- Email: [email protected]
Healthcare waste management scenario: A case of Himachal Pradesh (India)
G Model CEGH 194 No. of Pages 4
Clinical Epidemiology and Global Health xxx (2017) xxx–xxx
Contents lists available at ScienceDirect
Clinical Epidemiology and Global Health journal homepage: www.elsevier.com/locate/cegh
Healthcare waste management scenario: A case of Himachal Pradesh (India) Santosh Kumar Sharmaa,* , Sparsh Guptab a b
Indian Institute of Management, Jammu 180006, India Department of Management & Humanities, NIT Hamirpur, Himachal Pradesh, India
A R T I C L E I N F O
A B S T R A C T
Article history: Received 26 May 2017 Accepted 22 July 2017 Available online xxx
Objective: To explore healthcare waste management scenario in Himachal Pradesh (India). Method: Data has been collected through a survey questionnaire and accordingly analyses have been carried out by applying appropriate statistical techniques with the help of commonly acknowledged SPSS software. Results: Results highlight that private hospitals are generating more healthcare waste (yellow and red category of healthcare waste) as compared to public hospitals in the given context. However, in blue category of healthcare waste public hospitals are generating more waste than private ones. Conclusion: By considering number of beds, doctors, and staff as independent variables, the present study analyses healthcare waste management from the perspective of Human Resources and consequently marks some managerial and policy implications. © 2017 INDIACLEN. Published by Elsevier, a division of RELX India, Pvt. Ltd. All rights reserved.
Keywords: Healthcare waste management Human resource management Himachal Pradesh India
1. Introduction Economic activities are necessary for the existence of human beings as espoused by the great Indian scholarly book Arthashasthra.1 To make these activities viable, role of industrialisation is essential because industries will generate products and services in implicit way. Similarly, for the physical survival of human beings basic food elements are needed which come through agricultural base of a country. In this whole process of economic growth, industrialisation, and agricultural yield, a lot of waste is generated some of which is decomposed and most of it is dumped somewhere in the cities or at a point of waste collection. Scholars believe that if this waste is not managed properly it can be detrimental to the environment and human health.2–6 Moreover, if we scan the contemporary life style of people we can sense that people are busy through day and night in fulfilling their professional and personal desires beyond the limit which consequently impacts their health not only in physical form but also in psychological and mental way. This may be the possible reason that World Health Organization (WHO) defines ‘health’ and consequently ‘healthcare services’ in a holistic way (http://www. who.int/en). In response to making these services available, the number of hospitals which are providing diversified healthcare
* Corresponding author. E-mail address: [email protected] (S.K. Sharma).
services is increasing in India (https://www.ibef.org). There is no doubt that these healthcare service providers are not achieving their vision by serving people at large but because of healthcare treatment activities a lot of waste is produced which is a matter of cognizance. In this reference, the government of India has recently (2016) amended Part II, Section 3, Sub-section-i of Bio-medical Waste Rules (1998) which was published vide notification number S.O. 630 (E) dated the 20th July, 1998, by the Government of India in the erstwhile Ministry of Environment and Forests. These amendments (2016) have motivated the authors of this article to explore further and survey the literature of healthcare waste management and analyze its scenario in Himachal Pradesh (India). During the literature review we found total 45 studies which are available and highly relevant to the theme of the present study, some of which are briefed in the following section (Literature Review). 2. Literature Review This section highlights some of the studies related to healthcare waste management in foreign and Indian context. 2.1. Studies conducted in Foreign Context Oli et al. 7 have assessed the involvement of healthcare workers in waste management in public and private hospitals of Southeast Nigeria. It has been found that healthcare workers in the public hospitals have more awareness about waste management
http://dx.doi.org/10.1016/j.cegh.2017.07.002 2213-3984/© 2017 INDIACLEN. Published by Elsevier, a division of RELX India, Pvt. Ltd. All rights reserved.
Please cite this article in press as: S.K. Sharma, S. Gupta, Healthcare waste management scenario: A case of Himachal Pradesh (India), Clin Epidemiol Glob Health (2017), http://dx.doi.org/10.1016/j.cegh.2017.07.002
G Model CEGH 194 No. of Pages 4
2
S.K. Sharma, S. Gupta / Clinical Epidemiology and Global Health xxx (2017) xxx–xxx
practices as compared to their counter parts i.e., private ones. Results of this study also indicate that there is a significant difference in healthcare waste generation between public and private hospitals. Adhikari and Supakankunit 8 have done a costbenefit analysis of healthcare waste management in Bir hospital, Nepal. The study gives meaningful financial implications for healthcare waste management. Abor 9 has found that public hospitals generate more waste than the private hospitals. From the technical point of view, Shanmugasundaram et al.10 have shown the relevance of GIS modelling tool in relation to healthcare waste management in Lao People's Democratic Republic. This tool can be used as a decision support tool for the efficient management of healthcare waste by hospitals, government, and concerned authorities. Other studies which have deliberated the significance of research in the area of healthcare waste management and its related issues like segregation of wastes and educating healthcare executives about the waste management are Awodele et al.,11 Mahasa and Ruhiiga,12 Omar et al.,13 and Jang et al.14 2.2. Studies conducted in Indian Context Thakur and Anbanandam 3 have identified the important barriers that hinder healthcare waste management (HCWM) in the state of Uttarakhand (India). This study delineates valuable issues in healthcare waste management by employing meticulous literature review, field surveys, brainstorming sessions, and advanced statistical techniques. Chauhan et al. 15 have found that there is a limited participation from the private healthcare organizations of India in terms of setting up of waste recycling units which may be because of financial constraints. Somaiah and Shivaraj 16 have conducted a cross-sectional study to assess performance of biomedical waste management in Government District hospitals of Southern India. Data has been collected through direct observation, staff interview and documents reviews. The study concludes that improvements in biomedical waste management can be made by increasing the knowledge, awareness and practices among the healthcare workers by providing mandatory training. Thakur and Ramesh 5 have analyzed the healthcare waste management research in a systematic, structured and thematic manner wherein it has been found that (a) out of the total publications, 72.72% are covered by the two journals namely, Waste Management & Research and Waste Management (b) around 42% of the studies have been done in China, Iran, Greece, India and UK. (c) 60% of the articles are related with general healthcare waste management practices. The study provides a comprehensive overview of the research paradigm in the area of healthcare waste management during January 2005 to July 2014. Other studies which have highlighted the significance of waste management research in Indian context include Sunmeet and Gangawane,17 Patil et al.,18 Reddy et al.,19 Kumari et al.,20 and Bathma et al. 21 Moreover, there are some studies 22–24 in the area of healthcare waste management with reference to the state of Himachal Pradesh (India), still there is a research gap in the given context especially from management point of view. Therefore, the present study is an attempt to fill this gap with the following methodology. 3. Methodology 3.1. Objectives Objective 1: To compare the healthcare waste generation across private and public hospitals
Objective 2: To find the correlation between the healthcare waste across colour codes and other variables of the study i.e., number of bed, doctor, and staff Objective 3: To identify the factors responsible for healthcare waste generation 3.2. Sample The study has been conducted in a sample of six hospitals of Himachal Pradesh (India). Initially, a list of ten hospitals was prepared according to the purpose of the study. Out of these ten hospitals, only six hospitals permitted for data collection and other relevant research support for this study. Out of these six hospitals, three are from public domain and three are from private domain. Out of 3 public hospitals, 1 is from Hamirpur, 1 from Kangra, and 1 from Palampur district. In private domain the similar distribution has been followed (1 from Hamirpur, 1 from Kangra, and 1 from Palampur). All these hospitals have necessary healthcare infrastructures which are catering the needs of concerned patients; however, during data collection it was observed that these hospitals are lacking in terms of advanced technological facilities related to healthcare waste management. On ethical grounds of research, the names of these hospitals cannot be disclosed. 3.3. Data collection and analyses The data was collected through self-developed structured questionnaire and by visiting each hospital personally between Feb-April 2017. Ethical clearance from the institution and the permission of superintendent was needed for the collection of data regarding healthcare waste. It took approximately one month in collecting the required data. The questionnaire consists of total six closed ended question that provides the required data (name and location of the hospital; number of beds, doctors, and staff; healthcare waste generation according to month and year wise). Data analysis has been carried out by applying appropriate statistical techniques with the help of SPSS software. 4. Results Table 4.1 compares the average value of healthcare waste (colour wise) across public and private hospitals. It is clear from this table that there are total 108 data points which refers to 36 month’s data of 3 years (2014–2016) i.e., 36 3 = 108. In this table the descriptive statistics (mean values and standard deviation) of healthcare waste has been shown according to colour (Yellow, Red, and Blue) which indicates that there is difference in healthcare waste between public and private sector hospitals for which there could be many reasons. Table 4.2 indicates that relationship between yellow waste (Y) and bed is positive (0.44) and significant at 0.01 level. This implies that as the number of bed increases the waste of yellow colour also increases. The relationship between red waste (R) and bed is positive (0.80) and significant at 0.01 level. Similarly, the relationship between blue waste (B) and bed is Table 4.1 Mean value of healthcare waste across Public and Private hospitals. Waste Colour
Sector
N
Mean
Std. Deviation
Std. Error Mean
Y (Yellow)
Public Private Public Private Public Private
108 108 108 108 108 108
81.1392 183.377 277.053 348.612 125.803 62.2361
64.0355 123.161 301.944 359.579 151.499 52.2182
6.16182 11.8512 29.0546 34.6005 14.578 5.0247
R (Red) B (Blue)
Please cite this article in press as: S.K. Sharma, S. Gupta, Healthcare waste management scenario: A case of Himachal Pradesh (India), Clin Epidemiol Glob Health (2017), http://dx.doi.org/10.1016/j.cegh.2017.07.002
G Model CEGH 194 No. of Pages 4
S.K. Sharma, S. Gupta / Clinical Epidemiology and Global Health xxx (2017) xxx–xxx Table 4.2 Correlation between the healthcare waste and other variables. Waste (Colour)
Bed
Doctor
Staff
Y (Yellow) R (Red) B (Blue)
0.44** 0.80** 0.87**
0.61** 0.94** 0.55**
0.58** 0.65** 0.64**
Waste (Colour)
Bed
Doctor
Staff
Y (Yellow) R (Red) B (Blue)
0.44** 0.80** 0.87**
0.61** 0.94** 0.55**
0.58** 0.65** 0.64**
Table 4.3 Stepwise Regression Analysis.
positive (0.87) and significant at 0.01 level. From Table 4.3 , it is evident that out of three independent variables (Bed, Doctor, and Staff), only two variables (Bed and Doctor) are able to significantly predict the healthcare waste (Total) in the selected hospitals. 4.1. Discussions Before embarking upon the discursive part of the present article it is worthwhile to know briefly about the colour coding of healthcare waste. In healthcare waste management system there are three kinds of waste categories namely, Yellow, Red, and Blue. According to the information available (http://www.imanhb.org), yellow colour of waste refers to anatomical waste produced by human and animals, soiled waste (items contaminated with blood, body fluids like dressings, plaster casts, cotton swabs and bags containing residual or discarded blood and blood components), expired or discarded medicines, chemical liquid waste (liquid waste generated due to use of chemicals in production of biological and used or discarded disinfectants, silver X-ray film developing liquid, discarded formalin, infected secretions, aspirated body fluids, liquid from laboratories and floor washings, cleaning, house-keeping and disinfecting activities) etc. Red colour of waste refers to contaminated waste which is recyclable (wastes generated from disposable items such as tubing, bottles, intravenous tubes and sets, catheters, urine bags, syringes and gloves). Blue colour of waste refers to broken or discarded and contaminated glass including medicine vials and ampoules except those contaminated with cytotoxic wastes. In the aforementioned results, Table 4.1 indicates that in yellow category of waste, mean value of healthcare waste in private hospitals is higher than the mean value of healthcare waste in public ones which implies that in selected private hospitals of Himachal Pradesh anatomical waste produced by human and animals is higher and therefore, associated stake holders must take some controllable measures in the direction. In red category of healthcare waste, mean value is again higher for private hospitals as compared to public ones, however, such kind of healthcare waste can be recycled provided these private hospitals have technological infrastructures regarding recycling the healthcare waste. In case of blue category of healthcare waste, mean value is higher for public hospitals as compared to private one which is contrary to yellow and red category. This result implies that in selected public hospitals of Himachal Pradesh, glass related medical products are heavily used and if not controlled through autoclaving or similar kind of technology-based interventions, it may create environmental degradation of the land which will further affect the lives of human beings in the area directly or indirectly. In nutshell, the obtained result indicates a sectored
3
variation (Public vs Private) in healthcare waste categories (Yellow, Red, and Blues) which is a point of further discussions. However, because of limitations in word count of the manuscript, the authors are not able to extend this discussion. Table 4.2 indicate the obtained correlation between the healthcare waste across colour codes and other variables of the study i.e., number of bed, doctor, and staff. Though this result is in line with the previous studies,25 the underlying mechanism is still not explained in its full potential. However, from our intuitive and common understandings we can assume that the reason for this result may be that with the increasing human population, hospitals in India are increasing their number of beds, doctors, and staff which is very natural. However, this natural increase of beds and manpower may produce more healthcare waste which is detrimental for human health and environment. Therefore, this issue must be discussed on various integrated forums which include medical professionals, hospital administrators, public representatives, and management executives. On paradoxical grounds, this is very important to devise some waste management strategies which can cater the healthcare needs of people and simultaneously control healthcare waste generation. From the perspective of Human Resource Management (HRM) it is predicted that with the increasing healthcare waste in India, more number of skilled employees will be required which may not be directly related with medical profession but they can be trained on various fronts of healthcare waste management and accordingly deployed for the managerial tasks. Table 4.3 identifies the factors responsible for healthcare waste generation for which stepwise regression analysis has been carried out. The results shown in this table could not be verified through the available and relevant literature on similarity or differential stand. However, on logical grounds this result can be accepted. It can be seen (Table 4.3) that if the variable ‘Bed’ is entered alone to predict total value of healthcare waste it explains 94.2% variation and if it is entered jointly with another variable ‘Doctor’ it explains 94.9% variation in the dependent variable i.e. total waste. This result implies that as the number of bed and doctor will increase more healthcare activities will take place and as a repercussion total healthcare waste will increase which again comes under the optimised purview of management areas. 5. Conclusions There is an increasing awareness among various stakeholders of India including its citizens about the positive consequences of waste management which are implicitly or explicitly related to human health and environment. Possibly this is due to the Swachh Bharat-Swasth Bharat momentum and schemes such as Kayakalp (for more detail, please visit, http:// www.kayakalpindia.com) which have further motivated the hospital administrators and associated healthcare executives to chart out some action plans. However, the research and its applications in the given context are still under the concealment specifically with reference to complex geographical terrains of India such as Himachal Pradesh. This was the basic motivation which galvanised the authors of this article to deliberate on healthcare waste scenario in Himachal Pradesh (India). For this deliberation three divergent objectives have been set and accordingly methodology has been applied. In response to objective 1, it has been found that private hospitals in the selected hospitals are producing more healthcare waste as compared to the public hospitals which is a matter of serious concern for the concerned authorities in the state of Himachal Pradesh. In response to objective 2 and 3, which have been analysed from the statistical point of view, the results indicate that there is a dire need of Human Resource Management
Please cite this article in press as: S.K. Sharma, S. Gupta, Healthcare waste management scenario: A case of Himachal Pradesh (India), Clin Epidemiol Glob Health (2017), http://dx.doi.org/10.1016/j.cegh.2017.07.002
G Model CEGH 194 No. of Pages 4
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S.K. Sharma, S. Gupta / Clinical Epidemiology and Global Health xxx (2017) xxx–xxx
departments in the hospitals which can optimally design HR policies and processes related to healthcare waste management. The authors strongly believe that if this is accomplished proactively, healthcare waste can be managed in an effective and efficient way which will be eventually beneficial to human health and environment.
angles of finance, operations, and other streams of management sciences.
5.1. Implications
References
5.1.1. Managerial Implications The study observes that due to increasing healthcare demands, the number of hospitals, beds, and doctors will naturally increase in the coming future. However, this natural increment will have spill over effect on healthcare waste generation which needs to be proactively managed. Therefore, some managerial interventions are required. In the light of this backdrop, it is suggested that hospital administrators and healthcare executives should be proactive in human resource planning, recruitment, and designing training programs in the area of healthcare waste management through which effective results can be achieved and consequently human health and environment can be sustained for a time. 5.1.2. Policy Implications It is expected that in the coming future, India will become a preferred destination of medical tourism which can be foresighted by the entrepreneurial spirit of management professionals. For example, Manish and Pankaj who are the Alumni of IIM Lucknow have started a company in this direction (for more detail, please visit, http://www.vaidam.com) and similar other entrepreneurs are working in the context. This medical tourism will be of high appreciation with specific reference to the state of Himachal Pradesh as the state is globally acclaimed for its tourist destinations. Moreover, the increasing efforts of the Ministry of Tourism (Government of India) especially in reference to wellness and medical tourism (for more detail please visit, http://tourism. gov.in/wellness-medical-tourism) will also boost the medical tourists destinations in India. However, in spite of these progressive steps we may face an alarming signal when this medical tourism will increase the number of healthcare centres and hospitals. In this case it is pertinent that healthcare waste management systems should be analysed through a wide array of angles and accordingly action plans should be developed. As the present article is cardinally not related to medical tourism, the authors would like to stop at this juncture and believe that the present study will be of immense use for the associated stakeholders who are associated with medical tourism. 5.2. Limitations In spite of the potential managerial and policy implications of the present study, there are some limitations that must be acknowledged and should be minimised by future researchers. First, the sample consists of only six hospitals from a specific state of India (Himachal Pradesh) which restricts the generalisation of results at national level. Second, data has been collected through questionnaire method which may have some response bias. However, researchers tried their best to capture the required data through authentic sources and in an objective manner. Finally, the present study has deliberated on a specific management area (Human Resources) in relation to healthcare waste management which is incomplete and therefore, future researchers are encouraged to analyse healthcare waste management from the
Conflict of interest None.
1. Waldauer C, Zakha WJ, Paul S. Kautilya’s Arthashasthra a neglected precursor to classical economics’. Ind Econ Rev. 1996;XXXI:101–108. 2. Thakur V, Anbanandam R. Management practices and modeling the seasonal variation in health care waste: a case study of Uttarakhand, India. J Modell Manag. 2017;12:162–174. 3. Thakur V, Anbanandam R. Healthcare waste management: an interpretive structural modeling approach. Int J Health Care Qual Assurance. 2016;29:559– 581. 4. Chauhan A, Singh A. Healthcare waste management: a state-of-the-art literature review. Int J Environ Waste Manag. 2016;18:120–144. 5. Thakur V, Ramesh A. Healthcare waste management research: a structured analysis and review (2005k2014). Waste Manag Res. 2015;33:855–870. 6. Chartier Y, Emmanuel J, Pieper U, Prüss A, Rushbrook P, Stringer R, Townend W, Wilburn S, Zghondi R. Safe management of wastes from health-care activities. 2nd edition Geneva: WHO Press; 2014. 7. Oli AN, Ekejindu CC, Adje DU, Ezeobi I, Ejiofor OS, Ibeh CC. Healthcare waste management in selected government and private hospitals in Southeast Nigeria’. Asian Pac J Trop Biomed. 2016;6:184–189. 8. Adhikari SR, Supakankunit S. Benefits and costs of alternative healthcare waste management: an example of the largest hospital of Nepal. WHO South-East Asia. J Public Health. 2014;3:171–178. 9. Abor PA. Managing healthcare waste in Ghana: a comparative study of public and private hospitals. Int J Health Care Qual Assurance. 2013;26:375–386. 10. Shanmugasundaram J, Soulalay V, Chettiyappan V. Geographic information system-based healthcare waste management planning for treatment site location and optimal transportation routeing’. Waste Manag Res. 2012;30:587– 595. 11. Awodele O, Adewoye AA, Oparah AC. Assessment of medical waste management in seven hospitals in Lagos, Nigeria’. BMC Public Health. 2016;16:10.1186/s12889-016-2916-1. 12. Mahasa PS, Ruhiiga TM. Medical waste management practices in North Eastern Free State, South Africa. J Hum Ecol. 2014;48:439–450. 13. Omar D, Nurshahida S, Subramaniam N, Karuppannan AL. Clinical waste management in District Hospitals of Tumpat, Batu Pahat and Taiping. Procedia Soc Behav Sci. 2012;68:134–145. 14. Jang YC, Lee C, Yoon OS, Kim H. Medical waste management in Korea. J Environ Manag. 2006;80:107–115. 15. Chauhan A, Singh A, Jharkharia S. An ISM and DEMATEL method approach for the Analysis of Barriers of Waste Recycling in India. J Air Waste Manag Assoc. 2016;10.1080/10962247.2016.1249441. 16. Somaiah PT, Shivaraj BM. A study on bio-medical waste management using Kayakalp Tool at District Hospital in Southern India. Int J Commun Med. 2016;7:614–617. 17. Sunmeet, Gangawane A. Knowledge attitude and practices of healthcare personnel towards bio-medical waste disposal management at Arbor Biotech Limited Mumbai. Int J Innov Res Sci Eng. 2017;3:307–316. 18. Patil AS, Ranjitha AB, Yaseen M. Hospital waste generation and management-a case study for major hospitals of Davanagere’. Int Res J Eng Technol. 2016;3:1400–1406. 19. Reddy BS, Rao JN, Subrahmanyam BV. Awareness and knowledge practices about the bio medical waste management at tertiary care teaching hospital. Int J Sci Res Publ. 2014;4:1–11. 20. Kumari R, Tripathi GK, Singh A. Impact of healthcare waste management training among doctors and nurses at a tertiary healthcare institute, Lucknow’. Ind J Life Sci. 2014;3:91–94. 21. Bathma V, Likhar SK, Mishra MK, Athavale AV, Agarwal S, Shukla US. Knowledge assessment of hospital staff regarding biomedical waste management in a tertiary care hospital’. Nat J Commun Med. 2012;3:197–200. 22. Katoch SS, Thakur Y. Policies and practices of biomedical waste management in different healthcare facilities in a developing country. Int J Environ Waste Manag. 2017;19:42–51. 23. Kumar S, Mazta SR, Gupta AK. Biomedical solid waste management practices in major public hospitals of Shimla City. J Evol Med Dent Sci. 2014;3:4075– 4083. 24. Nema A, Pathak A, Bajaj P, Singh H, Kumar S. A case study: biomedical waste management practices at city hospital in Himachal Pradesh. Waste Manag Res. 2011;29:669–673. 25. Odette RH, Masika J, Venance T, Soatiana JE, Christiane NA, Lamine CM. Assessment of healthcare waste generation and its management systems: a prevalence survey of the healthcare facilities in Madagascar. J Environ Sci Toxicol Food Technol. 2014;8:20–29.
Please cite this article in press as: S.K. Sharma, S. Gupta, Healthcare waste management scenario: A case of Himachal Pradesh (India), Clin Epidemiol Glob Health (2017), http://dx.doi.org/10.1016/j.cegh.2017.07.002
Clinical Epidemiology and Global Health xxx (2017) xxx–xxx
Contents lists available at ScienceDirect
Clinical Epidemiology and Global Health journal homepage: www.elsevier.com/locate/cegh
Healthcare waste management scenario: A case of Himachal Pradesh (India) Santosh Kumar Sharmaa,* , Sparsh Guptab a b
Indian Institute of Management, Jammu 180006, India Department of Management & Humanities, NIT Hamirpur, Himachal Pradesh, India
A R T I C L E I N F O
A B S T R A C T
Article history: Received 26 May 2017 Accepted 22 July 2017 Available online xxx
Objective: To explore healthcare waste management scenario in Himachal Pradesh (India). Method: Data has been collected through a survey questionnaire and accordingly analyses have been carried out by applying appropriate statistical techniques with the help of commonly acknowledged SPSS software. Results: Results highlight that private hospitals are generating more healthcare waste (yellow and red category of healthcare waste) as compared to public hospitals in the given context. However, in blue category of healthcare waste public hospitals are generating more waste than private ones. Conclusion: By considering number of beds, doctors, and staff as independent variables, the present study analyses healthcare waste management from the perspective of Human Resources and consequently marks some managerial and policy implications. © 2017 INDIACLEN. Published by Elsevier, a division of RELX India, Pvt. Ltd. All rights reserved.
Keywords: Healthcare waste management Human resource management Himachal Pradesh India
1. Introduction Economic activities are necessary for the existence of human beings as espoused by the great Indian scholarly book Arthashasthra.1 To make these activities viable, role of industrialisation is essential because industries will generate products and services in implicit way. Similarly, for the physical survival of human beings basic food elements are needed which come through agricultural base of a country. In this whole process of economic growth, industrialisation, and agricultural yield, a lot of waste is generated some of which is decomposed and most of it is dumped somewhere in the cities or at a point of waste collection. Scholars believe that if this waste is not managed properly it can be detrimental to the environment and human health.2–6 Moreover, if we scan the contemporary life style of people we can sense that people are busy through day and night in fulfilling their professional and personal desires beyond the limit which consequently impacts their health not only in physical form but also in psychological and mental way. This may be the possible reason that World Health Organization (WHO) defines ‘health’ and consequently ‘healthcare services’ in a holistic way (http://www. who.int/en). In response to making these services available, the number of hospitals which are providing diversified healthcare
* Corresponding author. E-mail address: [email protected] (S.K. Sharma).
services is increasing in India (https://www.ibef.org). There is no doubt that these healthcare service providers are not achieving their vision by serving people at large but because of healthcare treatment activities a lot of waste is produced which is a matter of cognizance. In this reference, the government of India has recently (2016) amended Part II, Section 3, Sub-section-i of Bio-medical Waste Rules (1998) which was published vide notification number S.O. 630 (E) dated the 20th July, 1998, by the Government of India in the erstwhile Ministry of Environment and Forests. These amendments (2016) have motivated the authors of this article to explore further and survey the literature of healthcare waste management and analyze its scenario in Himachal Pradesh (India). During the literature review we found total 45 studies which are available and highly relevant to the theme of the present study, some of which are briefed in the following section (Literature Review). 2. Literature Review This section highlights some of the studies related to healthcare waste management in foreign and Indian context. 2.1. Studies conducted in Foreign Context Oli et al. 7 have assessed the involvement of healthcare workers in waste management in public and private hospitals of Southeast Nigeria. It has been found that healthcare workers in the public hospitals have more awareness about waste management
http://dx.doi.org/10.1016/j.cegh.2017.07.002 2213-3984/© 2017 INDIACLEN. Published by Elsevier, a division of RELX India, Pvt. Ltd. All rights reserved.
Please cite this article in press as: S.K. Sharma, S. Gupta, Healthcare waste management scenario: A case of Himachal Pradesh (India), Clin Epidemiol Glob Health (2017), http://dx.doi.org/10.1016/j.cegh.2017.07.002
G Model CEGH 194 No. of Pages 4
2
S.K. Sharma, S. Gupta / Clinical Epidemiology and Global Health xxx (2017) xxx–xxx
practices as compared to their counter parts i.e., private ones. Results of this study also indicate that there is a significant difference in healthcare waste generation between public and private hospitals. Adhikari and Supakankunit 8 have done a costbenefit analysis of healthcare waste management in Bir hospital, Nepal. The study gives meaningful financial implications for healthcare waste management. Abor 9 has found that public hospitals generate more waste than the private hospitals. From the technical point of view, Shanmugasundaram et al.10 have shown the relevance of GIS modelling tool in relation to healthcare waste management in Lao People's Democratic Republic. This tool can be used as a decision support tool for the efficient management of healthcare waste by hospitals, government, and concerned authorities. Other studies which have deliberated the significance of research in the area of healthcare waste management and its related issues like segregation of wastes and educating healthcare executives about the waste management are Awodele et al.,11 Mahasa and Ruhiiga,12 Omar et al.,13 and Jang et al.14 2.2. Studies conducted in Indian Context Thakur and Anbanandam 3 have identified the important barriers that hinder healthcare waste management (HCWM) in the state of Uttarakhand (India). This study delineates valuable issues in healthcare waste management by employing meticulous literature review, field surveys, brainstorming sessions, and advanced statistical techniques. Chauhan et al. 15 have found that there is a limited participation from the private healthcare organizations of India in terms of setting up of waste recycling units which may be because of financial constraints. Somaiah and Shivaraj 16 have conducted a cross-sectional study to assess performance of biomedical waste management in Government District hospitals of Southern India. Data has been collected through direct observation, staff interview and documents reviews. The study concludes that improvements in biomedical waste management can be made by increasing the knowledge, awareness and practices among the healthcare workers by providing mandatory training. Thakur and Ramesh 5 have analyzed the healthcare waste management research in a systematic, structured and thematic manner wherein it has been found that (a) out of the total publications, 72.72% are covered by the two journals namely, Waste Management & Research and Waste Management (b) around 42% of the studies have been done in China, Iran, Greece, India and UK. (c) 60% of the articles are related with general healthcare waste management practices. The study provides a comprehensive overview of the research paradigm in the area of healthcare waste management during January 2005 to July 2014. Other studies which have highlighted the significance of waste management research in Indian context include Sunmeet and Gangawane,17 Patil et al.,18 Reddy et al.,19 Kumari et al.,20 and Bathma et al. 21 Moreover, there are some studies 22–24 in the area of healthcare waste management with reference to the state of Himachal Pradesh (India), still there is a research gap in the given context especially from management point of view. Therefore, the present study is an attempt to fill this gap with the following methodology. 3. Methodology 3.1. Objectives Objective 1: To compare the healthcare waste generation across private and public hospitals
Objective 2: To find the correlation between the healthcare waste across colour codes and other variables of the study i.e., number of bed, doctor, and staff Objective 3: To identify the factors responsible for healthcare waste generation 3.2. Sample The study has been conducted in a sample of six hospitals of Himachal Pradesh (India). Initially, a list of ten hospitals was prepared according to the purpose of the study. Out of these ten hospitals, only six hospitals permitted for data collection and other relevant research support for this study. Out of these six hospitals, three are from public domain and three are from private domain. Out of 3 public hospitals, 1 is from Hamirpur, 1 from Kangra, and 1 from Palampur district. In private domain the similar distribution has been followed (1 from Hamirpur, 1 from Kangra, and 1 from Palampur). All these hospitals have necessary healthcare infrastructures which are catering the needs of concerned patients; however, during data collection it was observed that these hospitals are lacking in terms of advanced technological facilities related to healthcare waste management. On ethical grounds of research, the names of these hospitals cannot be disclosed. 3.3. Data collection and analyses The data was collected through self-developed structured questionnaire and by visiting each hospital personally between Feb-April 2017. Ethical clearance from the institution and the permission of superintendent was needed for the collection of data regarding healthcare waste. It took approximately one month in collecting the required data. The questionnaire consists of total six closed ended question that provides the required data (name and location of the hospital; number of beds, doctors, and staff; healthcare waste generation according to month and year wise). Data analysis has been carried out by applying appropriate statistical techniques with the help of SPSS software. 4. Results Table 4.1 compares the average value of healthcare waste (colour wise) across public and private hospitals. It is clear from this table that there are total 108 data points which refers to 36 month’s data of 3 years (2014–2016) i.e., 36 3 = 108. In this table the descriptive statistics (mean values and standard deviation) of healthcare waste has been shown according to colour (Yellow, Red, and Blue) which indicates that there is difference in healthcare waste between public and private sector hospitals for which there could be many reasons. Table 4.2 indicates that relationship between yellow waste (Y) and bed is positive (0.44) and significant at 0.01 level. This implies that as the number of bed increases the waste of yellow colour also increases. The relationship between red waste (R) and bed is positive (0.80) and significant at 0.01 level. Similarly, the relationship between blue waste (B) and bed is Table 4.1 Mean value of healthcare waste across Public and Private hospitals. Waste Colour
Sector
N
Mean
Std. Deviation
Std. Error Mean
Y (Yellow)
Public Private Public Private Public Private
108 108 108 108 108 108
81.1392 183.377 277.053 348.612 125.803 62.2361
64.0355 123.161 301.944 359.579 151.499 52.2182
6.16182 11.8512 29.0546 34.6005 14.578 5.0247
R (Red) B (Blue)
Please cite this article in press as: S.K. Sharma, S. Gupta, Healthcare waste management scenario: A case of Himachal Pradesh (India), Clin Epidemiol Glob Health (2017), http://dx.doi.org/10.1016/j.cegh.2017.07.002
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S.K. Sharma, S. Gupta / Clinical Epidemiology and Global Health xxx (2017) xxx–xxx Table 4.2 Correlation between the healthcare waste and other variables. Waste (Colour)
Bed
Doctor
Staff
Y (Yellow) R (Red) B (Blue)
0.44** 0.80** 0.87**
0.61** 0.94** 0.55**
0.58** 0.65** 0.64**
Waste (Colour)
Bed
Doctor
Staff
Y (Yellow) R (Red) B (Blue)
0.44** 0.80** 0.87**
0.61** 0.94** 0.55**
0.58** 0.65** 0.64**
Table 4.3 Stepwise Regression Analysis.
positive (0.87) and significant at 0.01 level. From Table 4.3 , it is evident that out of three independent variables (Bed, Doctor, and Staff), only two variables (Bed and Doctor) are able to significantly predict the healthcare waste (Total) in the selected hospitals. 4.1. Discussions Before embarking upon the discursive part of the present article it is worthwhile to know briefly about the colour coding of healthcare waste. In healthcare waste management system there are three kinds of waste categories namely, Yellow, Red, and Blue. According to the information available (http://www.imanhb.org), yellow colour of waste refers to anatomical waste produced by human and animals, soiled waste (items contaminated with blood, body fluids like dressings, plaster casts, cotton swabs and bags containing residual or discarded blood and blood components), expired or discarded medicines, chemical liquid waste (liquid waste generated due to use of chemicals in production of biological and used or discarded disinfectants, silver X-ray film developing liquid, discarded formalin, infected secretions, aspirated body fluids, liquid from laboratories and floor washings, cleaning, house-keeping and disinfecting activities) etc. Red colour of waste refers to contaminated waste which is recyclable (wastes generated from disposable items such as tubing, bottles, intravenous tubes and sets, catheters, urine bags, syringes and gloves). Blue colour of waste refers to broken or discarded and contaminated glass including medicine vials and ampoules except those contaminated with cytotoxic wastes. In the aforementioned results, Table 4.1 indicates that in yellow category of waste, mean value of healthcare waste in private hospitals is higher than the mean value of healthcare waste in public ones which implies that in selected private hospitals of Himachal Pradesh anatomical waste produced by human and animals is higher and therefore, associated stake holders must take some controllable measures in the direction. In red category of healthcare waste, mean value is again higher for private hospitals as compared to public ones, however, such kind of healthcare waste can be recycled provided these private hospitals have technological infrastructures regarding recycling the healthcare waste. In case of blue category of healthcare waste, mean value is higher for public hospitals as compared to private one which is contrary to yellow and red category. This result implies that in selected public hospitals of Himachal Pradesh, glass related medical products are heavily used and if not controlled through autoclaving or similar kind of technology-based interventions, it may create environmental degradation of the land which will further affect the lives of human beings in the area directly or indirectly. In nutshell, the obtained result indicates a sectored
3
variation (Public vs Private) in healthcare waste categories (Yellow, Red, and Blues) which is a point of further discussions. However, because of limitations in word count of the manuscript, the authors are not able to extend this discussion. Table 4.2 indicate the obtained correlation between the healthcare waste across colour codes and other variables of the study i.e., number of bed, doctor, and staff. Though this result is in line with the previous studies,25 the underlying mechanism is still not explained in its full potential. However, from our intuitive and common understandings we can assume that the reason for this result may be that with the increasing human population, hospitals in India are increasing their number of beds, doctors, and staff which is very natural. However, this natural increase of beds and manpower may produce more healthcare waste which is detrimental for human health and environment. Therefore, this issue must be discussed on various integrated forums which include medical professionals, hospital administrators, public representatives, and management executives. On paradoxical grounds, this is very important to devise some waste management strategies which can cater the healthcare needs of people and simultaneously control healthcare waste generation. From the perspective of Human Resource Management (HRM) it is predicted that with the increasing healthcare waste in India, more number of skilled employees will be required which may not be directly related with medical profession but they can be trained on various fronts of healthcare waste management and accordingly deployed for the managerial tasks. Table 4.3 identifies the factors responsible for healthcare waste generation for which stepwise regression analysis has been carried out. The results shown in this table could not be verified through the available and relevant literature on similarity or differential stand. However, on logical grounds this result can be accepted. It can be seen (Table 4.3) that if the variable ‘Bed’ is entered alone to predict total value of healthcare waste it explains 94.2% variation and if it is entered jointly with another variable ‘Doctor’ it explains 94.9% variation in the dependent variable i.e. total waste. This result implies that as the number of bed and doctor will increase more healthcare activities will take place and as a repercussion total healthcare waste will increase which again comes under the optimised purview of management areas. 5. Conclusions There is an increasing awareness among various stakeholders of India including its citizens about the positive consequences of waste management which are implicitly or explicitly related to human health and environment. Possibly this is due to the Swachh Bharat-Swasth Bharat momentum and schemes such as Kayakalp (for more detail, please visit, http:// www.kayakalpindia.com) which have further motivated the hospital administrators and associated healthcare executives to chart out some action plans. However, the research and its applications in the given context are still under the concealment specifically with reference to complex geographical terrains of India such as Himachal Pradesh. This was the basic motivation which galvanised the authors of this article to deliberate on healthcare waste scenario in Himachal Pradesh (India). For this deliberation three divergent objectives have been set and accordingly methodology has been applied. In response to objective 1, it has been found that private hospitals in the selected hospitals are producing more healthcare waste as compared to the public hospitals which is a matter of serious concern for the concerned authorities in the state of Himachal Pradesh. In response to objective 2 and 3, which have been analysed from the statistical point of view, the results indicate that there is a dire need of Human Resource Management
Please cite this article in press as: S.K. Sharma, S. Gupta, Healthcare waste management scenario: A case of Himachal Pradesh (India), Clin Epidemiol Glob Health (2017), http://dx.doi.org/10.1016/j.cegh.2017.07.002
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departments in the hospitals which can optimally design HR policies and processes related to healthcare waste management. The authors strongly believe that if this is accomplished proactively, healthcare waste can be managed in an effective and efficient way which will be eventually beneficial to human health and environment.
angles of finance, operations, and other streams of management sciences.
5.1. Implications
References
5.1.1. Managerial Implications The study observes that due to increasing healthcare demands, the number of hospitals, beds, and doctors will naturally increase in the coming future. However, this natural increment will have spill over effect on healthcare waste generation which needs to be proactively managed. Therefore, some managerial interventions are required. In the light of this backdrop, it is suggested that hospital administrators and healthcare executives should be proactive in human resource planning, recruitment, and designing training programs in the area of healthcare waste management through which effective results can be achieved and consequently human health and environment can be sustained for a time. 5.1.2. Policy Implications It is expected that in the coming future, India will become a preferred destination of medical tourism which can be foresighted by the entrepreneurial spirit of management professionals. For example, Manish and Pankaj who are the Alumni of IIM Lucknow have started a company in this direction (for more detail, please visit, http://www.vaidam.com) and similar other entrepreneurs are working in the context. This medical tourism will be of high appreciation with specific reference to the state of Himachal Pradesh as the state is globally acclaimed for its tourist destinations. Moreover, the increasing efforts of the Ministry of Tourism (Government of India) especially in reference to wellness and medical tourism (for more detail please visit, http://tourism. gov.in/wellness-medical-tourism) will also boost the medical tourists destinations in India. However, in spite of these progressive steps we may face an alarming signal when this medical tourism will increase the number of healthcare centres and hospitals. In this case it is pertinent that healthcare waste management systems should be analysed through a wide array of angles and accordingly action plans should be developed. As the present article is cardinally not related to medical tourism, the authors would like to stop at this juncture and believe that the present study will be of immense use for the associated stakeholders who are associated with medical tourism. 5.2. Limitations In spite of the potential managerial and policy implications of the present study, there are some limitations that must be acknowledged and should be minimised by future researchers. First, the sample consists of only six hospitals from a specific state of India (Himachal Pradesh) which restricts the generalisation of results at national level. Second, data has been collected through questionnaire method which may have some response bias. However, researchers tried their best to capture the required data through authentic sources and in an objective manner. Finally, the present study has deliberated on a specific management area (Human Resources) in relation to healthcare waste management which is incomplete and therefore, future researchers are encouraged to analyse healthcare waste management from the
Conflict of interest None.
1. Waldauer C, Zakha WJ, Paul S. Kautilya’s Arthashasthra a neglected precursor to classical economics’. Ind Econ Rev. 1996;XXXI:101–108. 2. Thakur V, Anbanandam R. Management practices and modeling the seasonal variation in health care waste: a case study of Uttarakhand, India. J Modell Manag. 2017;12:162–174. 3. Thakur V, Anbanandam R. Healthcare waste management: an interpretive structural modeling approach. Int J Health Care Qual Assurance. 2016;29:559– 581. 4. Chauhan A, Singh A. Healthcare waste management: a state-of-the-art literature review. Int J Environ Waste Manag. 2016;18:120–144. 5. Thakur V, Ramesh A. Healthcare waste management research: a structured analysis and review (2005k2014). Waste Manag Res. 2015;33:855–870. 6. Chartier Y, Emmanuel J, Pieper U, Prüss A, Rushbrook P, Stringer R, Townend W, Wilburn S, Zghondi R. Safe management of wastes from health-care activities. 2nd edition Geneva: WHO Press; 2014. 7. Oli AN, Ekejindu CC, Adje DU, Ezeobi I, Ejiofor OS, Ibeh CC. Healthcare waste management in selected government and private hospitals in Southeast Nigeria’. Asian Pac J Trop Biomed. 2016;6:184–189. 8. Adhikari SR, Supakankunit S. Benefits and costs of alternative healthcare waste management: an example of the largest hospital of Nepal. WHO South-East Asia. J Public Health. 2014;3:171–178. 9. Abor PA. Managing healthcare waste in Ghana: a comparative study of public and private hospitals. Int J Health Care Qual Assurance. 2013;26:375–386. 10. Shanmugasundaram J, Soulalay V, Chettiyappan V. Geographic information system-based healthcare waste management planning for treatment site location and optimal transportation routeing’. Waste Manag Res. 2012;30:587– 595. 11. Awodele O, Adewoye AA, Oparah AC. Assessment of medical waste management in seven hospitals in Lagos, Nigeria’. BMC Public Health. 2016;16:10.1186/s12889-016-2916-1. 12. Mahasa PS, Ruhiiga TM. Medical waste management practices in North Eastern Free State, South Africa. J Hum Ecol. 2014;48:439–450. 13. Omar D, Nurshahida S, Subramaniam N, Karuppannan AL. Clinical waste management in District Hospitals of Tumpat, Batu Pahat and Taiping. Procedia Soc Behav Sci. 2012;68:134–145. 14. Jang YC, Lee C, Yoon OS, Kim H. Medical waste management in Korea. J Environ Manag. 2006;80:107–115. 15. Chauhan A, Singh A, Jharkharia S. An ISM and DEMATEL method approach for the Analysis of Barriers of Waste Recycling in India. J Air Waste Manag Assoc. 2016;10.1080/10962247.2016.1249441. 16. Somaiah PT, Shivaraj BM. A study on bio-medical waste management using Kayakalp Tool at District Hospital in Southern India. Int J Commun Med. 2016;7:614–617. 17. Sunmeet, Gangawane A. Knowledge attitude and practices of healthcare personnel towards bio-medical waste disposal management at Arbor Biotech Limited Mumbai. Int J Innov Res Sci Eng. 2017;3:307–316. 18. Patil AS, Ranjitha AB, Yaseen M. Hospital waste generation and management-a case study for major hospitals of Davanagere’. Int Res J Eng Technol. 2016;3:1400–1406. 19. Reddy BS, Rao JN, Subrahmanyam BV. Awareness and knowledge practices about the bio medical waste management at tertiary care teaching hospital. Int J Sci Res Publ. 2014;4:1–11. 20. Kumari R, Tripathi GK, Singh A. Impact of healthcare waste management training among doctors and nurses at a tertiary healthcare institute, Lucknow’. Ind J Life Sci. 2014;3:91–94. 21. Bathma V, Likhar SK, Mishra MK, Athavale AV, Agarwal S, Shukla US. Knowledge assessment of hospital staff regarding biomedical waste management in a tertiary care hospital’. Nat J Commun Med. 2012;3:197–200. 22. Katoch SS, Thakur Y. Policies and practices of biomedical waste management in different healthcare facilities in a developing country. Int J Environ Waste Manag. 2017;19:42–51. 23. Kumar S, Mazta SR, Gupta AK. Biomedical solid waste management practices in major public hospitals of Shimla City. J Evol Med Dent Sci. 2014;3:4075– 4083. 24. Nema A, Pathak A, Bajaj P, Singh H, Kumar S. A case study: biomedical waste management practices at city hospital in Himachal Pradesh. Waste Manag Res. 2011;29:669–673. 25. Odette RH, Masika J, Venance T, Soatiana JE, Christiane NA, Lamine CM. Assessment of healthcare waste generation and its management systems: a prevalence survey of the healthcare facilities in Madagascar. J Environ Sci Toxicol Food Technol. 2014;8:20–29.
Please cite this article in press as: S.K. Sharma, S. Gupta, Healthcare waste management scenario: A case of Himachal Pradesh (India), Clin Epidemiol Glob Health (2017), http://dx.doi.org/10.1016/j.cegh.2017.07.002