1. SIGN Cambodia Oct. 20021 From Urban to Rural Health Care Waste Management in India Srishti Health Care Without Harm India

2. SIGN Cambodia Oct. 20022 Srishti Not for profit, non-governmental environmental organisation working of issues of waste, recylcing and toxics since 1992 areas of policy, research, projects, advocacy

3. SIGN Cambodia Oct. 20023 Brought attention to the issue in India in 1994. Involved in national legislation and standards setting. Coordiante a national multistakeholder network. Implemented 5 model hospitals, training programs, awareness campaigns. Documentation of best practices, field guides. Advocacy for cleaner appropriate technologies. Participated in WHO database, 1999, UNEP Basel Guidelines for bio- medical wastes,2000,SIGN –India partner Work on Medical Waste

4. SIGN Cambodia Oct. 20024 Rapid Changes in Urban settings since 1995 Perspective shift from technology to management solns. New national legislation in 1998 with tech. standards. Focus on In hospital program implementation. Training and capacity building. Segregation and sharps management. Offsite treatment and disposal with transport. Understanding of occupational safety issues Installation of off-site centralised facilities in 6 cities. Adoption and local manufacture of non-burn technologies

5. SIGN Cambodia Oct. 20025 Lessons learnt in Urban Settings Waste mgmt as part of housekeeping/ infection control. Hosptial staff has a rapid learning curve. Raising awareness about occupational safety issues is key. Simple devices work better such as for sharps mgmt. Rapid incorporation of non-burn technologies where availability is assured. Preference of technologies with lower cost of operation. Training and awareness play a citical role. Industry eager to fill in new markets with products.

6. SIGN Cambodia Oct. 20026 Non-Burn Technologies Being Used for Sharps On – site needle cutters and destroyers. On site Designed waste pits. Off site Waste encapsulation. On site and off site Autoclaving. On site and off site Micro waving. Off site Needle smelting. (Srishti study carried out for SEARO – WHO for evaluating above- Yr2002)

7. SIGN Cambodia Oct. 20027 Legislation applicable to Rural/peri urban settings in India Mandatory waste management system by 31 st Dec2002. Segregation of waste at source. Secured collection and transportation. Deep burial allowed (in populations < 500,000) Burning plastics/ especially chlorinated plastics not recommended.

8. SIGN Cambodia Oct. 20028 Broad Rural Health Structure Community Health Center (CHC) A 30 bedded Hospital/Referral Unit for 4PHCs with specialized services Primary Health Center (PHC) A referral unit for 6 sub centres 4-6 bedded Sub Center (SC) Most peripheral contact point between Primary health care system and community District Hospital Sub-District Hospital

9. SIGN Cambodia Oct. 20029 Coverage Rural Population: 72.2% of total population (2001 census) Community Health Centre: Caters to a population of 1.2 lakh. Approx 2600 nos. Primary Health Centre: Caters to a population of around 30,000. Approx 23000 nos. Sub Centre: Caters to a population of 5,000. Approx 36,258 nos. Other Health Care Facilities: Missionary health care facilities and Day care clinics

10. SIGN Cambodia Oct. 200210 Types of Health Services Routine Services provided in rural areas: Day care/ observatory beds Laboratory investigations Tuberculosis centers Mother and Child Care Campaigns: -Immunization drives

11. SIGN Cambodia Oct. 200211 Waste Types (based on survey of 5 centers) Infectious Waste: Body tissues, Blood soaked cotton and gauze pieces and body fluids Infectious Plastic: Disposable syringes, tubings, IV bottles and gloves Sharps: Broken glasses and metal sharps like scalpels and needles Average quantity of bio-medical waste/bed/day: 0.075- 0.1Kg II. General Waste: Packaging material & food waste

12. SIGN Cambodia Oct. 200212 Exisiting Practices Waste Segregation: Waste is generally mixed in a single bin/bag. In some districts waste is being segregated into different categories. Waste collection and storage: Open bins and drums. Bins are not bagged. Spills on floor at the time of generation. No regular pattern of waste collection and the waste is collected as and when required.

13. SIGN Cambodia Oct. 200213 Segregation at Source

14. SIGN Cambodia Oct. 200214 Existing Practices Waste Transportation: Waste is transported manually from point of generation to final treatment/disposal site. No protective gears are provided to the health care workers. No immunization/accident reporting. Waste Treatment: No specific waste treatment pattern is followed except in 2 cases.

15. SIGN Cambodia Oct. 200215 Existing Practices Waste Disposal: Open dumping of waste around the health care facilities Open burning of waste Scavenging of waste by waste sorters and animals Furnaces for burning of waste in some PHCs In facilities near urban areas waste is being carried by centralized facility

16. SIGN Cambodia Oct. 200216 Needle Destroyer

17. SIGN Cambodia Oct. 200217 Final Storage of Waste in a Health Care Institution

18. SIGN Cambodia Oct. 200218 Treatment and disposal methods observed: Encapsulation. Pit Disposal. Needle Devices – Destroyers/cutters. Small autoclaves.

19. SIGN Cambodia Oct. 200219 Deep Burial Pit

20. SIGN Cambodia Oct. 200220 Autoclaves

21. SIGN Cambodia Oct. 200221 Training and Awareness Staff are not aware of the concept of waste management. No specific training sessions on waste management. No posters/awareness material provided at the health care settings.

22. SIGN Cambodia Oct. 200222 Interventions possible Incorporating waste mgmt. into housekeeping and infection control. Raising occupational safety awareness. Training and capacity building for better segregation. Resolving transport issues (onsite/offsite decisions) Incorporating safe-easy to use, low operating cost technologies

23. SIGN Cambodia Oct. 200223 Lessons, understandings and perspectives from the urban experience can be applied to rural and peri-urban areas.