By Nick Crick MA MBA MInst MCIWEM MIWMSA of Integrated Skills Ltd & Derek Johnson MA, CEng, FICE, FlMgt, FIHEEM

A Health Post in Moshupa, Botswana
The waste management problems faced by many Sub-Saharan African countries are very different from those of Western Europe and the cultural and economic environment leads to the need for a different set of priorities. The writers were requested, in 1995, to advise on procedures and a Code of Practice for healthcare waste management in the Republic of Botswana, by GTZ, the German Agency for Technical Cooperation, who are advising the Botswana government on a long-term waste management project. This article outlines the approach taken and the progress made to date in implementation.

Any country has its own unique waste management needs and, whilst a number of important principles are universal, it is very important to recognise that solutions must be tailored to reflect this uniqueness. The major factors which characterise Botswana from a healthcare waste management viewpoint are:

• It is a large country (the size of France) with a relatively small population (I .5 million), growing fast (3%).
• A large proportion of the population live in small settlements, many of which are remote.
• The largest city - the capital, Gaborone - currently has a population of about 150,000. The main causes of ill health in Botswana are infectious diseases linked to poor socio-economic conditions. Respiratory diseases, such as TB, and gastrointestinal infections are dominant. HIV, as in many African countries, is prevalent. Of adults of sexually active age, infection is estimated to exceed 20%.
• Botswana, whilst one of the richest countries in Sub-Sahara Africa, does not have access to finance in the manner of, for example, Western Europe.
• The availability of technically trained human resources is limited at the present time.

A low quality hospital incinerator
Against this background, it was important to recognise that the priority in healthcare waste management must be directed to the protection of human health, with environmental impact, whilst important, taking second priority. As a consequence, the proposals made were based on achieving a high standard of health protection coupled with a balanced improvement in environmental impact, whilst minimising the capital and operating costs and the requirements for complex technology. Emphasis was also placed on making maximum use of the best of the existing facilities.

The healthcare sector in Botswana is well organised and, although trained staff are in short supply, the ratio of doctors to members of the population is probably the best in sub Saharan Africa. Primary care is available from mobile health stops, health posts and clinics. A health post serves some 500 - 1,000 people, usually in a remote area, and is a simple building offering out-patient care. Clinics serve a population of 5,000 to 10,000. The hospital service has three tiers. Primary hospitals have in-patient facilities, maternity beds and carry out simple surgery. Each District has a district hospital that carries out a full range of inpatient and outpatient services. Tertiary care is provided at two referral hospitals, one in Gaborone and one in the North East of the country.

Practice in 1995
Botswana is estimated to produce some 2,400 tonnes of healthcare risk waste per year, equating to 1.71 kg/capita. This is somewhat higher than the published average for EU countries but those in the UK are aware of the probable inconsistency in the EU statistics.

The awareness of and interest in the problems of healthcare waste management in Botswana was impressive. Very few facilities visited did not make some effort to treat healthcare wastes with care. Such shortcomings as were found can be summarised as follows:

• Lack of financial resources
• Shortage of physical facilities and equipment
• Absence of training for medical and non-medical staff
• No clear responsibility within hospitals for waste management
• Poor operating procedures for disposal equipment

There was some confusion over the use of colour coded bags and in very few cases was totally efficient segregation of healthcare risk waste from MSW observed. Due to shortages of supply, there was a tendency to use any coloured bag available. Modern sharps containers were used extensively, although not always correctly.

Intermediate storage of healthcare waste awaiting incineration or transport to another facility tended to be insecure and unsatisfactory. Handling of the waste within hospitals was haphazard, with the use of unacceptable methods of transportation, such as mortuary trolleys. Transport between healthcare facilities by road was highly unsatisfactory, the waste not being safely contained to prevent spillage and contamination.

Disposal of healthcare waste at health posts and some clinics was unsatisfactory, especially for sharps, which were often disposed of by open bunting or even dumping. Incinerators at the larger hospitals were generally acceptable, although they had no form of emission control. They were frequently operated, however, to a poor standard and the air emissions could be markedly improved.

A good quality 'low technology' incinerator
Botswana is already quite well endowed with "low technology" incinerators of a reasonable standard, capable of achieving a temperature of 800-900^oC. These plants have the capability of performing complete sterilisation and destruction of healthcare waste even if their emission standards leave something to be desired. Whilst their emissions are far from perfect, provided they are properly operated in accordance with the manufactures instructions, the absolute adverse environmental impact is unlikely to be great.

Recommendations
Given that the will to raise standards was clearly evident, the next step was to introduce a Code of Practice and a training programme. The Code of Practice proposed was derived and adapted from the UK methodology and the key elements were as follows.

• A classification system for healthcare waste should be introduced, similar to that used in the UK, which was considered equally appropriate for use in Botswana. A clear definition of responsibilities is required.
• A standardised system of red colour coded bags (as used in South Africa) for the segregation of risk waste should be used and rigidly followed. MSW should never be placed in such bags.
• Sharps containers should always be used for sharps.
• All outdated or used chemical/pharmaceutical wastes should be returned to the Central Medical Stores for destruction under controlled conditions.
• Radioactive wastes should be returned to the manufacturer.
• Secure secondary storage should be provided. A lockable wire cage should be used in hospitals and at those with incinerators it should have the capacity to hold at least two days' throughput.
• Waste in hospitals should be transported in suitable dedicated wheeled leakproof containers. They should be clearly marked and regularly cleaned.
• Healthcare waste transported by road should be carried in a special purpose vehicle or in a special leak-proof, lidded container.
• For remote locations, where waste quantities are small and it is impractical to transport healthcare waste to a more sophisticated facility, a simple incinerator may be used for sterilising healthcare waste. All health facilities should at least make use of such equipment. These incinerators should never be used for sharps.
• All hospitals should have the use of an incinerator capable of reaching at least 800^oC for all their healthcare wastes, either on-site or by means of transportation.
• A gradual move should be made towards the centralisation of healthcare waste incineration at the larger plants, thus reducing the management task to an acceptable minimum. Ultimately, it can be foreseen that central incineration could be introduced at six major population centres.
• Where good incinerators exist, every effort should be made to make maximum use of them.
• Centralised incineration of all sharps should be undertaken as soon as possible. The Ministry of Health Central Medical Stores (CMS) delivers supplies to all government healthcare facilities and consequently there should be little increase in cost if sharps containers are collected on the same vehicles and brought back to Gaborone. All sharps containers, except those arising in the larger towns with adequate facilities, should be collected and brought for destruction to a new incinerator at CMS.

Pilot projects
A new incinerator (without emission controls) was installed in early 1995 at a landfill in Lobatse, a town in the South East of Botswana. This could not be used without a collection and transport system. It was proposed that a pilot centralisation project should be developed based on Lobatse.

Gaborone is the natural location to establish centralised incineration in the future. It is the largest conurbation and air pollution is more critical than in smaller towns. There is currently, however, no single plant which is large enough to handle the volume generated and consequently a new plant will be required before such a scheme can be implemented. This is likely to be a medium term solution.

Subsequent Progress
The Code of Practice was accepted by the Botswana Government in October 1996. One of the authors has now developed and provided a training programme for at least one representative of every hospital and clinic in the country and a replication system has been established to ensure that the training is passed down to all relevant employees.

Ensuring that the resources are available and the infrastructure is in place is the next battle to be fought. Those that have been trained are pressing for better containers and disposal facilities. This is putting pressure on the authorities to act but it is a very slow process.

There have, however, been some the key achievements to date.

• Better quality red bags are now largely being used.
• The collection scheme in Lobatse is now in operation and a dedicated vehicle collects healthcare waste from all healthcare facilities in the town. A similar service has been started in Francistown, the second largest town.
• A plan has been prepared for the collection of sharps containers in rural areas and their transport to a modern incinerator. This is beginning to work but is by no means universal.
• For rural clinics and health posts, where the quantity of risk waste is small, a simple brick built incinerator, or one made from a 45-gallon drum, is now generally being used which at least provides sterilisation.
• An incinerator plant is urgently required in Gaborone as the incinerators at the referral hospital are beyond their useful life. This has proved the most difficult part of the project.
• A proposal has been put to the history of Health by a major South African company to provide a fully comprehensive service for the whole country. The company would construct two incinerators and provide a national collection system using plastic lined cardboard boxes and sharps containers. No decision has yet been taken but it is feared that the cost may make this unacceptable at the present time.