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An integrated solution for healthcare waste takes off in Nepal

An integrated solution for healthcare waste takes off in Nepal

© GIZ/Umong Shahi

In Nepalgunj, a Central Treatment Facility safely manages infectious waste from 190 different health facilities. Does this public-private partnership hold the answer to one of Nepal’s most intractable problems?

The city of Nepalgunj, located on the Terai plains of Nepal, is a burgeoning medical hub. Home to 189,000 people, it has more than 30 hospitals which attract patients from across southern Nepal and beyond. It has dozens of clinics, pharmacies and medical laboratories. What it has not had, until recently, is a way to safely manage all the infectious waste being generated at these healthcare facilities.

The consequences of this were harmful for both people and the environment. ‘Syringes, blood-soaked materials and other hazardous items used to be mixed in with general waste, or burned,’ explains Prashanta Bista, the Mayor of Nepalgunj. ‘As local government, we urgently needed to find a comprehensive solution to this problem.’

Mayor Prashanta Bista (c) Giz Suvash Nepal
Mayor Prashanta Bista
© GIZ/Suvash Nepal

The solution has come in the form of a Central Treatment Facility, established in late 2022 with support from the German Federal Ministry for Economic Cooperation and Development (BMZ). Public and private health facilities pay the company which operates the Central Treatment Facility to collect their infectious waste and to treat it before recycling or disposing of it at the nearby municipal landfill.

It took work to convince health facilities to come on board, explains Prashanta Bista. There were concerns about the added costs and additional oversight. ‘In the end, we won them over by providing them with a reliable and efficient way to manage waste.’

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This video, produced by the GIZ-implemented global programme Water Policy–Innovations for Resilience, is part of a broader social media campaign, featuring Nepali movie star and Goodwill Ambassador Dayahang Rai, which aims to raise awareness about waste management within the health sector and to make ‘healthcare waste management everyone’s business’. The campaign, supported by Support to the Health Sector Strategy (S2HSS) project and the GIZ Water Policy programme, builds on previous successful work with local influencers to break the taboo around menstruation in Nepal.

Healthcare waste challenges cannot be solved by the health sector alone

The Central Treatment Facility in Nepalgunj is the joint brainchild of the mayor’s office, the city departments of health and environment, and the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ), which works in Nepal on behalf of BMZ. Since 2016, GIZ-implemented health projects have been supporting the Ministry of Health, provincial and municipal governments, and large public hospitals to find sustainable, environmentally friendly solutions to healthcare waste management challenges. These efforts have demonstrated the clear environmental and health benefits of good waste management systems and have shown that healthcare waste, when properly managed, can become a source of revenue for the institutions which produce it.

Landfill (c) Giz Umong Shahi
Many landfills do not accept healthcare waste
© GIZ/Umong Shahi

At the same time, these experiences have also revealed some hard truths about what can be achieved working inside the health sector alone: ‘A major lesson we have learned is that it is not enough to improve waste management practices inside individual health facilities,’ explains Tirtha Kumar Sinha, deputy programme manager of GIZ’s Support to the Health Sector Strategy (S2HSS) project. Even when infectious waste is separated from general waste and is treated so that it can be handled safely, health facilities still need a legal way to dispose of the waste in the end. And this is often a sticking point: many municipal landfills will not accept healthcare waste – treated or not – and scrap dealers are hesitant to buy it for recycling.

‘It was an eye-opening moment for us when a hospital we supported to introduce good waste management practices ended up burning its treated waste for lack of an alternative,’ says Tirtha Kumar Sinha. The implications were clear:

Waste management systems in health institutions have to be integrated with municipal solid waste systems – and this means bringing together public and private sector actors at the local level.

Tirtha Kumar Sinha, GIZ Support to the Health Sector Strategy project

Nepalgunj wagers on an integrated approach

The authorities in Nepalgunj reached this same conclusion. In discussion with advisors with the S2HSS project, they decided that a Central Treatment Facility could help solve the city’s healthcare waste crisis by providing access to a specialised service which many healthcare institutions need, but do not have – due to technology, resource or space constraints. It would offer a collective solution to a shared challenge – first, by spreading the costs of treatment across the contributing healthcare facilities and second, by closing the ‘disposal gap.’ Because the facility would be built on a parcel of land next to the city’s large, new sanitary landfill, it would be seamlessly integrated into the municipal solid waste system: after treatment, waste that could not be recycled could be transferred to the landfill for disposal (see Figure 1).

Operational Process Flow, Ctf (c) Giz Dipendra Upreti 1
Figure 1. Operational process flow, Nepalgunj Central Treatment Facility
© S2HSS/Dipendra Upreti

After considering different governance and operational models, city officials opted for a public-private partnership – the first of its kind in Nepal for a Central Treatment Facility.  Under this model, the municipality would own and regulate the facility, but a private company would operate it under a 10-year contractual agreement.

A detailed waste audit provides evidence for planning

A seven-day, city-wide healthcare waste audit, undertaken in December 2019 with support from GIZ, provided concrete data around which to plan technically and financially: the overall volume of healthcare waste, the proportion of waste which was infectious, and the potential revenue from recyclable waste under improved segregation and treatment scenarios. It also provided insight into existing waste handling practices among healthcare workers and support staff – important for planning training measures.

Waste Segregation At Ctf (c) Giz Umong Shahi
Waste segregators at the Central Treatment Facility in Nepalgunj
© GIZ / Umong Shahi

For local officials the findings of the waste audit contained one particularly surprising result: more than 70 per cent of the healthcare waste being generated in the Nepalgunj metropolitan area was coming from privately-run healthcare facilities. This insight underscored the clear need to bring private hospitals, clinics and pharmacies into discussions about the management of healthcare waste. While an engineering firm got to work on the technical specifications for the Central Treatment Facility, city officials began holding consultations with representatives of healthcare institutions, including private-run facilities, to introduce the idea of the Central Treatment Facility, the envisioned roles and responsibilities of different stakeholders, and the proposed pricing structure for different categories of waste.

We recognised the importance of engaging with private health facilities and initiated multiple dialogues and sought their input on the design and operation of the Central Treatment Facility. This collaborative approach was crucial for the successful startup and operation of the Central Treatment Facility.

Prasantha Bista, Mayor, Nepalgunj Sub-Metropolitan City

The Central Treatment Facility is up and running – and turning a small profit

The Central Treatment Facility was constructed and equipped in 2022, with the costs split evenly between the city of Nepalgunj and the S2HSS project. The facility has been fully operational since November 2022, and now collects and treats the waste of 190 health facilities across the Nepalgunj metropolitan area.
Membership in the Central Treatment Facility is mandatory for health institutions. The health section of the municipal government plays a key role in ensuring compliance by checking that private health facilities applying to renew their licenses have a valid contract with the Central Treatment Facility. It also monitors compliance with healthcare waste management standards during onsite inspections. ‘This strong monitoring mechanism is central to the success of the model,’ says Suvash Nepal, the technical advisor with the S2HSS project who led the work in Nepalgunj. ‘Local government must be centrally involved, because a private company cannot regulate healthcare facilities by itself.’

Bidhayak Kc, Coordinator Ctf (c) Giz Umong Shahi
Bidhyak KC, Coordinator of the Central Treatment Facility
© GIZ/Umong Shahi

For Bidhyak KC, the coordinator of the Central Treatment Facility, monitoring and compliance are crucial for financial viability, as user fees make up by far the largest share of the facility’s revenue. ‘We are now running a slight profit, but the financial returns are less than projected,’ he explains. He would like to see even stricter monitoring and greater media coverage of cases where health facilities are visibly mismanaging waste.

The main reason that profits are less than expected is that larger health facilities have awoken to the possibility of selling their recyclable waste, rather than channelling it through the Central Treatment Facility. ‘Once health facilities began segregating their waste systematically in order to minimise the fees they would have to pay the Central Treatment Facility to manage their infectious waste, they realised that they could sell it directly to vendors and keep the revenue,’ explains Suvash Nepal of the S2HSS project.

From the point of view of improved waste handling practices and participation in the circular economy, this is a positive development. But for the longer-term financial viability of the Central Treatment Facility, it will be necessary to keep a close eye on the fee structure to ensure that the rates being charged are set at a suitable level to ensure continued smooth operations. The company operating the Central Treatment Facility not only has to pay its staff and running costs, but is also responsible for maintaining the autoclaves and repairing them when technical problems arise.

Paper And Cardboard (c) Giz Umong Shahi
Paper and cardboard ready for sale
© GIZ/Umong Shahi

Conditions for waste workers have become safer, but risks remain 

Collecting, treating and sorting waste is hard, hot work – temperatures in Nepalgunj regularly exceed 30 degrees Celsius – and unfortunately sometimes dangerous, too. The health and environment sections of the Nepalgunj municipal government, with support from the S2HSS project, have trained healthcare workers and support staff at 50 health facilities in proper waste management practices. However, high staff turnover and the large number of facilities means that improving waste segregation within facilities is still a work in progress. ‘Sometimes the syringes are still mixed with other infectious waste in the plastic bags and our staff get needle stick injuries,’ explains Bidhyak KC.

He explains that the employees at the Central Treatment Facility – drivers, waste segregators and autoclave operators – have benefitted from occupational health and safety measures supported by S2HSS via a project implemented by Médecins du Monde France which aims to improve the working conditions of 450 formal and informal waste workers in Nepalgunj. The changes are small, but important: waste workers now wear personal protective equipment, have been vaccinated against Hepatitis B and tetanus, and have subsidised access to health insurance for themselves and their families.

Sarita Sonar (c) Giz Umong Shahi
Sarita Sunar
© GIZ/Umong Shahi

Sarita Sunar has been working as a waste segregator at the Central Treatment Facility since it first opened its doors. ‘The situation is better now,’ she says, referring to the improved segregation practices at health facilities. ‘We do still see needles in general waste sometimes. But I am also experienced now and know how to handle waste safely.’

As part of the project, Médecins du Monde France has supported the local government to develop occupational health and safety guidelines for municipal waste workers. It has also helped informal waste workers to register as an association at the municipal level, and important step towards greater recognition.
According to Mayor Prashanta Bista, ‘These measures not only prioritise the health and safety of waste workers, but are also motivational, encouraging them to perform their duties effectively and with confidence.’

A complete healthcare waste solution which other municipalities can emulate

The Central Treatment Facility in Nepalgunj has closed a critical gap in the healthcare waste management ecosystem by offering a transparent and professional solution for healthcare waste which is compliant with all relevant legislation. Its existence has created the foundation for more meaningful monitoring of healthcare waste practices in Nepalgunj: whereas in the past, the city could cite health facilities for uncontrolled waste management, it did not always do this because it could not offer health facilities a legally compliant solution. Now, with an operational Central Treatment Facility, it can.

Future Ctf Dhangadhi (c) Giz Umong Shahi
A Central Treatment Facility is under construction in Dhangadhi
© GIZ/Umong Shahi

The advisors at the S2HSS project, along with two other GIZ-implemented projects working on governance and local economic development, are supporting the municipal authorities in Dhangadhi, in Sudurpaschim Province, to create a Central Treatment Facility following a similar model. Construction is underway and the facility should be operational in June 2024. 

Other development partners working in the area of solid waste management see the benefits of this approach. Experts at the Asian Development Bank, which financed the municipal landfill in Nepalgunj and is constructing another in Dhangadhi, see central treatment facilities as a logical element of an integrated solid waste management system in which different waste streams are managed in a single location. ‘The Central Treatment Facility helps to minimise the amount of waste which ultimately goes into landfills, and this contributes to the sustainability of our investments,’ explains Naresh Giri, Senior Project Officer in Urban Development. ‘The model which GIZ has supported in Nepalgunj provides a template for how hospital waste could be integrated into future municipal solid waste projects.’   

‘We’re very happy to see how interest has grown and how serious people have become about this topic,’ says Tirtha Kumar Sinha of GIZ. ‘Previously it was seen as the business of hospitals only. It’s important that local government has taken responsibility.’

Karen Birdsall
May 2024

Healthy DEvelopments thanks Sami Pande and Suvash Nepal for their assistance conducting interviews in Nepalgunj.

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