Article as seen in the BMZ website

Transforming Health Care Waste in Nepal
High-level support for national workshop signals growing commitment to tackle environmental health risks

Proper treatment and disposal of healthcare waste is a major challenge in Nepal. At a groundbreaking meeting convened by the Ministry of Health and Population, with support from Germany, key players took stock of the situation and committed to putting the country on a safer, healthier course.

From 10-12 December 2019 hundreds of people from across Nepal made their way to Kathmandu, eager to talk about waste and what to do about it. The occasion was the first-ever national workshop on the topic of healthcare waste management and water, sanitation and hygiene (WASH) in health facilities, convened under the motto ‘No Time to Waste: Together for a Healthy Nepal!’  The improper management of healthcare waste is an urgent public health and environmental challenge in Nepal. According to a 2019 global baseline study carried out by the World Health Organization (WHO) and UNICEF, only 1% of health facilities in the country meet basic standards for the segregation, treatment and disposal of hazardous waste.

Workshop generates a groundswell of interest

The workshop was the brainchild of the newly-established Environmental Health and Healthcare Waste Management Section of the Management Division of the Ministry of Health and Population, which invited key players from across the country to come together to learn from one another’s experiences and to debate what needs to be done to minimise the adverse effects of hazardous healthcare waste on public and planetary health. The workshop focused primarily on the safe management of existing healthcare waste, with the understanding that reductions in the the overall volume of waste being generated will also be necessary to put Nepal on a more sustainable path. The project ‘Support to the Health Sector Programme’ (S2HSP), implemented by the Deutsche Gesellschaft für Internationale Zusammenarbeit (GIZ) on behalf of Germany’s Federal Ministry for Economic Cooperation and Development (BMZ), provided significant assistance in the design and organisation of the workshop. Other partners supporting the workshop’s technical working group include the WHO, KfW Entwicklungsbank, the United Nations Development Programme (UNDP), UNICEF, WaterAid and SNV Netherlands Development.

The organisers were overwhelmed by the positive response: nearly 400 representatives of local municipalities, provincial governments, federal ministries, healthcare facilities, private companies, academic institutions, professional bodies, associations of informal waste workers, and civil society organisations attended in person, while another 10,000 people joined by livestream. In addition to dozens of experts from across Nepal, speakers from 10 countries shared international experiences in healthcare waste management and WASH in health facilities.

In a sign of the growing importance attached to the topic, Nepal’s newly-appointed Minister of Health and Population, Mr Bhanu Bhakta Dhakal, presided over the inaugural session. He was joined on the dais by Germany’s Ambassador to Nepal, Mr Roland Schäfer, and the WHO Representative in Nepal, Dr Jos Vandelaer. The State Minister for Health, Mr Navraj Rawat; the Secretary of the Ministry of Health and Population, Mr Khagraj Baral; and the Director General of the Department of Health Services, Dr Roshan Pokharel, were all present at the closing session.

‘The workshop was a clear success in terms of bringing together very different types of stakeholders,’ says Mr Tirtha Kumar Sinha, the senior technical advisor responsible for S2HSP’s work on health governance. ‘Healthcare waste management is not only a problem for the health sector. It requires an integrated solution, and we believe this message was heard loud and clear, including by decision-makers.’

The human and environmental costs of unmanaged waste
The enormous interest in the workshop is a reflection of the scale of the challenge in Nepal, where environmental health concerns are mounting rapidly. Nepal ranked 176th out of 180 countries on the 2018 Environmental Performance Index, with particularly low scores in areas of air quality, heavy metal exposure, and water and sanitation. Poor waste management practices in the health sector are part of the problem: these include the open burning of waste; the dumping of untreated infectious waste, expired medications, electronic waste, and diagnostic supplies in landfills; and the disposal of liquid waste from laboratories into pipes which drain directly into rivers or soil. Within health institutions themselves, improper waste management and inadequate WASH services increase the likelihood that patients develop infections at the very facilities where they have sought care and treatment. ‘Lives that are being lost to strokes, heart disease and other non-communicable diseases could be saved if we removed environmental risks,’ said Mr Bhogendra Raj Dotel, the Director of the Management Division at the Ministry of Health and Population, during his opening remarks. ‘If we don’t attend to these concerns, we will not meet our health objectives under the Sustainable Development Goals.’

‘I’ve been waiting for a meeting like this’

With the transition to a federal system of government in 2015, Nepal’s 753 municipalities have assumed responsibility for both waste management and the provision of basic health services, among others. As a result, they are under growing pressure to unravel a thorny conundrum: What can be done to safely integrate healthcare waste into municipal solid waste systems in a country where the majority of health facilities do not have basic systems in place for segregating and treating hazardous waste? Who should be responsible for doing what, and what models exist to guide the way?

Seeking answers to these questions, participants engaged enthusiastically in panel discussions and more than 20 working group sessions, filled the main hall to capacity during plenary sessions, peppered government officials with questions and demands, and visited the stands of more than two dozen vendors offering a variety of waste solutions at the workshop marketplace. They energetically debated gaps in the policy and regulatory framework, sought clarity over the respective roles and responsibilities of the three tiers of government under the federal system, and called for more effective monitoring and enforcement of waste management standards.

The sense of excitement was palpable: ‘I’ve been waiting for a long time for a meeting like this,’ said the mayor of the Birgunj Metropolitan City at the end of his comments on the opening day. During the question and answer periods at the end of the panel discussions, the moderator could barely channel the number of people in the hall who wished to have their voices heard. It quickly became clear that the topic of waste matters to people and that, until now, there had been few outlets to discuss the political and technical aspects of the problem.

‘Waste champions’ inspire with practical solutions

One of the main goals of the gathering was to shine a spotlight on promising healthcare waste management models already being implemented in various parts of Nepal and to encourage others to adapt them in their communities and institutions. Mr Mahesh Nakarmi, the founder of the Health Care Foundation Nepal (HECAF), is one of Nepal’s leading ‘waste champions’. Over the past 14 years HECAF has worked with more than 25 hospitals to introduce appropriate technologies for treating waste so that it can be sold to recyclers, and for safely transforming or disposing of non-recyclable waste without burning. At its stand in the marketplace, HECAF staff explained to visitors how the organisation trains teams of health workers to systematically segregate waste at source, to sterilise infectious waste using autoclaves, to turn pathological and biodegradable waste into biogas, and to use worms to compost gauze, bandages and menstrual health management materials, such as sanitary pads.

The mayor of Waling Municipality, Mr Dilip Pratap Khand, described how healthcare facilities have been integrated into the municipal solid waste system through the establishment of a treatment hub at the municipality’s largest primary health center. Infectious waste from outlying health facilities is brought to the hub for treatment; once disinfected, it is taken to the municipal recovery center along with the non-infectious waste, merged with general municipal waste, sorted and sold to recyclers. Waling Municipality doesn’t have a landfill and nothing is thrown away. In 2018 the municipality made 8.2 million Rupees (Euros 64,000) by selling its reclaimed waste: ‘What we used to call ‘waste’ is not waste. It’s a resource!’, Khand triumphantly declared, to loud applause.

Ms Uma Thapa Magar, the Deputy Mayor of Nepalgunj, explained the steps she and her fellow elected officials are taking to improve solid waste management for their 139,000 citizens. As part of an Integrated Urban Development Project financed by the Asian Development Bank, Nepagunj has built a state-of-the-art municipal landfill and has begun to introduce household-level waste segregation in selected wards. The next priority is to introduce systems for treating and disposing of the waste being generated by the more than 130 healthcare institutions in the sub-metropolitan area. Municipal officials intend to establish a central treatment facility for healthcare waste, linked to the landfill, and are currently exploring partnership models with private companies.

Nepalgunj has been inspired by the model in place in Pokhara, where Mr Santosh Poudel, a social entrepreneur working in the waste sector, has established in partnership with the local municipality a central treatment facility to manage risk waste from more than 150 public and private hospitals, laboratories, pharmacies and clinics across the city. The facility processes five tons of healthcare waste every day. ‘The key is to work together in an integrated way,’ Poudel noted. ‘If you’re still thinking about waste practices in individual hospitals, it’s time to make the move to an integrated approach.’

A national campaign to put Nepal onto a healthier, more sustainable path

On the final day of the workshop, Mr Chudamani Bhandari, the chief of the Environmental Health and Healthcare Waste Management Section, presented 12 resolutions which captured the learnings and reflections from the previous two days. Amidst commitments to clarify the policy framework, invest in training human resources, and promote technologically sound waste management practices, was a short but important statement: ‘We will prepare a roadmap to integrated healthcare waste management and implement it as a campaign.’ Technical solutions are available for the healthcare waste challenges facing Nepal, but these alone cannot solve the problem. Poor waste management is systemic, and improving it requires everyone to do their part – from hospital staff and managers, to municipal authorities, provincial and federal officials, private waste contractors and individual households. Development partners must also be engaged: global health initiatives are leading to greater waste generation and creating new waste treatment and disposal challenges for which solutions need to be found.

A campaign to change the way people think about waste, and therefore how they handle it, will not only make Nepal a cleaner and healthier country, but a more sustainable and prosperous one as well.

Karen Birdsall
, January 2020