The World Bank 1818 H Street N.W. (202) 477-1234

INTERNATIONAL BANK FOR RECONSTRUCTION AND DEVELOPMENT Washington, D.C. 20433 Cable Address: INTBAFRAD

INTERNATIONAL DEVELOPMENT ASSOCIATION U.S.A. Cable Address: INDEVAS

May 28, 1999

Dear Colleagues:

As many of you may know, the World Bank has been developing a Health Care Waste Management Guidance Note for Bank staff. It is meant to supplement technical guidelines that will soon be published by the World Health Organization (WHO), and not to replace these guidelines. Thus, we hope you can review this document as a resource for the Bank and not as an absolute set of guidelines for use by all countries. We have worked with WHO on this document.

The Bank's DRAFT Health Care Waste Management Guidance Note is an attempt to answer questions for World Bank Task Team Leaders (TTLs). Thus, issues discussed in this Note are particular to Bank policies on subjects such as goods procurement, transportation, and facility construction. Furthermore, since there are no global definitions of medical or health-care waste, this Note simply provides a series of checklists for TTLs who manage various types of health projects. The World Bank looks to the WHO for definition and dissemination of specific guidelines on medical or health care waste management.

There are several issues that may need further research in low- and middle-income countries (i.e., Bank clients) with relatively small amounts of medical waste. For example, the tradeoff between incineration and potential chemical releases (primarily dioxins and furans) needs to be examined. Second, procurement policies might be used to reduce the health care waste (HCW) load (especially in developing countries), but these policies may be limited in this regard by the type of contracting involved (i.e., national competitive bidding versus sole source contracting). In addition, procurement regulations should not create a prohibitive cost burden to countries that are struggling to provide adequate health care services with limited resources. Third, coordination is necessary between donor agencies and countries to assure that only necessary items are donated or procured, thereby reducing redundant materials that need disposal. Fifth, if the waste stream is relatively small, expensive treatment and disposal plants should not be erected. Rather, use of conventional waste management should be used, along with appropriate safe handling procedures.

Decision makers must weigh the social, environmental, public health, and fiscal implications of each waste management situation. Options which seem benign, such as land filling, create concerns about groundwater contamination and leaching. Another seemingly benign practice, autoclaving and sterilization, is a clean alternative only if enough energy and water is available for the process. Careful management of incineration can reduce emission levels (such as high incendiary temperatures and multiple scrubbers), but these may not be appropriate in higher income countries. Thus, each situation creates a separate set of equations, not necessarily solved by strict guidelines.

The World Bank considers this Note to be a living document, allowing for best practices and lessons learned to be incorporated as experience is gathered. Thus, we invite your input. We know the demands on your time and energy, but please try to provide these comments to us by June 30, 1999. Thereafter, the Note will be discussed with our WHO partners and disseminated internally at the Bank and to our country counterparts. Thank you in advance for your consideration and input.

Sincerely yours,

Thomas E. Novotny, MD MPH Jennifer Prah-Ruger, PhD

CDC Liaison, World Bank Economist

HDNHE HDNHE

cc: Annette Prüss (WHO); H. Saxenian, G. Boyer, C. Bartone, D. Hanrahan, M. Dijkmam