Financial resources are often more limited in district/ regional hospitals than large teaching hospitals. These institutions also usually produce both less HCW in terms of quantities and in terms of diversity of waste (no radioactive waste and cytotoxic drugs, etc.).

As for all HCFs, according to the “Polluter Pays Principle”, the waste generator must pay for all the costs associated with the appropriate treatment and disposal of their HCW. To help you keep costs as low as possible, here are a few basic steps to be taken.

Lower HCWM costs by optimizing current practices

Due to frequent limitations in financial resources available, medium size and small hospitals need to optimize as much as possible the existing system through the following steps.

1. Minimize quantity and toxicity of waste

As in all HCFs, carrying out a thorough study of all the waste streams of the HCF can help determine what alternatives can be taken with regards to source reduction, reuse and recycling. The aim here isn't just to reduce the quantity but also the toxicity of waste produced (which diminishes both disposal costs and hazards to health workers and the environment).

A special focus should be put on the reduction of unnecessary injections as explained in the priorities section.

Purchase of reusable materials and proper training of staff are investments that clearly pay off in the medium - long term.

2. Segregate and containerize HCW

Investing in waste segregation (mainly a training issue) that requires having appropriate containers for each waste category is the best way to reduce treatment and disposal costs significantly.

Expenditures typically include:

• Purchase of color-coded containers/ bags (+ eventual labels);
• Training of HCF staff;
• Personal protective equipment (PPE);
• Storage spaces within the facility;
• Packaging and transportation costs, if waste is treated off-site.

The segregation structure as well as the type of containers used will depend to a large extent on the HCW treatment system chosen. Will needle cutters be used to separate the steel needle from the plastic syringe for subsequent recycling or is the entire combination going to be disposed of into a sharp box to be autoclaved, encapsulated or incinerated ?

As mentionned earlier, the choice depends on numerous parameters that vary from one area to another and should be carefully assessed.

3. Select the most appropriate HCW treatment technologies

Before choosing a HCW treatment system, there is an initial point that needs to be decided upon: does one favor on-site or off-site treatment ?

To help you choose, please take a look at the advantages and drawbacks explained in the large HCFs section.

4. Final disposal costs

When evaluating treatment options, it is important to take into account final disposal costs that can vary significantly depending on the treatment system used: if incineration reduces significantly the volume and weight of waste left, the ashes can still contain certain toxic components; steam sterilization systems that don't include dryers may even increase the weight of waste to be disposed of, etc.

Elements of final disposal costs are provided in the large HCFs section.

Financial sustainability

Finding funds for the required initial investments is often easier than being able to mobilize resources to ensure medium-long term financial sustainability. It is therefore critical for each HCF to estimate what financial resources it can realistically rely on before setting up a system and purchasing equipment that can't be maintained in the long run due to insufficient funds.

If, ideally, recurrent costs and amortization should be covered by MoH and/ or MoEnv. budget(s), local recurrent costs in most HCFs are often best covered by local recurrent budgets. Hospitals should therefore budget for their own recurrent HCWM costs.

Looking into possible partnerships with surrounding HCFs to set up and use a common HCW treatment system when no private operators exist are simple yet effective ways of sharing costs.

Financial monitoring

Keeping track of what HCWM costs is the best way to:

• Ensure one will have the required funds to maintain the system (one can't budget something who's cost is unknown);
• Gain support from potential external donors by showing them that funds are properly tracked and well managed;
• Optimize the current system in terms of cost-effectiveness by being able to compare current expenditures with those linked to an eventual other technical/ management system.

To simplify this monitoring task, a specific HCWM accounting line is strongly recommended.

Resources

Tool B2 of the Excel costing spreadsheet provides costing methods as well as indicative reference values in Tool C.