**5. Diagnosis of HCW management**

In developing countries, depending on the conditions, the appearance of the problem in HCW management will differ, and some of the 14 problems mentioned in **Figure 6** and **Table 2**, combine to cause significant difficulties as a whole. Therefore, it is necessary to grasp the current situation of HCW, clarify the problems, and analyze the problems specifically.

A flowchart for diagnosing HCW management is shown in **Figure 8**. By answering 10 basic questions in the flowchart, required issues and challenges for capacity development in the HCW management are derived as follows:


*Technical Cooperation for Enhancing Infectious Healthcare Waste Management DOI: http://dx.doi.org/10.5772/intechopen.102604*

institute level is assessed based on the law and regulation, which includes the availability of HCW plan and also its practice including segregation of HCW at source, collection, storing, and treatment. If the answer to this Question 3 is negative, then the challenge for capacity development is to formulate an HCW management plan at each level, and establish an HCW management system and strengthen the capacity of the implementing organization. This question corresponds to Problem No.2.

#### **Figure 8.**

*A flowchart for diagnosing an HCW management system and for identifying challenges in capacity development, which are the targets of technical assistance.*


*Technical Cooperation for Enhancing Infectious Healthcare Waste Management DOI: http://dx.doi.org/10.5772/intechopen.102604*


### **6. Development of HCW management system in Palestine: a case study**

Over the past decades of experience in Palestine is a typical example of inadequate HCW management [35], where one of the major threats came from that much of hazardous infectious HCW had mixed with MSW [37] and flowed into dumpsites without any treatment and safety measure [38, 39].

In 2010, the Palestinian National Authority (PNA) compiled a report on the development of a National Master Plan for Hazardous Waste Management in the West Bank and Gaza [40]. According to the report, only one-third of the healthcare facilities used special bags for HCW collection, whereas all other facilities consequently collected all types of HCW together with MSW, except for sharps that were being collected in special boxes. The report also stated that 80% of healthcare facilities in Gaza had no way to securely store HCW generated. MSW was generally collected by local government units (LGUs) without any discrimination between HCW and MSW, and eventually, all types of solid waste were mixed and disposed.

In 2012, PNA enacted Palestinian Authority Cabinet Decision No. (10) of 2012, "Medical Waste Management System, and its Uses". The bylaw allowed both distributed (on-site) and centralized (off-site) systems of HCW treatment. As a practice based on the bylaw, the first systematic HCW collection & treatment service has been started in the southern area of West Bank (Hebron and Bethlehem governorates), where an HCW treatment (microwave) facility was equipped under the support of the EU. It is a typical "centralized system" and its operation and maintenance (O/M), as well as HCW collection, transportation, and disposal, were conducted by the Hebron-Bethlehem Higher Joint Service Council for Solid Waste Management (H-B JSC). However, in the remaining middle and northern part of West Bank and over the Gaza Strip, most of the HCW generated was still mixed and disposed without any treatment. The required local HCW management plan was little formulated at each healthcare institution and authority.

Under the circumstances described above, international technical cooperation projects for the capacity development of Palestinian authorities on HCW management were organized in the Gaza Strip from 2015 [22, 39, 41, 42], those are composed of five components: (1) assessment study to grasp the current state of HCW; (2) formulation of a strategy and preparation of HCW management plan; (3) capacity building activities such as seminars, workshops, and staff training courses; (4) Pilot projects on on-site and off-site HCW management to verify the effectiveness, efficiency, and feasibility of the HCW management plan; and (5) Provision of equipment by international donors.

As of 2015, there were 2245 inpatient beds in public hospitals and 619 inpatient beds in private/NGO hospitals in the Gaza Strip. The proper on-site segregation of the infectious and sharps showed that 2.4–0.7 kg/day of HCW is generated from hospitals and clinics. The generation rate from outpatients accounts for a rate of 11.0 g–9.5 g per outpatient [41]. The estimated total HCW generation amount was around 7199 kg/ day, and the estimated amount of infectious HCW was calculated around 1071 kg/day.

Healthcare institutions in the Gaza Strip are responsible for on-site management, where MOH conducts monitoring, supervision, and enforcing bylaw on all healthcare institutions for their compliance with appropriate on-site management; three categories of segregation at sources (sharps, infectious, and noninfectious), controlled storage, and separated discharge of HCW.

Regarding the responsibility for off-site HCW management in the centralized system, collection, transport, treatment by autoclave/microwave, and final disposal, the collection service have been managed by the Joint Service Council of Khan Yunisi, Rafah, and Middle Gaza (JSC-KRM) since 2017, and later JSC of North Gaza and Gaza (JSC-GNG) has started the service since 2020. An HCW management system was established over the Gaza Strip as the twin centralized systems using autoclave/ microwave facilities for the infectious waste treatment (**Figure 9**). From 2017 to 2019, intensive training courses have been held for the workers in healthcare institutes and service providers (JSCs).

The costs of HCW management services are borne by the HCW generator based on the polluter-pay principle (PPP), where each healthcare institute pays a reasonable fee to JSCs. In the pilot project in the southern Gaza Strip from 2018 to 2019, the real costs for waste collection, transportation, treatment, and final disposal operations

#### **Figure 9.**

*Centralized HCW management systems, service providers, and supervising authorities in Gaza Strip.*

were measured and aggregated, and the cost per unit weight of infectious HCW was determined. In this way, the HCW management systems in Gaza have basically been established.

HCW management is still not fully established in the West Bank area of Palestine. An international cooperation project supported by Japan (JICA) is currently conducting assessment surveys and planning, and in 2022, three centralized treatment facilities will be installed, staff training courses will be organized, and HCW management services will be started to the entire area.

More than 10-year process corresponds well with the 10-step diagnostic process described earlier (**Figure 8**), demonstrating that Palestine has gradually improved its capacity for HCW management.

In Gaza Strip, the 1st step was the enacting bylaw on HCW management in 2012, and then the 2nd step of the survey on the present state of HCW was conducted from 2010 (Master Plan) to 2016 (Gaza Local Plan). The 3rd step of the local HCW management plan and 4th step of the staff training program was conducted from 2017 to 2019. Under given conditions, public (JSCs) operating centralized treatment system was introduced as 5th and 6th steps in 2018, and autoclave and microwave facilities were equipped from 2018 (autoclave) to 2021 (microwave) as the 9th to 10th steps.

On the West Bank, it is still in the 2nd and 3rd steps, but in 2022, the treatment facility will be equipped, training will be conducted, HCW management services will be started, and 10 steps are expected to be achieved.

## **7. Conclusions**

Proper management of HCW in developing countries is an urgent issue. It is important not only for public health and environmental protection in developing countries, but also for controlling infections throughout the world, in the time of pandemics.

According to statistical cross-country analysis, the amount of HCW generation shows a moderate positive power correlation with economic growth (GDP/capita). It also shows a positive power correlation with the amount of MSW generated. This indicates that economic growth will lead to an increase in MSW as well as a rapid increase in the amount of HCW generated. On the other hand, in countries with a high level of service coverage of MSW collection of 83% or more, a sudden increase in the amount of HCW are observed. This is considered to indicate that the recognition of HCW generation and the necessity of its proper management are formed in the public administration of HCW issues when the MSW management service reaches a certain stage.

It is necessary to establish an effective HCW management system and strengthen its implementation capacity, especially in developing countries. When conducting international technical assistance for them to support the establishment of the HCW management system and capacity development, it is required to set the targets for technical assistance through conducting an assessment survey, analyzing the problems, evaluating risks, supporting to formulate HCW management plans, and provision of equipment.

A flow chart to the 10-step diagnosis of HCW management is proposed to identify issues and challenges of HCW management in developing countries. The results can be used for setting the targets of technical assistance and cooperation for enhancing HCW management. More than 10-year process of technical assistance

and cooperation program in Gaza Strip, Palestine corresponds well with the 10-step diagnostic process, demonstrating that Palestine has gradually improved its capacity for HCW management.
