1

Second Uttar Pradesh Health Systems Strengthening Project

Environment Management Actions Plan

I.

Introduction on biomedical waste management

In recent years, there has been a growing awareness of the need for safe management of hospital
waste for effective health service delivery. Nosocomial or Hospital-Associated Infections (HAI)
are estimated to affect approximately 5% of hospitalized patients. Hospitals are reservoirs for
strains of bacteria that are multi drug resistant strains. There are however effective interventions
for reducing the occurrence of HAIs. Studies have demonstrated that these infections are a
reason of prolonged hospitalization and therefore increased costs adding to the patients bill
burden in a number of cases.
As per the website of WHO the healthcare activities lead to the production of waste that can
have adverse health effects. Although most of this waste is not more dangerous than regular
household waste, some types of healthcare waste represent a higher risk to health: these include
infectious waste (15% to 25% of total healthcare waste) among which are sharps waste (1%),
body part waste (1%), chemical or pharmaceutical waste (3%), and radioactive and cytotoxic
waste or broken thermometers (less than 1%).
Sharps waste, although produced in small quantities, is highly infectious. Poorly managed, they
expose healthcare workers, waste handlers and the community to infections. Contaminated
needles and syringes represent a particular threat and may be scavenged from waste areas and
dump sites and be reused. WHO has estimated that, in 2000, injections with contaminated
syringes caused:

21 million hepatitis B virus (HBV) infections (32% of all new infections);

two million hepatitis C virus (HCV) infections (40% of all new infections);
260 000 HIV infections (5% of all new infections).

Epidemiological studies indicate that a person who experiences one needle-stick injury from a
needle used on an infected source patient has risks of 30%, 1.8%, and 0.3% respectively to
become infected with HBV, HCV and HIV. In 2002, the results of a WHO assessment conducted
in 22 developing countries showed that the proportion of healthcare facilities that do not use
proper waste disposal methods ranges from 18% to 64%.
Patients with hospital born infections have to pay higher bills for laboratory investigations and
antibiotics and end up having a higher financial burden than those not affected. Cost effective
interventions such as regular hand washing, skin disinfections, use of gloves, fumigation of
wards and OTs and an active microbiological surveillance system have proven to be effective in
reducing these infections. Due to cost and time constraints these interventions are often
overlooked. In addition hospital waste is highly infectious and toxic and their proper disposal is
essential for prevention of cross infection to all. In India, the rate of generation of hospital waste

is estimated to be 1.59 to 2.2 kg/day/bed and out of which 10-15% is found to be bio-medical
waste.
Inadequate waste management can cause environmental pollution, growth and multiplication of
vectors like insects, rodents and worms and may lead to the transmission of diseases like
typhoid, cholera, hepatitis and AIDS through injuries from syringes and needles contaminated
with human. Some indicators like progressive increase in hospital infection rate, increasing
resistance to wide variety of antibiotics are the pointers to the way in which poor hospital waste
management can contribute to the ill health plaguing the health care institutions. In addition to
health risks associated with the poor management of bio-medical waste, due consideration must
be given to the impact on environment, especially to the risks of pollution of water, air and soil.
Hence, collection and disposal of waste in the proper manner is of great importance as it can
decrease directly and indirectly health risk to people, and damage to flora, fauna and the
environment (Centres for Disease Control and Prevention, 2001).
The need of proper hospital waste management system and prevention of hospital born infection
are important for safeguarding the environment and public health and is an essential component
of quality assurance. During the last couple of decades, the public has also become increasingly
aware of one of the major consequences of development, that is, the quantity and diversity of
hazardous wastes that is generated. Recognizing the importance of this issue, the Government of
India notified the Bio-medical waste (Management &handling) Rules, 1998, which were further
amended in 2002 and 2003; and are in process of being amended again. Infection prevention
practices and hospital waste management systems need to be in place for assured quality of care.
It has been accorded top priority by Government of U.P.

II.

Implementation of Biomedical waste management in UP

Before commencement of the Health Systems Development Project in UP, there was no
effective, hygienic and systematic approach for biomedical waste management in the State. The
system prevailing was at best, collection of all categories of wastes including plastic and body
parts in cardboard boxes or metallic bins and dumping them into a pit where the waste was
periodically burnt. The disposable syringes and catheters were reused after inadequate
sterilization. Infectious pathological liquid waste was drained into sewerage without
decontamination. There was no training systems & module developed in the state for proper
disposal of the bio-medical waste. No training programs were being conducted for this activity.
The UP Health Systems Development Project was implemented in the state from26th July 2000
to 31st December 2008. However the Hospital Waste Management Activities were taken up from
2004 & implementation work started from August 2006 to till project period i.e. December 2008.
The purpose of implementing HCWM activity was to dispose of the Bio- Medical waste through
scientific systems as laid down in the Bio-medical Waste (Management and Handling) Rules
1998 & norms of the Pollution Control Board.
To achieve the above goal, the UPHSDP undertook the following key steps:

After mapping of the state, 10 zones were identified to have centralized treatment
facilities (CTFs). These were Meerut, Lucknow, Bareilly, Agra, Jhansi, Kanpur, Gonda/
Faizabad, Allahabad, Gorakhpur & Varanasi.
Implementation modality was through a turnkey approach under which the private service
provider was contracted to procure consumables, develop training modules and imparted
training to the doctors & paramedical.
Nine of the ten planned CTFs were made functional, addressing the needs of 998 hospitals in
the state. The following table details the facilities covered and the amount of waste
generate/treated per day in each CTF:
S.N. Name of CTF at
divisional level

1 Gonda/Faizabad
2 Jhansi
3 Meerut&
Aligargh
4 Lucknow
5 Varanasi
6 Allahabad
7 Gorakhpur
8 Kanpur
9 Barelly
10 Total

No of
Facilities
covered/
Contracted

No of
Sanction
average
bed
Occupied
Bed per
Day
75
1957
2110
40
948
987
210
3934
6297
134
148
70
105
111
105
998

3152
2300
1495
2088
2490
2099
20463

Average BioMedical Waste

generated/
Treated per day (
in Kg)
217
161
905

4474
4603
2706
3172
2989
3095
30433

709
276
299
376
448
241
3632

Additionally, the following activities were undertaken over the project period:

Trained the Doctors, Surgeons and all paramedical staff of the hospitals on the
importance and necessity of biomedical Waste Management, hazards of untreated
infectious waste and segregation practices as per the regulatory guidelines of the
Government of India.
Provided awareness materials including hoardings, wall writing stickers etc as per the
direction given by the project management unit and directorate of medical and health
time to time and as per the norms of the CPCB.
Supplied the equipments and consumables (including colour-coded bins, bags black
container and non perforating polycarbonate jars, needle cutters, trolleys, wheel barrows)
and personal protective equipments (such as gloves, masks, goggles boots non metal
helmets and aprons), weighing machines, chemical disinfectants, daily waste collection
records and biomedical waste manifest forms.
Construction of appropriate storage facilities in hospitals from where the CTFs could
collect the waste
Coordination with the UP Pollution Control Board was strengthened to facilitate
monitoring and supervision at health care facility and CTFs
Maintained daily waste collection record at CTF level

III.

Monitoring of segregation and collection practices within hospitals using medical

students and consultants.
Monitoring and verification of supplied consumables and other equipments
Verification of incinerated, shredded and autoclaved hospital waste collected from
different hospital as per CPCB norms by the Technologist / Assistant Engineers of the
concerned region where the CTF has been installed.
Verification of treated bio-medical waste by regional pollution control board officer from
time to time.
Meeting with hospital in-charges at state level to get feedback on implementation of
biomedical waste management practices.
Current Situation Analysis

While the Health Systems Development Project made a great deal of progress in improving the
condition of biomedical waste management in UP, there is still substantial effort needed to
improve the conditions in hospitals and ensure full compliance with the regulatory
requirements.
Of the total 3125 health care facilities in the state, only 998 continue to be contracted with CTFs
for waste treatment and disposal. This means that there are still large volumes of infectious
biomedical waste that is not treated and disposed as per scientific and legal requirements. The
amount of waste generated by the various facilities is given below:
Type & Amount of Waste by Type of Health facility
S.
No

Facility with No of
bed strength
faciliti
es
PHC/Block
806
PHC 4 bed
4 beds

Total
Sanctione
d bed
3224

CHC
30 beds

515

15450

Outpatient and inpatient care;

some specialty care;
some minor and
major surgery;
some
diagnostic
services

Combined
153
Hospital
100
beds
District
Hospital,
District
Hospital female
&other Super

13487

All of the above and

more specialty care.

Type of service

Category
waste

of Volume of
waste *

Out-patient services;
curative
and
preventive care;
inpatient services for
delivery

General waste;
infectious waste;
pharmaceutical
waste;
and
pathological
waste
General waste;
infectious
waste;
,
pharmaceutical
waste;
pathological
waste;
chemical waste
All of the above

5 Kgs per
day

36 Kgs per
day

120 KGs
per day

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specialty
hospitals
Total

3125

37521

11340 kg
per day.
Note: out of the above Medical colleges, nursing homes and other private are also generating
waste which is not included in the above data.

*Calculated for an attainable bed occupied rate of 80%

** On an average, hospitals produce 1.5 Kg of waste per bed day of which only 15%, i.e., 0.22 Kg/ bed day is infectious and / or
hazardous and needs pre-disposal treatment. Accordingly, the total waste, which needs to be segregated and treated in BPHC,
30,100, 200 and more than 200 bedded hospitals, will be 1 Kg, 7 Kg, 23 Kg, 46 Kg, and 70 Kg respectively.

Additionally the state lacks a dedicated inter-sectoral institutional mechanism for

implementation, coordination, monitoring and supervision of the biomedical waste management
and infection control activity. There is need for improving biomedical waste management
practices and improving existing systems for regular supervision within healthcare facilities. An
assessment needs to be undertaken with regard to the number of CTFs in the state, their
performance and contractual arrangement, including the current turnkey approach and a mapping
of whether there is need for establishing more CTFs in non-addressed areas.
The above concerns and other related issues are developed further and defined in the
Environment Management Plan, to be implemented in the second project

Environmental Management Plan

Second Uttar Pradesh Health Systems Strengthening Project:
1.

Creation of Environmental Management Cell in the State:

An institutional structure for management and coordination of biomedical waste management

and infection control, entitled Environment Management Cell (EMC), will be established within
the Directorate of Medical and Health (M&H) by issuance of a Government Order from
Principal Secretary/ Secretary (M&H).
The EMC will coordinate the environment related activities of all departmental health facilities
of Medical, Health & Family Welfare across the state. For effective functioning and
sustainability, funding of the EMC will be from the state budget resources, including NRHM.
The EMC will develop and implement a road map for proper implementation of biomedical
waste management and infection control activities as well as other environment related issues as
per the regulations of Government of India and guidelines of Central Pollution Control Board. It
will be responsible for issuance of instructions and guidelines related to environment
management issues, including mercury phase-out, biomedical waste management, water and
wastewater management, infection control and sanitation practices, promotion of energy efficient
initiatives etc. The EMC will also manage, coordinate and provide focused awareness and
training for relevant state agencies and health care facilities and laboratories and general
community. The EMC will be responsible for the instituting of effective and efficient systems for
implementation, procurement, capacity building and monitoring and reporting on environmental
management issues related to health care facilities. This will also include recommending the
appropriate institutional structure to be established or strengthened at different levels of state
administrations and of health care service delivery. The EMC will also review environmental
issues related to construction and up-gradation of health care facilities, including issues related to
site selection, design, materials used and construction waste management.
The environmental management tasks of the EMC require the close involvement of other
sectoral agencies and departments in the state. The EMC will be responsible for interaction and
coordination with the key departments and relevant agencies which are responsible for the
provision of utilities, including water and sanitation services and municipal solid waste
management in health care facilities across the state. These will include Urban local Bodies,
Nagar Nigams, Nagar Palikas, PRIs, Municipalities, water and sanitation authorities etc. The
EMC will also institute and strengthen operational coordination mechanism with the UP State
Pollution Control Board, for all aspects of biomedical waste management. To address the
requirements and compliance process of private and non-departmental health care facilities, it is
recommended that the EMC establish links with the Indian Medical association, Medical
Education Department, Nursing Home association, UP Pollution Control Board, Chief Medical
Officers, Urban local Bodies, Nagar Nigams, Nagar Palikas etc as well as the CTFs service
provider. The Structure of EMC at Directorate & Project Support Unit level will be as under:

a) Directorate level:
S.N. Description of Official
1
Director General or his nominee
2
Additional Director (Elect)
3
Joint Director
4
Hospital & Healthcare management Expert
5
Biomedical Waste Management Consultant
6
Assistant Engineer
7
Technologist /Assistant Engineer at each CTF unit
8
Support Staff
9
A representative of UP Pollution Control Board &
IMA & other departments related to this activity
b) Project Support Unit level:
S.N.
Description of Official
1
Joint Director/ Coordinator
2
Assistant Engineer/ Junior Engineer
3
Support Staff

No of Post
1
1
1
1
1
2
18
4
1 each

No of Post
1
1
2

Remarks
Additional Charge
Additional Charge
Full time
Full time
Full time
Full time
Additional Charge
Full time
Special Invitee

Remarks
Full Time
Full time
Full Time

It is expected that the EMC will comprise of officials from the Department of M&H, and
deputed officials from other relevant departments (listed above) or on contractual basis. The
EMC will report to the Secretary and the Project Director (during project lifetime).
Given the challenging task of setting up this inter-sectoral institutional mechanism, the task of
establishment of the EMC will be undertaken over the first two years of the project lifetime.
2.

Undertaking Needs Assessment for Improved Biomedical waste management &

Mapping of CTFs:

In year 1, a study will be undertaken to assess the current situation of biomedical waste
management, the existing gaps and shortcomings of the present system, mapping of existing
CTFs and their coverage, evaluation of CTF performance and recommendations for
improvement of the existing system. The findings and recommendations of this study will be
incorporated reviewing the study report the following actions will be undertaken:
3.

Development of Final Roadmap for Implementation of Environment Management

in health care sector

The Roadmap for Environment Management, including biomedical waste management and
infection control activities (as defined in point 1 above) will be finalized and ready for
implementation by start of Year 3. The responsible authority for its implementation will be the
Environment Management Cell. A consultation workshop on the draft Roadmap will be held
before it is finalized.

Once finalized and approved by Government of UP and the World Bank, the Roadmap will be
appended to this Environment Management Plan and re-disclosed
4.

Mid Term Evaluation

A mid-year evaluation at end of year 4 will be undertaken to assess effectiveness of the EMC
and the appropriateness of the Roadmap. Findings and recommendations will be built into a
revised Roadmap for subsequent roll-out across the state.
Activity Schedule
S.N
Activity
1 Identification of role, responsibility and scope of
Environmental Management Cell. Identification
of inter-sectoral coordination measures and
implementation and monitoring frameworks and
development of Capacity Building Plan
2 Needs Assessment & Mapping of CTFs
3 Establishment of Environmental Management
Cell through Government. Order; Finalization of
Roadmap for Implementation
4 Consultation workshop on the draft Roadmap and
its Finalization and Disclosure
5 Implementation of Roadmap on Biomedical waste
management and infection control
6 Midterm Evaluation by third party.
7 Road map for second Phase

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Proposed Budget: Rs 154.00 million (One Fifty Four Million rupees) only.

Note:
Any query/comments on the plan is invited within 30 days either in writing or through email on the following address:The Project Director,
Uttar Pradesh Health Systems Development Project (UPHSDP)
TRAINING BLOCK-2, SIHFW CAMPUS, SECTOR-C,
INDIRA NAGAR, LUCKNOW - 226 016 (UP), INDIA,
Email: pd_uphsdp@sify.com
Telephone No and Fax No.: +91-522-2310397

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