Waste Management & Research
2009: 00: 1–9
Los Angeles, London, New Delhi
http://www.sagepub.com © The Author(s), 2009. Reprints and permissions:
Hospital waste management system – a case study
of a south Indian city
P. Hanumantha Rao
Health Studies Area, Administrative Staff College of India, Bella Vista, Khairatabad, Hyderabad, India
It is more than 5 years since the prescribed deadline, 30 December 2002, for all categories of towns covered by the Biomedical
Waste Management (BMW) Rules 1998 elapsed. Various reports indicate that the implementation of the BMW Rules is not sat-
isfactory even in the large towns and cities in India. Few studies have looked at the ‘macro system’ of the biomedical waste man-
agement in India. In this context the present study describes the role of the important stakeholders who comprise the ‘macro-
system’ namely the pollution control board, common waste management facilities, municipal corporation, state government
(Directorate of Medical Education and Health Systems Development Project), professional agencies such as the India Medical
Association and non-governmental organizations, in the implementation of BMW rules in a capital city of a state in south India.
Brief descriptions of the ‘micro-system’ (i.e. biomedical waste management practices within a hospital) of six hospitals of dif-
ferent types in the study city are also presented.
Keywords: Macro-system, micro-system, pollution control board, common waste management facilities, hospitals and nursing
homes, hospital waste management system, wmr 08–0152
The Ministry of Environment and Forests, Government of
India promulgated ‘Bio-medical Waste (Management and
Handling) Rules’ (BMW) in July 1998. The main objective of
the BMW Rules 1998 was to promote scientific and system-
atic management (segregation, transportation and disposal
of hospital waste which is infectious) among healthcare
establishments in India. Schedule I of the rules prescribes
colour coding and types of container for segregated waste
and options for treatment and mode of disposal. According
to the first amendment to BMW Rules in March 2000, all
hospitals and nursing homes in towns with populations of 3
million and above should comply with the BMW Rules by
June 2000 at the latest. Press reports have highlighted the
unsatisfactory status of the implementation of the BMW
Rules even after the deadline was long past. According to a
Hindustan Times report, published on 18 August 2007 the
amount of incinerated waste in Delhi is about five times
higher than the amount that is autoclaved. This means that
hospitals and pathological laboratories in Delhi are not
being stringent enough about waste segregation. On 8 May
2008, the Times of India, reported that only the Goa Medical
College Hospital treated its own waste and that which comes
from the two district hospitals. One hundred and fifty other
hospitals in Goa either dump their BMW waste within their
premises or dispose of it with the other garbage that goes to
In the next section of the paper a review of the studies on
hospital waste management system in India is presented.
Studies of a single hospital
Awareness. The majority of the 64 dentists working in a
teaching hospital in New Delhi were not aware of proper
hospital waste management (Kishore et al. 2000). After cir-
culation of a hospital waste management manual among the
affected staff of a 600-bed super-specialty tertiary hospital in
Delhi, awareness was found to be around 80% among medi-
cal and professional staff, about 60% among nursing staff
and lower than 20% among sanitary staff, operating theatre
and laboratory staff (Saini et al. 2005). Similar differences
were observed in a teaching hospital in Sri Nagar, Jammu
and Kashmir (Waseem 2007).
Corresponding author: P. Hanumantha Rao, Professor & Chairperson – Health Studies Area, Administrative Staff College of India, Bella Vista, Khai-
ratabad, Hyderabad, 500082, India.
Received 29 October 2008; accepted in revised form 9 February 2009
Figure 2 appears in color online: http://wmr.sagepub.com
Waste Manag Res OnlineFirst, published on May 26, 2009 as doi:10.1177/0734242X09104128
P. Hanumantha Rao
Was t e gener a tion. Daily generation of biomedical waste in the
Outdoor Department of Baripada district hospital, Orissa
was studied by Mohanty & Tiwari (2001). It ranged from 9.9
to 14.0 kg day–1 with an average of 11.6 kg day–1, and 22.4%
of the waste was infectious.
Segregation. Studies in Uttar Pradesh revealed that segrega-
tion of biomedical waste was not properly done and disposal
was unscientific; for example, the burning of waste inside the
hospital campus in a premier government hospital in Luc-
know (Gupta & Boohj 2006) and a government hospital in
Agra (Khajuria & Kumar 2007). A study by Gupta et al.
(2008) of a polyclinic in Lucknow, Uttarpradesh concluded
that there is a need to improve the capability of the staff in
terms of providing state-of-the-art facilities and on-going
training in order to develop a model biomedical waste man-
Good practices. Das et al. (2001) documented how TATA
Main Hospital in Jamshedpur, Jharkhand implemented
proper handling and management of hospital waste materi-
als within the time frame specified by the Government of
India by using a total quality management approach. Post-
test scores on biomedical waste practices were found to be
significantly higher than pre-test scores among the nursing
staff of a teaching hospital after the provision of an informa-
tion booklet on bio-medical waste management (Singh et al.
2002). Patil & Pokhrel (2005) documented how a 500-plus
bed hospital in Belgaum, Karnataka manages and treats bio-
medical solid waste according to the BMW Rules. This hos-
pital also extends the use of its facility to the neighbouring
clinics and hospitals by accepting the waste they produce for
incineration. A World Health Organization (WHO)-aided
pilot project conducted at the Air Force Hospital, Bangalore
between January 1999 and May 2000 developed a compre-
hensive system of hospital waste management using a ‘multi-
option’ approach for disinfection and eco-friendly disposal
(Verma & Srivatsava 2006). Utilizing undergraduate medical
students as monitors to correct deficiencies led to a statisti-
cally significant improvement in waste segregation practices
in all areas in a teaching medical college in Mumbai, Mahar-
ashtra (Nataraj et al. 2008).
Studies of hospitals in a town/city
Mohansundarm (2003) enumerated the number and distribu-
tion of hospitals, both private and government, in Coimabtore,
Tamil Nadu. Whereas the 1000-plus bed Government medi-
cal college hospital in the city did not adopt scientific method
of collection, segregation, transportation and disposal of bio-
medical waste, the 350-bed corporate hospital used an elec-
trically operated incinerator. A study assessing generation
and disposal of biomedical waste in the various medical
establishments in the urban and rural areas of the Chandi-
garh found that although the major hospitals were equipped
with incinerators, proper bio-medical waste management sys-
tems had yet to be implemented (Singh et al. 2004). A study
among doctors, paramedical staff, house surgeons, students
and auxiliary staff in hospitals and nursing homes in Pon-
dicherry in 2004 revealed low levels of awareness of biomed-
ical waste management rules. Only about one-quarter segre-
gated and used the services of the authorized waste collection
agencies (Joseph 2005). An assessment of waste management
practices in three apex government hospitals of Agra, Uttar
Pradesh indicated a lack of knowledge and awareness regard-
ing legislation on bio-medical waste management even among
qualified hospital personnel. None of these hospitals was
equipped with higher technological options such as an incin-
erator, autoclave or microwave and had no facilities to treat
the liquid waste generated inside the hospital (Sharma &
Good practices: A survey undertaken during 2005–2006 among
53 smaller nursing homes and hospitals in Delhi showed that
there was a marked improvement in the segregation prac-
tices of biomedical waste and the majority used the services
of a common waste management facility (CWMF) for collec-
tion, management, and disposal of healthcare wastes (Verma
et al. 2008).
Studies of hospitals in a district
A study of 30 hospitals with more than 30 beds in Sabarkan-
tha district, Gujarat revealed that although most of the doc-
tors knew about the existence of the law relating to biomedi-
cal waste, details were not known to many other personnel.
In the case of auxiliary staff (ward boys, ayabens, sweepers)
knowledge was poor. There was no effective waste segrega-
tion, collection, transportation and disposal system at any
hospital in the district (Pandit et al. 2005). Banerjee & Mani
(2006) studied the effect of training on knowledge, attitude,
segregation practices, availability of equipment such as
needle destroyers, jerry cans for segregating needles, lidded
buckets, etc. in three government, two co-operative and one
private hospital along with seven primary health centres and
three community health centres in the Kannur district of
Hospitals in multiple states
A study of government and private hospitals/nursing homes
and private medical practitioners in urban as well as rural
areas in Andhra Pradesh, Maharashtra and Uttar Pradesh in
2007 observed that access to the services of CWMFs in these
states was low at about 35% and dumping biomedical waste
on the roads outside the hospital is still prevalent (Rao 2008).
The above review indicates that the focus of most of the
Indian studies on hospital waste management systems has
been on the ‘micro-system’, namely what is happening within
a hospital with respect to biomedical waste management.
These studies looked at the knowledge and attitudes of staff,
waste generation and management practices and the use of
CWMFs. Adherence to BMW Rules by hospitals and nursing
homes is also influenced by other stakeholders; namely the
‘macro-system’ consisting of the pollution control board,
Hospital waste management system – a case study of a south Indian city
CWMFs, the municipal corporation, the state government,
professional associations such as the Indian Medical Associ-
ation (IMA) and non-governmental organizations. The present
study aimed at filling this gap. It also looks at the micro-system
of a representative sample of hospitals in the city. The hospi-
tals were selected to represent (a) different types of manage-
ment (government, for-profit and missionary) and (b) differ-
ent sizes (large, medium, small and nursing homes). A capital
city of a state in south India was chosen for the present study.
All the larger cities are expected to comply with the BMW
Rules, 1998 by June 2000. In India, the south Indian cities in
general are better performers in the health area. Selection of
a south Indian city provides an opportunity to determine the
status with respect to the implementation of the BMW
Objectives of the study
The main objective of the study was to understand the role of
different stakeholders – the macro-system – in the implemen-
tation of the BMW Rules 1998 and assess the status of bio-
medical waste management practices – the micro-system –
among a sample of different types of hospitals and nursing
homes in the study city.
Interviews were conducted with the representatives of impor-
tant stakeholders. Published and unpublished documents and
reports were studied. Visits to selected hospitals were made
to get first hand information about the micro-system. Struc-
tured interviews were conducted with relevant officials in
each hospital. The issues touched upon in the interviews
include waste management officer training, use of coloured
bins and plastic covers, display of posters, management of
sharps, services provided by the CWMFs, etc. The purpose
of preparing a case study was explained and oral consent was
obtained. Pseudonyms were used for the hospitals as agreed
with the stakeholders. The data for the study was collected in
December 2005 and March 2006.
The macro-system of the hospital waste management system
of the capital city of a south Indian state is shown in Figure 1.
Pollution Control Board
The state Pollution Control Board (PCB) has conducted a
census of hospitals in the entire state, which generated infor-
mation on the number of hospitals/nursing homes in the
public as well as the private sector, and their bed-wise distri-
bution. In the initial stages (around 2002) it selected three
hospitals in the capital city of the state for developing as
‘model hospitals’ for hospital waste management practices.
A number of government and private hospitals have put up
incinerators for handling hospital waste. Identification of
appropriate technologies, initially for incinerators put up by
individual hospitals and later by the CWMFs was one of the
important responsibilities of the state PCB. Initially, six
CWMFs were considered adequate to cover the entire
state, but later the number was increased to 10. The state
PCB authorized two agencies to set up CWMFs in the study
Fig. 1: Macro-system of hospital waste management system in the capital city of a south Indian state.
P. Hanumantha Rao
The Environmental Training Institute of the state govern-
ment has brought out a booklet entitled Biomedical Waste
Management – A Practical Guide for Administrators and Regula-
tors in 2002. Using this module the PCB organized training pro-
grammes for various private and government hospitals in the
city in collaboration with IMA and a private teaching medical
college in the city. The later prepared a booklet Guidelines for
Management of Liquid Waste Streams in Biomedical Waste.
Common waste management facility
The first CWMF started during 2005–2006 covered the
whole city. After the second CWMF was approved, the
city was subdivided as the south part and north part and
was assigned to the two CWMFs. The Head of the second
CWMF is a member of the technical committee of the PCB.
CWMF1 handles about 7000 beds and CWMF2 handles
about 5000 beds. The treatment plants of both CWMFs are
located in an adjacent district, at a distance of about 50–
60 km from the capital city. In addition to catering for the
hospitals in the capital city, these two CWMFs are also
expected to cater for the hospitals of the district in which
they are located and also one other near-by district. In addi-
tion to collecting, transporting, treating and disposing of hos-
pital waste, both CWMFs supply plastic bins, plastic bags,
sharps containers, etc. The bags are printed with the CWMF
name as receiver of the hospital waste and have provision for
writing the hospital name and code along with space for date,
month, year, date of generation and weight. The biohazard
symbol is also printed on the bags and bins.
Posters have been prepared by both CWMFs in English as
well as the local language. CWMF1 uses pictures and has
three different coloured posters whereas CWMF2 has only
one poster, which uses only text. The later in a bid to simplify
segregation, combined red and blue categories into one –
‘red’ as shown in Figure 2.
Both CWMF plants have all the equipment prescribed by
the BMW Rules, 1998. ‘Present charges of Rs 3 per bed per
day was fixed about 2 years ago, when diesel price was half of
the current price’, lamented a representative of CWMF1.
‘The progress of deliberations with IMA, the PCB and others
to revise the charges upward had been slow’, he added.
Before the CWMFs were set up the municipality was respon-
sible for disposing of segregated waste from hospitals. Now it
is only responsible for collecting general waste from the hos-
pitals, as the CWMFs collect the infectious hospital waste,
which is segregated by the hospitals.
Directorate of Medical Education
The Directorate of Medical Education (DME) is responsible
for waste management in hospitals attached to the government
medical colleges in the state. Two of the teaching medical col-
leges in the city manage their biomedical waste themselves,
with the help of a grant from the World Health Organiza-
Health Systems Development Project
The state is implementing a Health Systems Development
Project (HSDP) with the support of the World Bank. The
HSDP started a pilot in two districts of the state covering 11
secondary-level government healthcare facilities for 1 year in
February 2006. The HSDP is also coordinating activities
between medical college hospitals run by the DME and WHO
in connection with hospital waste management-related activ-
ities. The HSDP has plans for deep burial pits at primary
health centres for disposing of hospital waste.
Hospitals and nursing homes
At the time of the study, only private hospitals/nursing homes
in the study city were using the services of the CWMFs.
According to a representative of one of the CWMFs a sub-
stantial proportion of small nursing homes are yet to join
Fig. 2: Changes in poster prepared by CWMF2.
Hospital waste management system – a case study of a south Indian city
them. According to one of the CWMFs, the hospitals of one
corporate group in the city alone accounts for one-quarter of
the total hospital waste produced in the city because of their
very high use of disposables.
None of the government hospitals were using the services
of a CWMF at the time of the study. Negotiations were taking
place between the government hospitals and the CWMFs, but
they have been taking a long time to arrive at a mutually satis-
factory agreement. Limited or non-use of CWMF services,
especially by government hospitals was also reported from
Pune city in Maharashtra (Rao et al. 2004).
Indian Medical Association
The IMA has two main functions. One is to facilitate training
and workshops to improve awareness among the hospital
staff (especially among the private sector) in collaboration
with the PCB. The other role is to negotiate the fee to be
paid from time to time to the CWMFs and the package of
services to be rendered by them. It is also expected to play
the role of troubleshooter in cases of non-payment of fees by
the member hospitals and non-provision of services by the
According to a representative of CWMF1, the IMA does
not know much about nursing homes but was given the
responsibility by the PCB to negotiate the rate and package
of services with them. He mentioned that the nursing home
board (he is a member of this board’s committee) is the right
agency for this work. In another south Indian state, IMA
started a CWMF called IMAGE; an acronym for IMA Goes
Eco-friendly (The Hindu 2002).
Local non-governmental organizations (NGOs) have been
playing an active role in healthcare waste management in the
study city. A consumer activist group conducted three sur-
veys over a period of 2 years (2000 to 2002) to gain knowl-
edge about the status of biomedical waste management in
the city and also to examine the changes over a period of
time. The survey findings were disseminated in a one-day
workshop and offered recommendations to hospitals, which
approached them. It also brought out four informative posters.
The local NGO along with a national NGO was engaged
by the PCB for the auditing of 18 government-run public
healthcare institutions on their medical waste management
practices. Comprehensive training programmes for core
groups at these healthcare institutions were also organized;
they were co-ordinated by the state Environmental Training
Institute. As a part of these training programmes, a visit was
organized to one city medical college that was implementing
a hospital waste management programme with the help of
The Center for Environment Education (CEE), which has
branches all over the country, prepared a package of infor-
mation, education and communication and training material
(including a CD) on hospital waste management. It provided
a set of this material to the government medical college hos-
pitals that are receiving WHO funding. It is negotiating with
the DME and hospitals under the DME with a view to con-
ducting training on biomedical waste management.
The micro-system of Hospital Waste Management System
(HWMS) in Chennai city is described by means of case stud-
ies of six hospitals of different types, which bring out specific
issues related to management of hospital waste at individual
This is a 600-bed super specialty hospital. The housekeeping
manager is assisted by a team of 10 people exclusively devoted
to waste management. Hospital waste management is a part
of the infection control committee of the hospital. The hos-
pital did not conduct a waste management audit.
The hospital uses white bins for all types of segregated
waste for aesthetic reasons. The white bins are in the process
of being replaced by blue bins, which will be kept in a stain-
less steel chest of drawers, to keep them out of sight. The
hospital has recently purchased a drum-type needle cutter
and syringe destroyer for managing sharps.
All the consumables such as bins, bags, needle cutters, etc.
are procured on their own and not from the CWMF. All the
bags contain the hospital name as the sender and the CWMF
name as receiver. A provision is also made to write specific
details of date, weight, etc. on the bags. For non-infectious
waste, garbage chutes are used. Food waste is stored in big
blue drums and is taken away by a contractor who uses it for
piggeries. They have equipment for composting but it is not
The housekeeping department has prepared ‘a check list’
for different categories of staff to define their responsibilities
with respect to hospital waste management. Training mate-
rial and standard operating procedures were prepared in-
house and training is also carried out in-house.
The general manager of the hospital felt that the PCB was
not clear themselves about certain aspects and needed
updating about the latest methods.
Private teaching hospital
The private teaching hospital is a 1600-plus-bed hospital
attached to a private medical college on the outskirts of the
city. It is one of the three hospitals selected by the PCB as
model hospitals in 2002, before the CWMFs started. As the
hospital is in the process of obtaining accreditation by an
international body, they have all systems in place. The medi-
cal superintendent of the hospital stated that the hospital
staff was trained by an external expert in hospital waste man-
The hospital uses red and blue covers for infectious waste
and green for general waste. When questioned as to why the
yellow colour is not being used for infectious waste as pre-
scribed by the BMW Rules, the medical superintendent
replied that they have a choice of using blue. For manage-
P. Hanumantha Rao
ment of sharps, white transparent plastic containers with red
lids are used. The lids have large holes, which tempts nursing
and other staff to throw needles and syringes from a dis-
tance, leading to spilling of these on floor. As the hospital
normally carries a 3-month stock of bags and other consuma-
bles it does not have any shortage of bags and other items.
The posters displayed near the bins were designed by a third
party for the hospital and were in the local language.
The waste materials from wards, etc. are transferred to
the ground floor with the help of a ‘hoist’ exclusively meant
for transferring hospital waste, a unique feature of HWMS in
their hospital according to the housekeeping manager. This
minimizes the movement of infectious waste within the hos-
pital wards and lobby.
The medical superintendent felt that the system of CWMF
was better than the old system (when they used to operate
their own incinerators) because it has taken away a lot of the
burden on them. ‘As we are paying we can demand service’,
he asserted. The liquid waste is treated by the hospital’s own
sewerage treatment plant.
Government Medical College Hospital
The Government Medical College Hospital (GMCH) is
located at the north end of the city. It has about 1300 beds. A
professor in leprosy and veneral diseases is the nodal officer
responsible for hospital waste management of GMCH. In
2003, the hospital waste was simply dumped along the bound-
ary walls in areas marked as ‘hospital waste.’ It used to
attract rag pickers. GMCH has installed an incinerator but
had to stop using it as under the new guidelines no incinera-
tor is permitted within the city limits.
A waste audit revealed that GMCH generates about
1200 kg day–1, of which about 175–225 kg is the bio-medical
waste. They started segregating the waste generated by the
hospital but the municipality, which collects it, was dumping
the segregated waste together with the general waste, thus
defeating the purpose of segregation. Hence, the staff of the
hospital lost motivation to segregate the hospital waste.
Recently, the WHO has given GMCH the funds required
for 4 months for managing hospital waste systematically. In
this context GMCH is co-ordinating with HSDP. Training the
hospital staff on segregation of hospital waste is organized in-
house. Using WHO assistance, the hospital waste is being
segregated at source and is being kept in bins of different col-
ours, with matching plastic covers placed inside the bins.
Some of the bins have lids and some do not. The bins with lids
are foot operated. A set of eight poster/stickers, three red,
two blue, one green, one yellow and one white were also pre-
pared for use on containers that hold segregated waste. At the
HIV/AIDS counselling centre in the hospital, funded by the
State Aids Control Society, open-top bins of uniform size, are
being used for segregated waste. A poster depicting the use of
the four coloured bins is put on the wall opposite the bins.
Syringes and needles are disinfected in two plastic trays.
The bottom of the inner tray is like a sieve, allowing the hypo
solution in the outer tray coming into contact with the mate-
rial inside the inner tray. The syringes and other material are
autoclaved before disposal.
Segregated waste from 14 wards of the hospital is col-
lected and brought to a central place and municipal staff col-
lect it from there. ‘What they do with the infectious waste is
not known’, the nursing superintendent commented.
By the time the funds provided by WHO have been used
they expect to have received the necessary approval from the
government enabling them to make use of the services of the
CWMFs. The nodal officer thinks that both CWMFs in the
city are in collusion because they quoted the higher price of
Rs. 4, for GMCH, whereas they were charging less to the pri-
vate hospitals. When questioned about this, the CWMFs
increased the price of private sector hospitals. The state gov-
ernment gave them permission for Rs. 2.50 only and the
nodal officer is negotiating with both CWMFs. When asked
about the negotiations with GMCH, a representative of one
of the CWMF mentioned that the delay was due to typical
government functioning. The frequent change of college
deans was another problem faced with regard to the imple-
mentation of a hospital waste management system at GMCH.
Four deans have come and gone in a span of 2 years bringing
discussions to nothing every time a new dean was appointed.
The GMCH has another hospital at the south end of the city.
Owing to the geographical distribution of the two CWMFs in
the city, they both need CWMFs. However the nodal officer
of the GMCH wants one agency to handle both hospitals.
The Missionary Hospital
The Missionary Hospital (TMH) is a multi-disciplinary
super-specialty hospital with about 200 beds. It was one of
the model hospitals identified by the PCB in 2002 for hospi-
tal waste management.
The housekeeping officer is the waste management officer
at TMH, but the nursing superintendent is presently looking
after this function, as the position of housekeeping manager
is vacant. According to the nursing superintendent, because
of the change in the person in charge of HWMS in the hospi-
tal some time back, monitoring has become weak. TMH did
not conduct a waste management audit, hence, the nursing
superintendent hads no idea what is the average waste gener-
ated per bed.
Four members of the staff attended the seminars conducted
by PCB in 2002. About 15 minutes is devoted to this subject
during the induction training of new staff.
Waste is segregated at source and stored in plastic bins of
the same colour, with plastic covers of different colours
inside. The bins are foot-operated and a plastic tape strip (of
different colours) is put on the cover of the bin, to differenti-
ate bins for different categories of hospital waste. They had
problems with the quality of the foot-operated bins supplied
by the CWMF and so the hospital started buying them from
the open market. The nursing superintendent mentioned that
they buy plastic bags and relevant details are printed on them.
However, the sample bags shown were supplied by CWMF.
When it was brought to her attention, the nursing superin-
Hospital waste management system – a case study of a south Indian city
tendent mentioned that probably the system had been
changed recently, as the management might have felt that
buying them from CWMF is cheaper than buying them and
getting them printed independently. Strips of different col-
oured tape are used on a black and white poster, to denote
different categories of hospital waste. The poster is enclosed
in a polythene cover and displayed by the bins. These posters
were prepared when it was a model hospital and CWMF had
not started to supply services.
For operating theatre waste, a dumper system is used. It
takes waste directly to the basement. For waste from other
places a special time is allocated for the lifts and they are not
used for anything else during that time. From the lift the
material is transported using trolleys to the central garbage
area, from where the CWMF collects the infectious waste.
TMH started using the services of CWMF1 initially but
was later changed to CWMF2 because of the sudivision of
the areas between the two CWMFs. Posters were not sup-
plied by either of them. The nursing superintendent men-
tioned that she was not sure what happens after the material
is handed over to the CWMF. Before they stated using the
services of the CWMF, they used to autoclave the syringes
before disposing of hem. They did use the incinerator for
infectious waste but the local people objected and they had
to close it down. She felt that the system of CWMF is better
than each hospital trying to maintain their own system and it
is also more economical.
The Soft Line Hospital
The Soft Line Hospital (SLH) is a 50-bed private hospital.
There is no specific waste management officer.
In the injection room, only red bins and black bins were
available. In the operating theatre a stainless steel bucket
was placed near the operation table, without a plastic cover
inside. Initially it used CWMF1 and later was changed to
CWMF2, based on the demarcation of areas of operation.
Near the recovery room the posters of both CWMFs are dis-
played, but they are not near the place where bins for collect-
ing the waste are kept. This is the only place in the hospital
where such posters are displayed. Only red bins are being
used and there are no yellow bins. Although the chart shows
four colours, the medical superintendent of the hospital
stated that the present CWMF combined red and blue
(which was later confirmed by the CWMF). When asked about
the training, he replied that the matron had been on leave for
the past 20 days and details were not available for the others.
Singapore Health Care
Singapore Health Care (SHC) is a nursing home owned by
an orthopaedician. It has 30 beds and is a polyclinic with a
number of specialists offering their services. The administra-
tor looks after the waste management activities and an ayah
and a boy support her. In the casualty department three bins
are used to collect different types of waste. The covers of the
bins are of different colours, denoting the type of waste.
They were procured from the CWMF. All of them have
white coloured bags. When this was pointed out, the admin-
istrator mentioned that, they exhausted the stock and has
already placed another order.
In the laboratory, syringes, bottles and a number of other
items are put into a big blue drum with a cover. The nurse in
the laboratory explained that they segregate them later.
When questioned on whether she received any training, the
administrator mentioned that she is a recent recruit and did
not attend the training. Out of the 18 nurses working in
the organization very few had attended, a workshop organ-
ized by the CWMF about two and half years ago. A needle
destroyer/syringe cutter is used for sharps management. In
the laboratory a cardboard box is used put the cut syringes
and also cotton etc. used for collecting the waste.
Outside the inpatients wards, large plastic bins are kept
for collecting different types of waste. When questioned, if
they use plastic covers, the administrator said that they had
exhausted supplies of bags and had placed an order. The boy
and the ayah had attended the training course.
When questioned about the change since beginning to use
the CWMF the administrator mentioned that it is good that
segregation is being done and the extra cost they need to pay
is not a problem.
Major findings emerging from the study, their implications
for policy and recommendations to improve adherence to
BMW Rules are discussed here.
The major finding of the study is non-compliance of BMW
Rules, 1998 by almost all government hospitals and a sub-
stantial number of smaller nursing homes in the selected
capital of a south Indian state.
1. The possible reasons for non-compliance by government
hospitals are listed here.
a. Low priority accorded by the state government to
implementation of BMW Rules, 1998. This again could
be due to the absence of adequate appreciation of the
cost-savings and benefits due to scientific management
of biomedical waste.
b. The government hospitals are dependent on the state
government for additional budget to implement a sci-
entific management of biomedical waste programme
and comply with the BMW Rules, 1998 by making use
of the available CMWFs’ services. Economic calcula-
tions very clearly demonstrate that using CWMFs is
more cost-effective than individual hospitals trying to
manage the entire process of biomedical waste man-
agement (Chandra et al. 2006).
2. As the initial focus of the PCB and CWMFs was on bigger
hospitals and securing their contracts, compliance by
smaller hospitals was not addressed.
3. The inability or unwillingness to penalize the erring hospi-
tals by the state PCB is another reason contributing to
P. Hanumantha Rao
non-compliance, not only by the government hospitals but
also by small hospitals/nursing homes. With strong leader-
ship the PCB can bring out a change in this regard.
1. The government hospitals need strong advocacy skills to
secure adequate funding from the state government to
start using the services of CWMFs. The State Health Sys-
tems Development Project can play a vital role in the imple-
mentation of BMW Rules by the government hospitals.
2. State government should realize that non-adherence by
government hospitals could be used by the private sector
hospitals as an excuse to escape implementation of BMW
3. Strong leadership skills are essential in the PCB personnel
who are responsible for implementation of BMW Rules,
1998 by the city hospitals. The PCB also needs to increase
its competence so that monitoring is regular.
4. More importance should to be given the BMW Rules and
there should be methods to punish the erring hospitals.
The PCB should be able and willing to take action against
both government and private hospitals.
5. The PCB also needs to play the role of a facilitator between
the government/government hospitals and the CWMFs
more effectively so that rapid agreement can be reached
between the two parties.
6. Professional bodies such as the IMA should be more
proactive and see that their members follow the BMW
7. NGOs can play an important role not only in conducting
training but also in establishing an effective monitoring
1. Different types of posters are being used by the two
CMFWs in the city. This can cause confusion among
hospital staff, especially among those who changed
their CMFW. The PCB should ensure that different
messages are not communicated by the CMFWs to the
2. The non-use of uniform colour bins may cause confusion
among the lower-level staff, which may result in preventa-
ble mix-ups of segregated waste. Hence, the PCB and
CWMFs should insist that the hospitals and nursing homes
adhere to uniform colour coding for both bins and plastic
covers that they use.
3. The management of sharps and methods of transporta-
tion of biomedical waste within the hospital varies signifi-
cantly from hospital to hospital.
4. The training of the staff is predominantly CWMF driven.
Changes to nursing staff are frequent, leading to new
recruits, but their training in hospital waste management
receives little attention. The internal training system in the
hospitals needs to be strengthened and needs to be con-
ducted at regular intervals.
5. Ensuring that all hospitals have a waste management
officer who monitors the bio-medical waste management
system at regular intervals is also important.
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