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Hospital waste management system - A case study of a south Indian city

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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 satisfactory even in the large towns and cities in India. Few studies have looked at the ;macro system' of the biomedical waste management in India. In this context the present study describes the role of the important stakeholders who comprise the 'macrosystem' 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 different types in the study city are also presented.
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ISSN 0734–242X
Waste Management & Research
2009: 00: 1–9
DOI: 10.1177/0734242X09104128
Los Angeles, London, New Delhi
and Singapore
http://www.sagepub.com © The Author(s), 2009. Reprints and permissions:
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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
Introduction
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
municipality dumps.
In the next section of the paper a review of the studies on
hospital waste management system in India is presented.
Literature review
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.
E-mail: drphrao@asci.org.in
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
2
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-
agement system.
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 &
Chauhan 2008).
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
Kerala.
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
3
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
Rules.
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.
Methods
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
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
city.
Fig. 1: Macro-system of hospital waste management system in the capital city of a south Indian state.
P. Hanumantha Rao
4
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.
Municipal corporation
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.
State government
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-
tion.
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
5
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
CWMF.
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).
Non-governmental organizations
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 WHO.
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
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
institution level.
Corporate hospital
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
in use.
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-
agement.
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
6
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
7
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.
Conclusions
Major findings emerging from the study, their implications
for policy and recommendations to improve adherence to
BMW Rules are discussed here.
Macro-system related
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
8
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.
Implications
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
Rules, 1998.
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
Rules.
7. NGOs can play an important role not only in conducting
training but also in establishing an effective monitoring
system.
Micro-system level
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
hospitals.
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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... WHO also released the second edition of "The Blue Book" in the year 2014, adopting newer practices compared to the first edition published in 1999 [11]. Government of India has also released the first BMW management guidelines around the same timeline (in the year 1998), which was subsequently amended in 2000, 2003 and 2011 [12,13]. The latest BMW management guidelines was published in the year 2016 [14]. ...
... Observation checklists were made after consensus with the subject experts and literature search. The observation was considered as appropriate BMW disposal practice if the wastes were disposed of in the appropriate colour coded bins as per the latest BMW management guidelines (Supplementary Table 2) [13]. Information related to BMW management practices such as presence of separate BMW committee, standard operating procedures, training and management facilities were also obtained in the individual facilities as part of the patient safety study. ...
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Purpose The ongoing COVID-19 crisis has drastically changed the practice of biomedical waste (BMW) generation and management. Studies venturing into the facility level preparedness at various levels of healthcare delivery during pandemic situation is the need of the hour. Hence, we did this study to assess the BMW disposal practices amongst secondary and tertiary health facilities during COVID-19 pandemic in Tamil Nadu. Materials and methods This cross-sectional survey was conducted amongst doctors, nurses and allied healthcare staffs across various departments in 18 public health facilities across six districts of Tamil Nadu. Multivariable logistic regression analysis was done based on the random-intercept model to assess the determinants of BMW disposal practices. The effect size was reported as adjusted odds ratio (aOR) with 95% confidence interval (CI). Results In total, 2593 BMW disposal observations were made. During nearly three-fourth of the observations (73%), the BMW was disposed of appropriately. Nurses (aOR = 1.54; 95%CI: 1.06–2.23) and doctors (aOR = 1.60; 95%CI: 1.05–2.45), healthcare workers in Paediatrics department (aOR = 1.77; 95%CI: 1.13–2.76), healthcare workers in inpatient department (aOR = 2.77; 95%CI: 1.95–3.94) and injection outpatient department (aOR = 2.69; 95%CI: 1.59–4.47) had significantly better odds of having appropriate BMW disposal practices. Conclusion Our study shows that nearly during three-fourth of the observations, healthcare workers performed appropriate BMW disposal practices. However, measures should be taken to achieve 100% compliance by healthcare workers especially the target groups identified in our study by allocating appropriate resources and periodically monitor the BMW disposal practices.
... Ali et al., 2016b;M. Ali et al., 2017a;Cheng et al., 2009;Daxbeck and Amrusch, 2007;Hanumantha Rao, 2009;Ishtiaq et al., 2018;Kadiyala et al., 2008;Koo and Jeong, 2015;Saad, 2013;Taghipour and Mosaferi, 2009b;Tesfahun et al., 2014;Townend and Cheeseman, 2005;Tudor et al., 2008a,b;Tudor et al., 2009;Yang et al., 2009) ...
... Abd El-Salam, 2010; Al-Khatib et al., 2016a,b;Hanumantha Rao, 2009;Insa et al., 2010;Mihai, 2020;Saad, 2013;Tesfahun et al., 2016;Townend et al., 2009) 23Communication among stakeholdersCommunication among stakeholders refers to the cooperation, coordination, and establishment of proper communication between the hospital and individuals or stakeholders such as municipalities, road transport, etc. (G. Ali et al., 2010; Caniato et al., 2016, 2015, 2014; Chauhan and Singh, 2018; Ferreira and Teixeira, 2010; Katsiri and Moschou, 2016; Mannocci et al., 2012; Mihai, 2020) 24 Safety The safety of the waste produced is the result of safety and health considerations in the hospital environment. ...
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Effective hospital waste management (HWM) has become a significant environmental and green healthcare domain issue. In this regard, recent outstanding technological advances in artificial intelligence, the Internet of Things, and blockchain technology have made significant contributions in solving environmental challenges. This study aims to address how blockchain technology would meet the requirements of HWM. Hence, a comprehensive systematic literature review is done to identify and critically appraise blockchain applications in the field of study. These applications are classified into waste generation, waste separation and packaging, waste storage containers, waste collection, temporary waste storage area, waste treatment, off-site and on-site transport of waste, waste disposal, hospital staffs training, waste management regulations, hospital sewage system, energy, and waste recycling and reuse. Moreover, each cluster's current limitations and challenges to enlighten the existing research gaps and clarify future trends are addressed. The findings of this study would be helpful for researchers interested in green healthcare, specifically drug, pharmaceutical, and HWM and related fields.
... It generates a variety of potentially hazardous compounds known as "medical waste [1,2]. Infectious waste such as sharps and communicable diseases such as AIDS, hepatitis B, and hepatitis C account for 10% to 25% of medical waste, whereas non-infectious waste accounts for 75% to 95% [3][4][5]. Owing to the harmful yet contagious nature of medical waste, it is one of the particular issues of municipal solid waste that is of utmost significance [6]. It is not only required by law to manage medical waste effectively and securely but it is also a social responsibility because this process affects the health and safety of numerous employees, patients, and other individuals [7]. ...
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This study aims to encourage innovative participation in the management of medical waste by bedridden patients in the research region of Khon Sawan, Chaiaphum Province, through research and development. The steps were as follows: Phase 1: Study of bedridden patient waste management situations using the amount of waste generated through innovation with relatives, non-relatives, village health volunteers (VHVs), and community leaders. Phase 2: Developing creative waste management engagement requires two steps: (1) analyzing the problem or its cause and generating management alternatives through collaborative brainstorming with a community member and (2) gathering the thoughts and suggestions of a number of agency specialists. The outcome is a novel model of participation in waste management by bedridden patients termed “Four Joins of Power,” which includes (1) participatory activities and enhancing community knowledge and attitudes, and (2) providing information on the management of each type of waste. (3) cooperation in waste management (analytical thinking, planning, execution, etc.) and regulation by mutually agreed-upon rules. (4) joint expansion of the waste management network: Phase 3 is the innovation trial, and Phase 4 is the innovation assessment. The paired t-test was used to compare pre-and post-development knowledge and attitudes, and to conduct qualitative data analysis. In Phase 3, after implementing collaborative innovations, the average knowledge (X¯ = 13.23) and attitudes (X¯ = 4.14) regarding waste management increased considerably (p < 0.05), and in Phase 4, waste management behavior comprising sorting, storage, and disposal was observed. There were progressively substantial gains (X¯ = 4.25 and X¯ = 4.27). Among the most collaborative participants, 93.50% were satisfied. To reduce the amount of waste that must be sorted and collected, it is necessary to emphasize the participation of people and networks from all sectors in the area through joint thinking, planning, and comprehensive analysis, to ensure the sustainability of waste management in the community.
... White category included waste sharps including metals and blue category includes broken or discarded and contaminated glass. [2][3][4][5] Approximately 774 tonnes of biomedical waste is generated in India as per the annual report on biomedical waste management for the year 2020. With the advent of Corona virus disease 2019 (COVID-19) pandemic, use of Personal protective equipment (PPE) including masks and other biomedical waste generation from treatment aspects and vaccination stupendously increased adding to the already over burdened aspect of biomedical waste management especially in India due to the huge population and vast health care sector providing services against COVID-19. ...
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Introduction: Management of biomedical waste (BMW) has become a very serious health problem in developing countries. Every day, in the health care hospitals and in various facilities large amount of hazardous and potentially infectious wastes is generated. Inappropriate waste management and chaotic disposal of biomedical waste that occur in hospital cause various types of health effect on society. Objectives: To estimate the quantity of BMW generated by various departments of a hospital and to determine their compliance with BMW norms. Materials and methods: With regards to quantum of BMW generated a retrospective study was conducted for a period of 3 years from January 2019 to December 2021, and with regards to compliance of bio-medical waste management an observational study was conducted for a period of 3 months from July 2021 to September 2021. Selected areas of hospital were included in the study. Area wise waste collected, segregated and disposed off was observed and recorded on checklist designed on existing BMW management rules 2016. Results: The quantum of BMW generated during 3 years is in 20-19-106563 kg/year, 2020-98353 kg/year, and 2021-75951 kg/year. Yellow waste constituted the maximum of all during all 3 years(52%). Overall compliance with BMW rules 2016 was 85%. Conclusions: The quantum of biomedical waste generated is high as per permitted norms by local regulatory body. All the concerned staff should be frequently trained in this regard to avoid excess wastage, in order to bring down biomedical waste generated.
... Various reports indicate that the implementation of the BMW Rules is not satisfactory even in the large towns and cities in India [9]. Looking at the results of the survey from Irbid city of Jordan, it can be observed that the healthcare facilities in the city have less appropriate practices when it comes to the handling, storage, and disposal of wastes generated in comparison to the developed world. ...
... The Ministry of Environment and Forest notified the "Bio-medical Waste Management and Handling Rules" in July 1998 (later amended in 2003,2011, and now in 2016) under the Environment Protection Act, 1986 [5]. Even after a decade of its implementation in India, hospitals have not achieved the desired standards for BMWM practices [6][7]. ...
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Background Biomedical waste management has recently emerged as an issue of major concern for every health facility and healthcare provider due to human and environmental hazards. As per government guidelines, every health facility, either large medical institutes or small clinics, should ensure appropriate biomedical waste management at their facilities level. Objective To assess biomedical waste management in various health care facilities of Etawah district. Methodology It was a facility-based cross-sectional assessment that included government and private health facilities. The selection of facilities was done based on a simple random sampling method. All the people in charge of concerned health care facilities were interviewed to know the current biomedical waste management situation concerning health facilities and the problems they face in biomedical waste management. Health care professionals' knowledge was also assessed. Results A total of 56 health care facilities (HCFs) from both government and private sectors were selected. Biomedical waste guidelines are mainly available at tertiary care centers (93%) and secondary care centers (51.5%). Awareness among doctors related to hazards and prevention of hazards (<0.001), knowledge of unused sharps (0.048), contact with a blood-related product (0.003), hazardous waste (<0.001), and need for training (<0.001) are statistically significant with respect to nurses. Conclusions Government of India guidelines on biomedical waste management (BMW) are in place, but the use of guidelines currently is not up to the mark or at a satisfactory level. Spreading awareness of the BMW guidelines and their strict implementation is the need of the hour.
... In a study conducted in 1300bedded Government College and Hospital and 50-bedded private hospital of a south Indian city, it was found that waste segregation was not proper. 10 However, the number of areas where it was not proper has not been mentioned in the study. Another study conducted in Jordan also, it was found that waste segregation practices were non-existent in spite of existence of a regulatory framework. ...
... Contrasting results have been reported in the previous studies with some authors reporting good and some bad segregation practices. 15,16 Previous studies have reported a better knowledge and practices among nurses and lab technicians. 17,18 Waste segregation practices were found to be good in a study conducted by Patil GV et al in a 574-bed tertiary care Medical Institute in Belgaum, Karnataka, India. ...
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Introduction: Bio-Medical Waste (BMW) consists of solids, liquids, sharps and laboratory waste that are potentially infectious and dangerous. In India, lack of knowledge and practice in relation to availability of resources and processes in place has been reported in many studies. Hence, the present study has been carried out with an objective of assessing awareness and practices of healthcare providers regarding BMW. Materials and methods: This cross-sectional study was conducted in tertiary care hospital with 300 beds in Karnataka over a period of one month using preformed, pre-structured proforma. Results: Almost all health personnel were aware about BMW guidelines; adequate segregation of BMW was noticed in only 4 sites (11.8%). Conclusion: The awareness about BMW management among healthcare providers in our study was found to be adequate but with low segregation practices. The staffs are well aware to manage the spills and will use if all the sites are provided with spill kits. Key words: Biomedical waste, color coding, India, tertiary hospital, waste segregation
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Not much attention has been paid to the management of biomedical waste.(BMW) in recent years, in thedental colleges and hospitals With increasing population, the number of dental colleges and hospitalshas also increased. The medical waste generated by these hospitals are disposed of together withmunicipal and industrial solid wastes. There is no effective waste segregation, collection, transportation &disposal system. There is lack of segregation between infectious and non-infectious biomedical waste as well as failure to implement the prescribed rules for proper management of hospital waste and also inadequate training of personnel, insufficient protective equipment, and lack of knowledge regarding use of such equipment There is immediate and urgent need to train and educate all dental and paramedical staff to adopt effective waste management practices. It is high time, we realize the importance of hospital waste management and the need of sensitizing the top-level managers orienting them with various type of waste, their generation, segregation, collection, transportation &final disposal, also, it is important that all the hospital waste is managed in a proper scientific fashion. The present paper describes various safety precautions to be taken for the hospital employee and measures to be adopted to minimise health risks due to hospital waste, the implication of hospital waste on employee, the public & the environment. To enhance co-ordination managers must comprehensively describe the total system and specify the roles of key functions and individuals. The generation, handling and disposal of hospital waste involve every department in the hospital. Formation of Hospital Waste Management Committee! A team for effective waste disposal is needed to be implemented. Key-words: Biomedical waste disposal(BMW), Infectious and Non-infectious waste, Segregation
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Health care wastes include anatomical, pathological and clinical infectious/ hazardous organic and inorganic waste. The waste is disposed off in unscientific manner. The study has been conducted in the government health care establishment only to reveal the per day waste generation on each patient, present mode of waste management within the units bed, our suggestions which have helped the units to improve their waste management practices, in the city of Agra. Keywords: Waste management, Health scare waste, Management, Government hospitaldoi:10.3126/on.v5i1.794Our Nature (2007)5:25-30
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The treatment cost of biomedical waste (BMW) is a limiting factor for all the hospitals due to resource crunch. Therefore to minimize the BMW and to contain the costs are the only solutions. As recycling is not permitted under the Biomedical Waste Management (BMW) Rules, cost-benefit analysis is not possible also. BMW management on outsourced system, but under the supervision of hospital staff, is still the best option. The present model has been prepared by taking the reference of U.P. Health System Development Project, Lucknow, India, to achieve the cost-benefit/ containment while treating the BMW. The cost of inhouse treatment facility was calculated and was compared with cost of treatment if it was outsourced. The cost of inhouse treatment comes to Rs. 19.50 per bed/day whereas in case of outsourcing it is Rs. 17.50 per bed/day for a hospital ranging from 250-600 beds (with 80% bed-occupancy rate). Thus Rs. 157500 can be saved per year (Rs. 1575000.00 in 10 years) on the basis of Rs. 2.00 per bed/day saving. This model is under consideration for implementation at the Sanjay Gandhi Post Graduate Institute of Medical Sciences, Lucknow, India.
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With the aim of assessing the awareness about biomedical waste and its disposal practices at the SMHS Hospital of Kashmir, this study included 150 subjects including medical and paramedical staff. The awareness was significantly satisfactory among doctors and nurses whereas there is lack of knowledge and awareness among laboratory personnel and other members of the paramedical staff,which needs effective teaching and training to prevent adverse outcome on human health.
Article
Background: The Ministry of Environment & Forests notified the Biomedical Waste (management & handling) Rules, 1998" (BMW Mgt) in July 1998. In accordance with the rules, every hospital generating BMW needs to set up requisite BMW treatment facilities on site or ensure requisite treatment of waste at common treatment facility. No untreated BMW shall be kept stored beyond a period of 48 hours. The cost of construction, operation and maintenance of system for managing BMW represents a significant part of overall budget of a hospital if the BMW rules have to be implemented in their true spirit. Two types of costs are required to be incurred by hospitals for BMW Mgt, internal and external. Internal cost is the cost for segregation, mutilation, disinfection, internal storage and transportation including hidden cost of protective equipment. External costs are off site transportation, treatment and final disposal. Methods: A study of hospitals was carried out from various sectors like Govt, Private, Charitable institutions etc. to assess the infrastructural requirement for BMW Mgt. Cost was worked out for a hospital where all the infrastructure as per each and every requirement of BMW rules had been implemented and then it was compared with other hospitals where hospitals have made compromises on each stage of BMW Mgt. Results: Capital cost incurred by benchmarked hospital of 1047 beds was Rs.3 lakh 59 thousand excluding cost of incinerator and hospital is incurring Rs. 656/- per day as recurring expenditure. Pune city has common regional facility for BMW final disposal. Facility is charging Rs.20 per kg of infectious waste. As on Dec 2001 there were 400 institutions including nursing homes, labs and blood banks which were registered. Conclusion: After analyzing the results of study it was felt that there is an urgent need to standardize the infrastructural requirement so that hospitals following BMW rules strictly do not suffer additional costs.
Article
The study was conducted in Andhra Pradesh, Maharashtra and Uttar Pradesh in India. Hospitals/nursing homes and private medical practitioners in urban as well as rural areas and those from the private as well as the government sector were covered. Information on (a) awareness of bio-medical waste management rules, (b) training undertaken and (c) practices with respect to segregation, use of colour coding, sharps management, access to common waste management facilities and disposal was collected. Awareness of Bio-medical Waste Management Rules was better among hospital staff in comparison with private medical practitioners and awareness was marginally higher among those in urban areas in comparison with those in rural areas. Training gained momentum only after the dead-line for compliance was over. Segregation and use of colour codes revealed gaps, which need correction. About 70% of the healthcare facilities used a needle cutter/destroyer for sharps management. Access to Common Waste Management facilities was low at about 35%. Dumping biomedical waste on the roads outside the hospital is still prevalent and access to Common Waste facilities is still limited. Surveillance, monitoring and penal machinery was found to be deficient and these require strengthening to improve compliance with the Bio-medical Waste Management Rules and to safeguard the health of employees, patients and communities.