As mentioned in previous sections, HCWM is first of all a management issue before being a technical one. Significant improvements can already be achieved with basic equipment, some sound planning as well as by raising the level of awareness and training HCF staff.

Basic actions to be taken

At different steps along the HCW stream, simple actions can be taken to help reduce overall HCWM costs with limited financial investments.

1. Minimize waste

"The less waste you produce and the more you recycle/ reuse, the less you will have to spend on HCW treatment and final disposal" is another way of formulating what waste minimization is about.

Actions should be taken both before waste is generated (also called "source reduction") - through efficient purchasing policies and good stock management (which are effective ways of reducing purchasing, storage and elimination costs) - and after, by recycling or reusing non-hazardous materials.

In many countries, a high percentage (up to 70-90%) of the injections administered are unnecessary, either because the substance injected is inappropriate (such as injecting vitamins to address fatigue) or because the substance can be given in non-injectable (primarily oral) form. Reducing the number of unnecessary injections is a high priority issue. It will not only help eliminate an important number of unsafe injections (see point 4) but will also reduce purchasing costs (injection equipment) and waste treatment and disposal costs significantly.

2. Segregate waste

Proper HCW segregation and containerization is one of the most critical actions in terms of security and cost effective, since this reduces significantly the amount of waste that needs specific and costly treatment (treating HCRW costs approx. 10-20 times more than general waste).

In most instances, implementing a simple three-bin system (with appropriate colour-coding) will already introduce significant improvement:

• Sharps (yellow or red containers)
• Infectious HCW (yellow or red bags/ bins)
• General non-infectious HCW (black bags/ bins)

3. Select the most appropriate treatment/ final disposal method

If a number of low-cost solutions exist such as burial pits, they may not be sustainable due to space constraints for example. It is therefore critical to take into account the different parameters that will help select the most appropriate system for medium-long term sustainability.

Whenever possible, implementing a regional centralised HCW treatment policy through the installation of larger units is not only more cost effective, reduces the amount and number of point sources of pollution, but also renders monitoring of these treatment facilities easier to carry out.

The technical database provides costing information (capital and recurrent costs) as well as capacity data that can be used to help select the most appropriate solution for a given setting.

4. Focus on sharps

Each year some 16 billion injections are performed worldwide for both the curative and immunization sectors. Due to both the high percentage or needle reuse (approx. 40% of all injections globally) and the number of needle-stick injuries, some 21 million hepatitis B (30 percent of all new infections), 2 million hepatitis C (40 percent of all new infections), and over 1/4 million HIV infections (5 percent of all new infections) occur each year.

As published in a WHO study (Bulletin 81(4), 2003: p. 277-285), the cost-effectiveness of implementing safe and appropriate use of injections (which includes sharps waste collection and management) has been demonstrated.

Currently, it is estimated that for each injection 0.01 USD is spent on sharps waste disposal interventions. By investing 0.04 USD per injection to improve current disposal systems, one could reduce significantly the current public health burden caused by this especially hazardous HCW category.

Investing in sharps waste management is a critical component of injection safety and shouldn’t focus only on immunization services that represent only a fraction (approx. 6% of all injections) performed.

The next pages provide advice on the steps that should be taken as well as several approaches to estimate/ calculate the necessary funds required to set up and maintain an efficient HCWM system.