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| ORIGINAL ARTICLE |
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| Year : 2023 | Volume
: 11
| Issue : 3 | Page : 190-195 |
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Assessment of infrastructure and status of biomedical waste management in primary health-care facilities in a district of West Bengal, India: A mixed method study
Supriya Dey1, Ritu Ghosh2, Sayantan Mondal3, Sarmila Mallik4
1 Family Medicine Practitioner, Nadia, India
2 Department of Community Medicine, Murshidabad Medical College, West Bengal, India
3 Department of Pediatrics, R G Kar Medical College, Kolkata, West Bengal, India
4 Principal, Tamralipto Government Medical College and Hospital, Purba Medinipur, West Bengal, India
| Date of Submission | 25-Jul-2022 |
| Date of Decision | 18-Oct-2022 |
| Date of Acceptance | 03-Nov-2022 |
| Date of Web Publication | 01-Jun-2023 |
Correspondence Address:
Sarmila Mallik
C/5, Ideal Association, VIP Road, Kolkata - 700 054, West Bengal
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/mjhs.mjhs_63_22
Background: The absence of proper waste management, lack of awareness about the health hazards from biomedical wastes, insufficient financial and human resources, and poor control of waste disposal are the most critical problems connected with biomedical waste management (BMWM).
Objectives: The objectives of this study were to assess the infrastructure available for BMWM in primary health-care facilities in Murshidabad district of West Bengal and to find out the gaps in the management.
Materials and Methods: This descriptive, observational, facility-based mixed method study with cross-sectional design was conducted in primary health-care facilities selected by multistage random sampling technique. In-depth interview was done with important stakeholders related to BMWM at block, subdivision, and district level.
Results: The gaps were identified related to infrastructure, logistic supply, and workforce resources in the studied primary health-care facilities. Segregation at source and disposal of biomedical waste were improper. Training on BMWM and posttraining evaluation were also seen deficient. Information, education, and communication materials and proper record keeping were seen to be absent with lack of supervision.
Conclusion: Logistics supply with emphasis on the supply chain with proper allocation of the fund at the primary health-care level should be ensured. Filling up of the vacancies of the Group D staff is essential. Training of health workers with supervision and monitoring by block and district officials needs to be strengthened for efficient BMWM.
Keywords: Biomedical waste, gap analysis, infrastructure, logistics, mixed method study, primary health-care facilities
How to cite this article:
Dey S, Ghosh R, Mondal S, Mallik S. Assessment of infrastructure and status of biomedical waste management in primary health-care facilities in a district of West Bengal, India: A mixed method study. MRIMS J Health Sci 2023;11:190-5 |
How to cite this URL:
Dey S, Ghosh R, Mondal S, Mallik S. Assessment of infrastructure and status of biomedical waste management in primary health-care facilities in a district of West Bengal, India: A mixed method study. MRIMS J Health Sci [serial online] 2023 [cited 2023 Oct 3];11:190-5. Available from: http://www.mrimsjournal.com/text.asp?2023/11/3/190/380569 |
| Introduction | |  |
The management of biomedical waste (BMW) is getting importance due to its potential environmental hazards and public health risks, in the context of rapidly expanding health-care facilities in developing countries. Although nonhazardous waste is produced in higher quantities from any medical facility, it can become hazardous if it is not segregated, treated, and disposed properly. Infected needlestick injuries can increase the risks of acquiring hepatitis B virus, hepatitis C virus, and HIV.[1] The direct and indirect consequences of improper BMW management (BMWM) include the intentional reuse of disposable materials, air pollution, and production of toxic emissions due to inadequate burning of medical waste, which leads to significant impacts on the environment.[2]
Although legal provisions (BMW [management and handling] Rules 1998) with its time-to-time modifications (revised in 2016) exist to mitigate the impact of hazardous and infectious hospital waste on the community,[3],[4] still these provisions are yet to be fully implemented. The absence of proper waste management, lack of awareness about the health hazards from biomedical wastes, insufficient financial and human resources, and poor control of waste disposal are the most critical problems connected with health-care waste.[5] International Clinical Epidemiology Network (INCLEN) explored the existing BMW practices, setup, and framework in primary, secondary, and tertiary health-care facilities (HCFs) in India across 20 states and found that around 82% of primary, 60% of secondary, and 54% of tertiary HCF had no credible BMWM system.[6] Mukherjee also highlighted issues and challenges of BMWM in West Bengal.[7]
In spite of having a vast network of primary health-care facilities in rural West Bengal and Murshidabad district, no study was found on BMWM in primary health-care system in this setting. Under this context, this study was conducted to assess the infrastructure available for BMWM in primary health-care facilities in Murshidabad district and to find out the gaps in the management.
| Materials and Methods | | |
This descriptive, observational, facility-based mixed method study with the cross-sectional design was conducted in primary health-care facilities that are subcenters (SCs), bedded and nonbedded primary health centers (PHCs) of two selected subdivisions under Murshidabad district of West Bengal. Study period was from January 2020 to June 2020.
A multistage random sampling technique was employed in this study. In the first step, two subdivisions of Murshidabad district were chosen randomly out of five subdivisions considering the feasibility of the survey and time constraints. In the second step, considering the PHCs as the sampling unit, in each subdivision, 20% of PHCs were chosen by systematic random sampling method. Thus, three (3) PHCs each from two subdivisions were selected giving a total of six PHCs. Then, in the last step, from these six PHCs, 10% SC had been selected randomly thus giving a total of 14 SCs (total number of SCs in 6 PHCs were 140 and its 10% had been chosen). Population covered by each SC was 7000–9000.
For the qualitative study, the important stakeholders related to BMWM at the level of block, subdivision, and district, namely the Block Medical Officer of Health (BMOH), Deputy Chief Medical Officer of Health (CMOH I), and the quality assurance managers (a total of seven stakeholders), were selected for interview.
A set of open-ended questionnaires was prepared for in-depth interviews of the important stakeholders of the block, subdivision, and district. A schedule and observation checklist were used for assessing the infrastructure and BMWM in the selected health facilities. Face validity of each item and content validity of each domain were checked by public health experts. Reliability was checked by test–retest method (r = 0.9).
Informed consent was taken before commencing the interview. Ethical approval was obtained from the Institutional Ethics Committee before the commencement of the study.
Study variables were availability of infrastructure, logistics, workforce, generation and segregation of BMW, disposal of BMW, information, education, and communication (IEC), and monitoring.
For the quantitative part, data collected had been entered in MS Excel and analyzed subsequently in MS Excel and also in Stata 16.0 version (Statacorp, California, USA).
For the qualitative part, transcripts were written in Bengali, then translated into English. Transcriptions were reverse translated into Bengali to capture the real essence of research information. Manual coding was done to develop concepts and derive key emerging themes. The in-depth interviews were analyzed as deductive themes.
| Results | | |
Quantitative results
Among the six PHCs, three were bedded and others were nonbedded. The average number of patients got admitted in those bedded PHCs was seen as 11, and the average BMW had been produced per bed per day was 121.67 g. In outpatient department (OPD), the average number of patients was 215. The total amount of BMW generated was little more in bedded PHCs. Average number of patients was calculated based on OPD and inpatient department register for the last 3 months.
The average footfall of the patients was 8–10 in SCs based on the last 3 months' data, and the average amount of BMW generated per patient per day in SC was 15.86 g. No BMW register was available in any SC. On immunization day and outreach session, the BMW and all the used/broken vials were sent in a simple carry bag or sometimes in blue bag without doing the proper sterilization to the respective block PHC (BPHC) in the same vaccine carrier van.
The medical officers, nursing staffs, pharmacists, laboratory technicians, and other staff were the available workforce at the PHCs and auxiliary nurse midwives (ANMs) 1 and 2 and somewhere supervisors were the workforce available in the SC level, as evident in [Table 1].
In this [Table 2], it was seen that segregation at source was done only in 33.33% of PHCs and 21.43% of SCs. In the case of availability of logistics, two third of the PHCs had red-, yellow-, and blue-colored bags and complete floor mopping equipment, whereas SCs were facing scarcity of logistics. | Table 2: Distribution of health-care facilities as per availability of segregation area and logistics
Click here to view |
Regarding the availability of personal protective equipment (PPE), it is evident in [Table 3] that all four components of PPE were not available in the majority of PHCs and SCs. Similar were the findings regarding the availability of deep burial pit, which was also not maintained properly. | Table 3: Availability of personal protective equipment and final disposal area
Click here to view |
In the present study, proper IEC materials were not available in any PHC. Only one SC had this IEC with proper placement and content. Register was not available anywhere and only one PHC had BMWM committee. Considering the training session, 66.67% PHCs and 35.71% SCs had proper training sessions. Although there was no proper training schedule only for BMWM in the primary level, the public health nurse (PHN) and BMOH used to talk on BMWM in these facilities.
Qualitative results
In-depth interview was conducted with the seven important stakeholders, namely District Quality Managers, BMOHs of the respective blocks of studied PHCs and SCs, and Deputy CMOH I of Murshidabad district. The interview was analyzed in the following themes and subthemes:
A. Status of the BMWM
i. Review committee, ii) Nodal person for the supervision
B. Rules management
C. Infrastructures and logistics
i. Fund allocation, ii) Supply from the higher level
D. Workforce
E. Training schedule (allocation of the training yearly basis)
F. Evaluation of the health-care worker (HCW) after training.
Status of the biomedical waste management
In-depth interviews revealed the poor status of the BMWM at PHC and SC levels due to lack of proper collection mechanism, transport system, and lack of proper infrastructure in the SC level, though little improvement was observed after the “Kayakalp” program. Collection was outsourced to an agency who would collect the BMW up to the PHC level, where SCs would send BMW through the vaccine carrier vehicle.
There was no review committee in PHC or SC level. BMOH and infection control nurse (ICN) were entrusted to act as nodal persons for supervision, though from the discussion with the different stakeholders, a gap of proper communication was observed from primary health-care level to the managerial level.
Rules management
BMWM rules were not followed properly at PHC and SC levels. As per the opinion of the District Quality Manager, after “Kayakalp” BPHCs were performing well but it was not satisfactory in PHC and SC levels. They uttered “used needles were segregated properly using hub-cutter in every aspect of health-care level, except in PHC and SC.”
Infrastructure and logistics
The infrastructure and logistics availability in the primary health-care level showed a mixed type of scenario. In the case of bedded PHCs, the infrastructure was quite good, but the reverse picture was observed in nonbedded PHCs and SCs. There was no proper place for the final disposal of the sharp metals or anatomical wastes in PHC and SC levels. Few had one pit, but that was also not in working condition.
According to the quality manager, the problem lied in the supply chain. Another quality manager commented – “logistics shortage hoar annoy karon holo murshidabad district er huge population ebong huge amount of PHC and SC”* (Reasons for shortage of logistics in Murshidabad district were huge population and large number of PHCs and SCs). As per the opinion of the BMOH, although there was shortage of supply, the ANMs did not use the colored bags in spite of its availability.
Regarding fund allocation, it was revealed that there was no scarcity of funds after the “Kayakalp” and “LAQSH” programs, but the problem lied with the “awareness” and “utilization.” The BMOHs had reverse opinion that they did not get proper funds for the BMWM. One BMOH said that – “we got one fund for all the purpose.”
Workforce
All the stakeholders viewed the problem of BMWM due to the shortage of the workforce at all levels. There was no permanent post of sweeper or other staff; part-time staff were not available all the time. One BMOH said that “In the aspect of the huge population, we need more manpower but we continuously face lack of it.”
Training
According to the stakeholders, under the “Kayakalp” program, the training schedule on BMWM had been planned yearly basis in the district level, but at block, training depended on PHN. One of the quality managers said that – “Sab PHC ba SC level e giye to ar training deoa jay na” (It was not possible to train all PHC or SC workers by going at that level). Similar was the opinion of the BMOH that the training was given to the primary health-care staff by the PHN or ICN on different topics, not separately on BMW.
Evaluation of the health-care workers after training
The district-level quality managers opined that they had to submit quarterly review reports of at least 106 secondary health-care facilities, hence felt impossible to visit and evaluate the HCWs after the routine training on BMWM. They added, “It should be done by the BMOH or PHN or ICN.” As there was no proper BMWM committee in this level, so no evaluation was done.
Gap analysis
After the conduction of both quantitative and qualitative study, some gaps had been found out.
Related to the infrastructure
- Scarcity and improper condition of deep burial pits in both PHC and SC level
- Lack of adequate sharp pits and poor condition of waste dump area in SC level, in some places, it was nearer to the locality
- Service of BMWM provider company was not available at hard-to-reach areas.
Logistics
- Yellow bags were used only in the bedded PHCs, either it was not available or not used in nonbedded PHCs. In SCs, only black and red bags were available
- Lack of awareness about waste carriers in the SC level
- BMW was used to be sent to BPHC from SC or vaccination camp by vaccine carrier vehicle
- Nonavailability of adequate PPE at all levels
- Lack of IEC materials
- Absence of register and review committee for maintaining BMW
- Irregular supply of logistics, problem with supply chain
- Lack of financial allotments at primary HCFs.
Workforce
- Lack of permanent house-keeping staff in the primary level and nonavailability of contractual staff round the clock
- Lack of training.
| Discussion | | |
The present study attempted to assess the infrastructure, logistics, and workforce related to BMWM in primary HCFs in the district of Murshidabad. It revealed the average amount of BMW per bed per day in PHC as 121.67 g, and the average at SC was 15.86 g of BMW per patient per day. The mean hospital waste in eight nonteaching hospitals of Lucknow was 0.56 kg per bed per day.[8] The difference of waste generation is due to the inclusion of both bedded and nonbedded PHCs in the present study. No study was available regarding BMW generation at the SC level.
Segregation of BMW at source, transport, and disposal was considered the most important component of the BMW (management and handling) rules, and color-coded bags were the main prerequisite for proper segregation. In India, most of the studies on the assessment of infrastructure and management related to BMW were rare and conducted in secondary and tertiary settings. Very few studies were available Win et al. conducted a study in Myanmar where nonhospital type PHCs were more likely not to have color coding systems, did not have equipment for accidental spillage of BMW, and separated staff for BMWM compared to hospital type PHCs.[9] The present study observed segregation at source only in 33.33% PHCs and 21.43% of SCs. Majority of the primary HCFs had red-, black-, and yellow-colored bags, but most of the SCs did not maintain the proper color coding process and majority of them did not get all types of colored bags most of the time. Dixit et al. also observed a poor picture of the availability of color-coded containers and segregation according to color coding in primary HCFs of Etawah district in Uttar Pradesh, compared to secondary and tertiary ones.[10] Nagaraju et al. at the PHC level in Bagepalli Taluk in India had a better observation of the practice of 82% regarding classification and color coding.[11]
In 2015, a joint WHO/UNICEF assessment found that just over half (58%) of sampled facilities from 24 countries had adequate systems in place for the safe disposal of health-care waste.[12] The present study observed that more than 85% SCs never heard the term waste carrier and only 50% PHCs had puncture-proof containers. Similar poor finding was seen by Badar et al. where only 32.4% of nonhospital type PHCs and 54.5% of hospital-type PHCs had sufficiently supported PPE.[13] INCLEN study also observed the availability of PPE as 63% in primary HCFs, which was comparatively lower than secondary and tertiary ones.[6]
Sharp pit was absent in more than 50% HCFs, where present was in dilapidated condition; deep burial pit was absent in 66.6% of PHCs and 92.8% of the SCs as observed in the present study. Özkan conducted a health-care-based study in Turkey which revealed that 78.5% of PHCs used a method of burning in pits as their final disposal of HCW including sharps.[14]
Regarding IEC material display in primary HCFs, the present study failed to see any IEC material in PHC and observed only 1 SC (7.14%) having IEC in the proper place and content. No register was available for BMWM in any primary HCFs and the BMWM committee was present only in one PHC. INCLEN study also found that primary HCFs were lagging behind regarding the display of guidelines or charts for BMW, location of charts, appropriateness, and readability of contents compared to secondary and tertiary HCFs.[6] The present study also did not find any register or logbook related to BMW at the primary setting.
Gap analysis
In this study, the gaps were identified related to infrastructure, logistic supply, and workforce resources in the studied primary health-care facilities.
In the whole world, more than of half HCFs had unsatisfactory BMWM, the predictors being a lack of awareness about the health hazards, inadequate training in proper waste management, the absence of waste management and disposal systems, and insufficient financial and human resources.[12] In South-East Asian region countries, 44% of facilities lack adequate waste disposal and treatment.[15] These outcomes complicate health challenges in resource-limited settings with a high burden of disease in countries with economies in transition.[12] Ali et al. had shown that proper waste segregation practices, training of staff, standard labeling, proper dumping, and transportation procedures are not up to the standards in both public and private hospitals of Pakistan.[16] The present study also revealed the gaps in the training component and supervision and monitoring. The stakeholders in the study in Etawah considered lack of regular training, inadequate budget, and logistics as the main bottlenecks, but not the lack of manpower, lack of monitoring, and supervision for maintaining appropriate BMWM.[10] However, INCLEN study revealed that surveillance and monitoring of BMWM were consistently deficient and the process of BMWM was poorest in primary care settings as compared to secondary and tertiary care settings.[6]
Limitations of the study included the amount of BMW that was written on the basis of the verbal data, as the BMW register was not available in most of the places.
| Conclusion and Recommendation | | |
The study highlighted the gaps in BMWM that were found related to infrastructure, logistics supply, and fund allocation in selected primary health-care facilities of Murshidabad district of West Bengal. Moreover, segregation at the source was deficient with the nonavailability of proper final disposal area and poor status of the IEC. To improve the present scenario of BMWM, logistics supply with emphasis on the supply chain with proper allocation of fund at primary health-care level should be ensured. The service of the authorized agency for the collection and transport of the BMW should be available at PHC and SC levels. Filling up the vacancies of the Group D staff is essential. Moreover, issues such as the display of IEC material with relevant content at proper places, the constitution of the BMWM review committee, and supervision and monitoring by block and district officials need to be strengthened for efficient BMWM.
Acknowledgment
The authors owe to the Director, Institute of Public Health, Kalyani, West Bengal, India, for his valuable input and support in the concept and study design. They are also indebted to the district, block authority, and also health workers at PHC and SC levels for their cooperation during data collection.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]
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