infectious -175 - - NCC Demarcated Incineratorav Waste - yes Applicati
– Ampara 200Kg area available ailable – not water ons
Sharps – 50 -70 adequate treatme Submitte
Kg nt d
system
availabl
e
26. DGH 676 - 873 Infectious – - NCC Yes Open Connect yes No No
_ 400Kg burning/ ed to
Negambo Sharps – 300Kg burring Sewera
ge
System
27. DGH 427 90% 617 Infectious – 50 10 liters NCC Storage Disposed at Connect yes yes No
– Nuwara Kg Available the land fill ed to
eliya Sharps- 05Kg Sharps – sewerag
Sharp pit at e
the land fill System
28.DGH – 526 69.3% 567 Infectious – 25- 4000- NCC yes Buring Connect Yes – needs yes Applicati
Nawalapiti 30Kg 6000 liters burning ed to repairs ons
ya sewerag submitted
Sharps – 12-15Kg e
29.DGH - 737 60.62% 22 Infectious 250 Kg 2500 liters NCC yes Incineration Connect Sewerage conduc Applicati
Matale Sharps 10Kg ed to system ted ons
Pharmaceutical Sewera available submitted

nt
waste -650 mg ge pit .
Chemical – 10
liters
Mercury – 120 g
per year
30. GH – 435 0.61% Infectious – 62Kg - No Incineration/ Connect Sewerage No No

Trincomal Sharps-07Kg Placenta pits/ ed to system
ee burning sewerag
e
system
31.GH – 747 72% 1159 Infectious – 400m3 NCC yes Open Connect Yes yes Yes ???
Polonnaru 130kg burning ed to
wa Sharps – 130Kg sewerag
Chemical – 03 e plant
liters
Radio – active 08
liters
32. BH - 352 82.9 488 Infectious – 10 - NCC yes Incineration - - No No
Gampola Kg
Sharps – 10 Kg
33. BH = 87 45-50% 75 Infectious – 05Kg - NCC yes Incinerator ( Filterati No No No
Teldeniya Sharps – 500g Locally on
made) Method
34.BH- 231 43.36% 388 Infectious – 20Kg 320 Liters NCC Yes Incineration No Request yes No
Kantale Sharps – 10kg & Placenta made
Pit
35. Base 135 100% 246 Infectious 50 kg 400 liters NCC yes Open Soakage - No No
Hospital - Sharps 1 Kg burning/ pit
Dehiattaka Pharmaceutical incineration
ndiya waste 1 Kg
Chemical 3 Kg
Radio active

nt
waste – 3kg
E waste 01 Kg per
year
Cytotoxic waste
0.5l per year

Strategic Management Accounting

Uploaded by

Document Information

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Strategic Management Accounting

Uploaded by

Copyright:

Available Formats

¥rl:k 2698475

Environmental management framework for healthcare waste &

Dr. Y.D. Nihal Jayathilake,

THE GOVERNMENT OF SRI LANKA

Environmental Management Framework

Second Health Sector Development Program Page 1

CEA : Central Environmental Authority

Second Health Sector Development Program Page 2

Chapter 2: Existing policy/regulatory framework for HCWM in Sri Lanka

Chapter 3: Review of the present scenario of HCWM in Sri Lanka

3.1: Types of HCW generated .. .. .. .. .. .. .. .. 25

Chapter 4: Strategy for scaling up HCWM under HSDP II

Second Health Sector Development Program Page 3

Chapter 5: Implementation and monitoring arrangements for HCWM under the

Chapter 6: Technologies available for HCWM and comparison of alternatives

Chapter 7: Safeguard requirements for infrastructure development under 2nd HSDP..

Second Health Sector Development Program Page 4

Second Health Sector Development Program Page 5

Chapter 1: Overview of the Second Health Sector Development Program

1.1: Program objectives and proposed activities

1.2: Development Objectives of the 2nd HSDP

1.3: Project Description

Second Health Sector Development Program Page 6

Achieving sustainable improvements in nutrition results is fundamentally a multi-sectoral cross-

Second Health Sector Development Program Page 7

Second Health Sector Development Program Page 8

Secondary prevention interventions: The secondary prevention strategies include introduction,

Second Health Sector Development Program Page 9

Modernized health management information system (HMIS):

Second Health Sector Development Program Page 10

An effective health care quality assurance system

Better skilled human resources for health, matching sector needs

(Reference: Draft Project Appraisal Document, June 25 2012)

Second Health Sector Development Program Page 11

1.4 Objectives of the framework and the intended audience

Second Health Sector Development Program Page 12

1.5: Structure of the report

Chapter 1  Introduction to 2nd HSDP

Chapter 2  Overview of the organization of the health

Chapter 4  National Health Development Plan and HCWM

Chapter 5  Institutional arrangements for implementing and

Chapter 6  Technologies available for HCWM and

Chapter 7  Safeguard requirements for civil works

Second Health Sector Development Program Page 13

1.6 Sources of information

Second Health Sector Development Program Page 14

Chapter 2: Existing policy/regulatory framework for HCWM in Sri Lanka

2.1 Overview of the organization of the Health sector in the country

Provincial Health Services1.

Second Health Sector Development Program Page 15

Private health care service sector

Second Health Sector Development Program Page 16

Health Administration HCF category Type of Medical Type of HCW

Table 2 - Overview of the administration of Health Services and classification of medical

Second Health Sector Development Program Page 17

2.2: Health care waste management in Sri Lanka

2.2.1: General Background

Second Health Sector Development Program Page 18

2.3 Existing health care waste management framework in the country

2.3.1: National Policy

Second Health Sector Development Program Page 19

2.3.2: National Guidelines

Second Health Sector Development Program Page 20

2.3.3: Code of Hygiene