POLICY AND PRACTICE OF HEALTH CARE WASTE MANAGEMENT IN

COMMUNITY-BASED CARE IN SOUTH AFRICA

By
Lydia Hangulu
(210546147)

Supervisor: Dr Olagoke Akintola

Submitted in partial fulfilment of the requirement for the degree

Doctor of Philosophy (Health Promotion)
 DECLARATION

I declare that the work in this thesis has not previously been submitted for a degree in any other
institution other than the University of KwaZulu-Natal.
I certify that this thesis is my original work and all information sources and literature used have
been duly acknowledged. All the research assistants that provided assistance during the research
process have been acknowledged.

Name: Lydia Hangulu

Student Number: 210546147

Date: 22-March-2016

ii
 ACKNOWLEDGEMENTS

I am grateful to my supervisor Dr Olagoke Akintola for mentoring me throughout my studies.

I am grateful to my husband Peter Mudenda for the encouragement and support provided during
this study.

I acknowledge and value the support of my research assistants Noloyiso Dlilanga, Samantha
Moodley and Cassidy Shaw who assisted me with data collection.

I am grateful to my friend Dr Kwaku Oppong Asante for his encouragement and moral support
during the study.

My heartfelt gratitude goes to my friends Ola Adewumi, Ida manyina, Vimbai Chibango, Danford
Chibvongodze, Bianca Netsai Gwelo, Alpha Kose and all my colleagues from Disability Unit for
their encouragement and support while doing this study.

I would like to thank my family for their constant prayers and understanding during my school
programmes.

I acknowledge and thank the Health Economics and HIV and AIDS Research Division for
providing me with a three year PhD scholarship (2013-2015).

I also acknowledge and thank the African Doctoral Dissertation Research Fellowship (ADDRF)
2014-2016 programme for a doctoral research grant awarded by the African Population and Health
Research (APHRC) in partnership with the International Development Research Centre (IDRC).

Most importantly I would like to thank God who has brought me this far and for providing me
with all the blessings that I deserve.

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 ACRONYMS

AIDS Acquired immune deficiency syndrome

ART Antiretroviral therapy

CBC Community-based care

CBOs Community-based care organisations

CHWs Community health workers

DOH Department of Health

HCW Health care waste

HCWM Health care waste management

LMICs Low-and-middle-income countries

PLWHA People living with HIV/AIDS

OVC Orphaned and vulnerable children

UNEP United Nations Environmental Programme

USAID United States Agency for International Development

WHO World Health Organization

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 ABSTRACT

Health care waste management (HCWM) is a growing concern more especially in the low- and

middle-income countries (LMICs). Improper management of health care waste (HCW) has

negative effects on the environment and on the health of the people. Unfortunately, no study has

been found so far that addresses policy and practice of HCWM in community-based care (CBC)

in South Africa. This thesis begins to address HCWM issues through five manuscripts that use

various methods and approaches to develop an understanding of HCWM in CBC. The main scripts

in this thesis present: 1) a scoping review that highlights the terminologies of HCW, definitions,

categories and its classifications; 2) analysis of international and national policies that govern

HCW in South Africa; 3) media analysis which explains how the South African media frames the

issue of HCWM; 4) results from interviews with policy makers and stakeholders regarding their

opinions on the practices of HCW in CBC; 5) results from focus group discussions, informal

interviews and participant observations from the community health workers (CHWs) indicating

their experiences about HCWM practices. This study is the first to be conducted in CBC. The

methodologies used in this study provide useful insights into HCWM and the findings are an

addition to the body of literature on HCWM in CBC, environmental health and public health.

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 TABLE OF CONTENT
DECLARATION......................................................................................................................................... ii
ACKNOWLEDGEMENTS ...................................................................................................................... iii
ACRONYMS .............................................................................................................................................. iv
ABSTRACT ................................................................................................................................................. v
TABLE OF CONTENT ............................................................................................................................. vi
CHAPTER ONE: INTRODUCTION ....................................................................................................... 1
Background of the study ............................................................................................................................... 1
The problem statement .................................................................................................................................. 3
Main objective and the significance of the study .......................................................................................... 3
Specific objectives ....................................................................................................................................... 3
Specific research questions ......................................................................................................................... 4
Contributions of the study ............................................................................................................................. 6
References ..................................................................................................................................................... 8
CHAPTER TWO:THEORETICAL FRAMEWORK........................................................................... 13
Introduction ................................................................................................................................................. 13
The ecological systems theory .................................................................................................................... 13
Assumption of the ecological systems theory ............................................................................................. 15
Application of the theory to this study ........................................................................................................ 15
Figure 2 Ecological systems theory as applied to this study sourced from (Bronfenbrenner, 1974) .......... 16
Conclusion .................................................................................................................................................. 17
References ................................................................................................................................................... 18
CHAPTER THREE: Health care waste in the health care sector: A scoping review......................... 19
Abstract ....................................................................................................................................................... 21
Introduction ................................................................................................................................................. 22
Database search/literature search ................................................................................................................ 25
Review and selection of literature ............................................................................................................... 25
Mapping of the literature............................................................................................................................. 27
Results ......................................................................................................................................................... 28
Table 6. Terms, definition and classification of health care waste ............................................................. 34
Discussion Principal Findings ..................................................................................................................... 35
Strengths and limitations............................................................................................................................. 37
Future research ............................................................................................................................................ 37

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References ................................................................................................................................................... 39
CHAPTER FOUR: A REVIEW OF INTERNATIONAL AND SOUTH AFRICAN POLICIES
THAT ADDRESS HEALTH CARE WASTE MANAGEMENT ....................................................... 42
Abstract ....................................................................................................................................................... 44
Introduction ................................................................................................................................................. 45
Table 1.Timeline for the international policies governing health care waste .............................................. 46
Background to the development of health care waste management policies .............................................. 47
Table 2. Categories of health care waste ..................................................................................................... 51
Table 3. Summary of sources of health care waste ..................................................................................... 52
Details of health care waste management recommendation by WHO ........................................................... 53
Table 4. WHO recommended storage scheme ............................................................................................ 53
Table 5. Summary of categories of wastes and their disposal methods ...................................................... 55
Health Care Waste Management Guidance Note World Bank, 2000 ......................................................... 56
Health care waste management policies in South Africa ............................................................................ 57
The South African Constitution (Act 108 of 1996) ...................................................................................... 58
The White Paper on Integrated Pollution and Waste Management for South Africa, 2000 ....................... 59
The National Environmental Management Act 107 of 1998 (NEMA) ........................................................ 60
The National Health Act, 61 of 2003 .......................................................................................................... 60
The Occupational Health and Safety Act 85 of 1993 .................................................................................. 61
Health care waste at the national level: The SANS CODE, 2004............................................................... 61
The provincial regulations on health care waste management .................................................................... 64
The National Health Care Risk Waste Management Regulations of 2008 ................................................. 66
CHAPTER FIVE: PRINT MEDIA REPORTING OF HEALTH CARE WASTE MANAGEMENT
IN SOUTH AFRICA ............................................................................................................................... 71
Introduction ................................................................................................................................................. 74
Table 1: Key health care waste management policy developments relevant to South Africa ..................... 76
Methods ...................................................................................................................................................... 78
Newspaper search and selection strategy ................................................................................................... 79
Table 2: Characteristics of newspapers covered in analysis ....................................................................... 80
Search strategy for news stories ................................................................................................................. 81
Selection and analysis of news stories ........................................................................................................ 82
Data analysis ............................................................................................................................................... 82
Results ......................................................................................................................................................... 85
Problems and causes ................................................................................................................................... 88
Conclusion ................................................................................................................................................ 104
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Strengths and limitations........................................................................................................................... 105
References ................................................................................................................................................. 106
CHAPTER SIX: HEALTH CARE WASTE MANAGEMENT IN COMMUNITY-BASED CARE
IN SOUTH AFRICA: PERSPECTIVES OF POLICY-MAKERS AND STAKEHOLDERS ....... 112
Abstract.................................................................................................................................................... 113
Methods Research design ....................................................................................................................... 116
Study setting and context Background ...................................................................................................... 116
Participants................................................................................................................................................ 117
Table 1: Roles and demographic characteristics of policymakers and stakeholders................................. 117
Data collection procedure ......................................................................................................................... 118
Data analysis ............................................................................................................................................. 119
Results ....................................................................................................................................................... 119
The perceived health care waste management practices in community-based care .................................. 119
The perceived challenges with health care waste management practices in community-based care at
household level ....................................................................................................................................... 121
Lack of segregation of waste in homes by households .............................................................................. 122
Illegal dumping ......................................................................................................................................... 123
The perceived causes of challenges with health care waste management practices in community-based
care at the household level ...................................................................................................................... 124
Perceived challenges with health care waste management practices at the municipality level................. 127
Corrupt tender processes .......................................................................................................................... 127
Inadequate funding for health care waste management programmes: ..................................................... 128
Strategies used to deal with health care waste management challenges in community-based care combined
at the household and municipality levels ................................................................................................. 129
Reporting and liaising with government ................................................................................................... 131
Discussion ................................................................................................................................................. 131
Conclusion ................................................................................................................................................ 135
Areas for further research.......................................................................................................................... 136
References ................................................................................................................................................. 137
Appendix 1: Introducing the study to the policy makers and stakeholders............................................... 142
Appendix 1: Introducing the study to the policy makers and stakeholders (the Zulu version) ................. 143
Appendix 2: Consent Form ....................................................................................................................... 144
Zulu version .............................................................................................................................................. 144
Appendix 3: interview guide for ward councillors and community-based care managers........................ 147

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Appendix 3: interview guide for the education officers (Zulu version) .................................................... 149
Appendix 3: interview guide for the area cleansing officers (Zulu version) ............................................. 150
Appendix 3: interview guide for ward councillors and community-based care managers (Zulu version).
.................................................................................................................................................................. 152
CHAPTER SEVEN: HEALTH CARE WASTE MANAGEMENT IN COMMUNITY-BASED
CARE: PERSPECTIVES OF COMMUNITY HEALTH WORKERS IN SCARCE RESOURCE
COMMUNITIES IN SOUTH AFRICA .............................................................................................. 153
Abstract ..................................................................................................................................................... 155
Key words: Health care waste, community-based care, caregivers, HIV/AIDS. ...................................... 156
Introduction ............................................................................................................................................... 156
Methods .................................................................................................................................................... 158
Study setting and context .......................................................................................................................... 158
Table 1: Demographics of the organisations ............................................................................................. 159
Participants................................................................................................................................................ 160
Data collection method and procedure...................................................................................................... 160
Table 2. Characteristics of community health workers ............................................................................. 162
Data analysis ............................................................................................................................................. 163
Results ....................................................................................................................................................... 163
Activities responsible for generating health care waste in community-based care ................................... 163
Management of health care waste in community-based care .................................................................... 164
Barriers to proper health care waste management .................................................................................... 167
Lack of assistance from family members .................................................................................................. 167
Irregular waste collection by waste collectors ......................................................................................... 168
Inadequate water for practicing hygiene and sanitation .......................................................................... 169
Long distance between the house and the toilets ...................................................................................... 170
Discussion ................................................................................................................................................. 172
The community level ................................................................................................................................ 172
The municipality level .............................................................................................................................. 175
Conclusions ............................................................................................................................................... 178
Strengths and limitations of the study ....................................................................................................... 178
Areas for further research.......................................................................................................................... 179
References ................................................................................................................................................. 180
Appendix 1: Introducing the study to the community health workers ...................................................... 186
Appendix 1: Introducing the study to the community health workers (the Zulu version) ........................ 187
Appendix 2: Consent Form ....................................................................................................................... 188

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IncwadiYemvume ..................................................................................................................................... 188
Appendix 3: Focus group guide for community health workers Checklist for Caregivers ....................... 189
A. Organizational demographics questions .............................................................................................. 189
General questions ...................................................................................................................................... 189
Appendix 1: Focus group guide for community health workers the (Zulu version) Checklist for
Caregivers ................................................................................................................................................ 192
Organizational demographics questions ................................................................................................... 192
CHAPTER EIGHT: Integrative Conclusion ........................................................................................ 194
Introduction ............................................................................................................................................... 194
Chapter two: Theoretical framework ........................................................................................................ 194
Chapter 3: The scoping review ................................................................................................................. 196
Chapter 4: Review of international and South African policies governing health care waste management.
.................................................................................................................................................................. 196
Chapter 5: Print media analysis ................................................................................................................ 198
Chapter 6: Interviews with policy makers and stakeholders ..................................................................... 198
Chapter 7: Practices and perspectives of community health workers on HCWM .................................... 199
1. The policy aspect of health care waste management in community-based care ................................... 200
2. The practices of health care waste management in community-based care .......................................... 202
Lack of segregation of HCW ..................................................................................................................... 202
Illegal dumping ......................................................................................................................................... 203
Practical interventions ............................................................................................................................... 204
Overall academic contribution of the study .............................................................................................. 205
References ................................................................................................................................................. 207

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 CHAPTER ONE

INTRODUCTION

Background of the study

Fay, Beck, Fay and Kessinger (1999) explain that, as modern medicine in the health care industry
continues to maintain and sustain people’s wellness and quality of life; by-products such as the
health care waste (HCW). Health care waste that is generated could have adverse effects on both
people and the environment. HCW is a by-product of health care activities and it includes waste
that is produced in homes where there is care for the patient (Pruss, Giroult and Rushbrook, 1999).
Usually, about 75% to 90% of the waste that is produced in health care facilities poses no risk as
it is comparable to domestic waste. It contains waste from administrative and housekeeping
sections of the facilities. The remaining 10% and 25% of it is hazardous (Pruss et al., 1999;
Hossain, Santhanam, Norulaini and Omar, 2011). Proper health care waste management (HCWM)
involves: segregation and classification of HCW according to the risks it poses, storage, collection,
transportation, processing and disposal (Pruss et al., 1999). HCWM is important because it protects
the health of the public and the environment (Zurbrugg, 2003; Ruoyan et al., 2010:246).

Literature on HCWM in low-and-middle-income countries (LMICs) shows that large volumes of

HCW is produced (Alagoz and Kocasoy, 2008) and it is poorly managed (Hossain et al., 2011).
The challenges that are reported with HCWM are lack of clear policies for HCWM (Leonard,
2005; Soliman and Ahmad, 2007; Alagoz and Kocasoy, 2008; Sawalem, Selic and Herbell, 2009),
and most staff working in health care facilities lack sufficient knowledge on handling HCW
(Abdulla, Qdais and Rabi, 2008; Kumar, Khan, Ahmed, Khan, Magan, Nausheen and Mughal,
2010; Ruoyan et al., 2010; Abah and Ohimain, 2011). HCW is not segregated (Mundia and
Mbewe, 2006; Sawalem, Selic and Herbell, 2009; El-Salam, 2010; Ferreira and Teixeira, 2010;
Mangaa, Fortonb, Moforc and Woodardd, 2011); it is transported using vehicles not meant for
transporting HCW (Mohee, 2005; Mbongwe, Mmereki and Magashul, 2008; Franka, El- Zoka,
Hussein, Elbakosh, Arafa and Ghenghesh, 2009; Sawalem et al., 2009; Gabela and
Knight, 2010); HCW handlers do not have protective materials (Mohee, 2005; Soliman and

1
Ahmad, 2007; Mangaa et al., 2011); HCW is dumped in poorly managed dumpsites and
scavenging is allowed without any measures put in place (Bendjoudi, Taleb, Abdelmalek and
Addou, 2008; Sawalem et al., 2009); and HCW is incinerated openly (Nemathaga et al., 2008;
Hassan et al., 2008; Bendjoudi et al., 2009; Patwary et al., 2009; Coker et al., 2009). Improper
management of HCW causes environmental pollution (Drackner, 2005; Kassim and Ali, 2006;
Abdulla et al., 2008; Ramokate, 2008). HCW in the environment also exposes the public to
infections and toxins (Bdour, Altrabsheh, Hadadin and Al-Shareif, 2007; Harhay, Halpern, Harhay
and Olliaro, 2009; Ferreira and Teixeira, 2010; Magdy and El-Salam, 2010).

As much as there are challenges with managing waste in health care facilities, the waste that
emanates from community-based care (CBC) is of greater concern because unlike in hospitals,
homes are not built to accommodate HCW (Verma, Mani, Sinha and Rana, 2008). CBC is the care
that is provided to the chronically ill patients in the comfort of their own homes in the communities
by community-based organizations (CBOs) (Buhler-Wilkerson, 2001). Wilson, Lavis and Guta
(2012) argue that CBOs provide services and support to the marginalised, disadvantaged and
stigmatised communities because they understand and are connected to the community members.
Similarly in South Africa, CBOs provide various services that range from orphan and vulnerable
children (OVC) programmes, home-based care and AIDS awareness programmes, antiretroviral
therapy (ART), palliative care, counselling, education on increasing health of the patients,
symptom control and psychosocial services (Akintola, 2008; Young and Busgeeth, 2010).
Community health workers (CHWs) who are volunteers are recruited and trained by the CBOs to
assist family members to provide basic nursing services to the patients (Akintola, 2006).

Some studies on CBC allude to the fact that CHWs are at risk of HIV or tuberculosis (TB)
infections and have low knowledge of prevention of such infections (Akintola, 2006; Kang’ethe,
2009; McInerney and Brysiewicz, 2009). Furthermore, challenges that impede the CHWs’ work
in CBC are lack of materials for providing nursing care (Akintola and Hangulu, 2014), lack of
toilets in some households (Phorano, Nthomang and Ngwenya, 2005; Kgalushi, Smits and Eales,
2008), lack of water taps in some homes (Azwidihwi and Davhana-Maselesele, 2009), CHWs are
ridiculed by their friends and some family members of the patients (Akintola, 2008), there is lack
of remuneration for CHWs (Akintola, 2006; Shaibu, 2006), and CHWs experience stress and
2
burnout (Dageid, Sedumedi and Duckert, 2009). However, it is not clear how and to what extent
HCW is managed in CBC. I found no single study focused on this theme in South Africa.

The problem statement

Some previous studies on CBC in South Africa have focused on the global financial crisis and its
impact on the CBOs (Akintola, Gwelo, Labonte and Appadu, 2015), infection control practices
(Akintola and Hangulu, 2014), perceived burnout by caregivers (Akintola, Hlengwa and Dageid,
2013), perceptions of rewards among caregivers (Akintola, 2010), the burdens of care by CHWs
(Akintola, 2008), and challenges faced by CHWs (Akintola, 2006). There is no study that has been
conducted to explore the policies and practices of HCWM in CBC within South Africa.
Furthermore, little is known about media framing of HCW in South Africa; the experiences of
policy makers and stakeholders and CHWs regarding HCWM in CBC within the South Africa.

Main objective and the significance of the study

This study sought to explore health care waste management policies and practices in community-
based care in Durban metropolis in South Africa. The findings could be useful for policy makers
as well as programme planners for developing and designing policies aimed at improving HCWM
in CBC across the country. The findings will also be an addition to the body of literature on CBC,
public health and environmental health because health care waste management cuts across the
mentioned disciplines. This main objective will be achieved through the following specific
objectives and research questions.

Specific objectives

1. To explore the terminologies used in literature to describe, define, categorise and classify health
care waste. This objective will help us understand the consistencies and the inconsistences that
exist with the terminologies.
2. To review international and South African national policies that govern health care waste
management. Reviewing these policies will provide information on what the policies and

3
regulations say about how health care waste from homes in community-based care should be
managed.
3. To explore media framing of health care waste management in South Africa. Media frames help
to get the attention of policy makers. Thus, understanding how the media frames issues relating to
health care waste management in South Africa could help inform policy and decision making about
health care waste management in general and specifically in community- based care.

4. To explore the experiences of policy makers and stakeholders regarding health care waste
management practices in community-based care in South Africa. The perspectives of policy
makers and stakeholders on HCWM in CBC in South Africa are important because such insights
will be useful for informing policy making and implementation of HCWM in CBC in South Africa.
5. To explore health care waste management practices of community health workers in South
Africa. The experiences of CHWs help to understand how health care waste management policies
are implemented in practice.

Specific research questions

1. What terminologies are used in literature to describe, define and categorise health care waste.
2. What are the international and South African national policies that govern health care waste and
what do they say?
3. How does the print media frame issues relating to health care waste management in South
Africa?
4. What are the experiences of policy makers and stakeholders regarding health care waste
management in South Africa?
5. What are the practices of health care waste management by community health workers in South
Africa?

Ethical considerations

Ethical clearance was sought and obtained from the Humanities and Social Science Research
Ethics Committee of the University of KwaZulu-Natal, South Africa. Permission to conduct the

4
study in CBOs was sought and granted by the CBO managers/gatekeepers. Informed consent was
also obtained from the participants: policy makers, stakeholders and community health workers.
Participants were informed of the beneficence of the study, participation was voluntary and
participants were informed of their right to withdraw from the study when they wished to do so.
No names were mentioned in the study to ensure anonymity. For confidentiality purposes,
participants were informed that all the data collected would be stored in the supervisor’s offices
and will be discarded after 5 years. Details of ethical approval and appendices are included in
chapters 6 and 7.

Structure of the thesis

To answer the research questions, the ecological systems theory by Urie Bronfenbrenner (1974)
will be used as a theoretical framework to guide this study. The theory is presented in Chapter 2
where I explain how the theory was developed; provide a brief discussion of its four levels, how it
has been applied in other studies and how it applies to this overall thesis on policy and practice of
HCWM in CBC.

Chapter 3 presents a scoping review to achieve the first objective. Scoping reviews are approaches
used to map broad topics (Anderson et al., 2008; Davis et al., 2009; Brien et al., 2010; Pham et
al., 2014). A scoping review was appropriate because it helped to map the broad terminologies
used to describe HCW, its definitions, categories and classification of HCW. The scoping review
includes literature with various study designs from different disciplines both from high as well as
low-and middle- income countries.

To achieve objective two, Chapter 4 presents a review of international and South African policies
that govern HCW. The context in which these policies were formed and what they say about
HCWM in CBC is discussed.

Chapter 5 provides a print media analysis of HCWM in South Africa. This was conducted to
achieve objective 3. Media analysis was conducted because the news media is known to be a major
source of information for the public and it can be used as a platform for communicating policy
initiatives by policy makers (Collins, Abelson, Pyman and Lavis, 2006). For example in South
Africa, media analysis has been proved to provide media frames of the causes and
solutions of the management of Multi-Drug Resistant and Extensive Drug resistance
6
Tuberculosis both at the individual and the health systems level (Daku, Gibbs and Heymann,
2012). Conducting media analysis will assist in understanding media frames of the problems and
their causes and the options available as well as implementation considerations relating to HCWM
in South Africa.

Chapter 6 presents the perspectives of policy makers and stakeholders about HCWM in CBC. This
aims to achieve objective 4. Semi-structured interviews were conducted with managers of CBOs,
the ward councillors who oversee development programmes in the communities, area cleansing
officers who are responsible for overseeing waste management programmes in the communities
and also education officers who are responsible for developing and conducting health awareness
and waste management programmes in the communities.

Chapter 7 sought to achieve objective 5. The study drew on ethnographic techniques: focus group
discussions (FGDs) and participant observations were used to gain a deep understanding of
HCWM practices of CHWs and households? During and after observations, informal discussions
were conducted with CHWs to help understand HCWM practices. An integrative conclusion of all
findings is presented in Chapter 8. The aim contributions of the study will be discussed and the
areas for further research.

Contributions of the study

As a whole, this study on policy and practice of HCWM in CBC is the first to be conducted in the
country. Improper management of HCW has adverse effects on the health of the people and the
environment. This makes HCWM an area of interest to public health and environmental health.
The overall insights that are provided in this study will be an addition of knowledge to the body of
literature on HCWM and to primary health care in general and to community-based care in
particular. The study also contributes to the field of public and environmental health more broadly.
Most studies on health care waste management have been conducted in hospitals and clinics. This
is the first study that has been conducted in community-based care. Therefore, this study is a
contribution to the body of literature on health care waste management in CBC. Methodologically,
this is the first study that has combined various methods: a scoping review,
review of policies, media analysis, qualitative interviews, ethnography: interviews focus group
7
discussions, participant observations and informal discussions on HCWM in CBC and in South
Africa. Additionally, using the ecological systems theory, this study has explains the link that
exists between policy and practices of HCWM in CBC in particular and HCWM in South Africa
more broadly.

8
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Kassim, S. M. & Ali, M. (2006). Solid waste collection by the private sector: Households’
perspective—Findings from a study in Dar es Salaam city, Tanzania. Habitat
International, 30(4), 769-780.

Kang'ethe, S. M. (2009). Traditional healers as caregivers to HIV/AIDS clients and other

terminally challenged persons in Kanye community home-based care programme
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Research Alliance, 6(2), 83-91.

Kgalushi, R., Smits, S. & Eales, K. (2004). People living with HIV/AIDS in a context of rural
poverty: the importance of water and sanitation services and hygiene education.
Johannesburg: Mvula Trust and Delft: IRC International Water and Sanitation Centre. Cited
June, 23, 2008.

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Kumar, R., Khan, E. A., Ahmed, J., Khan, Z., Magan, M. & Mughal, M. I. (2010). Healthcare
waste management (HCWM) in Pakistan: current situation and training options. Journal
of Ayub Medical College Abbottabad, 22(4), 101-106.

Leonard, L. (2004). Health care waste in Southern Africa: A civil society perspective. In
Proceedings of the International Health Care Waste Management Conference and
Exhibition, Johannesburg, South Africa.

Leonard, L. (2005). Healthcare Waste in Southern Africa: A civil society perspective.

Unpublished paper.

Mangaa, E. V., Fortonb, T.O., Moforc, A. L. & Woodardd.R. (2011). Health care waste
management in Cameroon: A case study from the Southwestern Region. Journal of
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Mbongwe, B., Mmereki, B. T. & Magashula, A. (2008). Healthcare waste management: current
practices in selected healthcare facilities, Botswana. Waste Management, 28(1), 226-233.

McInerney, P. & Brysiewicz, P. (2009).A systematic review of the experiences of caregivers in

providing home-based care to persons with HIV/AIDS in Africa. The JBI Database of
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Mohee, R. (2005). Medical wastes characterisation in healthcare institutions in Mauritius.Waste

Management, 25(6): 575-581.

Mundia, A. Y. & Mbewe, A. R. (2003). National Health-Care Waste Management Plan 2004-
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12
 CHAPTER TWO

PRESENTATION OF THE THEORY THAT IS GUIDING THIS STUDY:

THE ECOLOGICAL SYSTEMS THEORY

THE THEORY FOR HUMAN DEVELOPMENT

BY URIE

BRONFENBRENNER 1976

13
 CHAPTER TWO
THEORETICAL FRAMEWORK
Introduction

A theoretical framework in research is needed because it emphasises the context in which the study
is applied. It also justifies why a particular study is conducted and for which purpose it serves
(Grossman, Smagorinsky and Valencia, 1999). This study was guided by the ecological systems
theory (EST). This chapter will discuss what this theory is, who developed it and the various levels
of the EST will be explained. The chapter will also discuss how the EST has been applied in
various disciplines and how it applies to this study.

The ecological systems theory

The EST was first developed by Urie Bronfenbrenner as a theory of human development in the
1970s as shown in Figure 1 below. It explains how different environmental systems influence the
development of an individual (Bronfenbrenner, 1994). The theory includes the term “ecological”
which is borrowed from the word ecology. Using the scientific perspective, ecology is the study
of interactions of organisms in their environment. Additionally, ecology from the sociological
perspective explains how humans or groups relate to their existing environment (Begon, Harper
and Townsend, 1996). The word “systems” involves beliefs that a person is in constant interaction
with in the environment within networks. These networks can either have a positive or a negative
impact on an individual (Wilder, 2009). The EST is used in social work as a meta- paradigm which
is commonly referred to as “person in the environment”. This meta-paradigm describes how an
individual and various complex environments interact with each other and how they affect each
other (Weiss-Gal, 2008: p. 65). The ecological systems theory mainly focuses on individuals as
part of and integrating with other systems in the environment (WeissGal, 2008).

The EST has been used in health promotion studies to design interventions directed at changing
the intrapersonal, interpersonal, organisational, community and public policy (McLeroy, Bibeau,
Steckler and Glanz, 1988). The EST has also been applied in different health research studies. For
example, it has been applied in research to understand the experiences of family caregivers taking
care of aging adults (Wilder, 2009), to understand the caregiver’s perceptions on financing

14
community-based long-term care (Davis, 2009) and to understand the experiences of

15
caregivers in practicing infection control in home-based care settings (Hangulu, 2012). The EST
has four levels of influence and these are micro-system, meso-system, exo-system and macro-
system (Wilder, 2009).

Figure 1 Ecological theory for human development (Bronfenbrenner, 1974)

The micro-system is where the individual belongs and it comprises the influences relating to the
individual. These influences come from the individual’s family, peer groups and the
neighbourhood and these are called social agents. Social agents interact directly with an individual
and influence the individual’s behaviour either positively or negatively. The meso- system is the
level where the social agents belong and it is related to the micro-system were the family
experiences are related to the peers’ experiences and the peers’ experiences to the neighbourhood
experiences (Wilder, 2009). The exo-system is a level where organisations belong. It shows an
organisation that an individual works for. The organisation either affects an

14
individual’s life positively or negatively and vice-versa. The macro-system describes the nation
which describes the culture in which individuals live (Wilder, 2009). This level also includes
developing and industrialised countries’ socio-economic status, poverty and ethnicity (Woodside
et al., 2006).

Assumption of the ecological systems theory

The EST is based on an assumption that, when a person or group is connected and engaged in a
supportive environment, the functioning also improves (Davis, 2009).
Application of the theory to this study
This study applies four levels of the EST. The macro level: applied to this study, it is the
international policies’ level. The Exo level is the South Africa’s national policies level. The meso
level is the policy makers and the stakeholder’s level. The micro level is the community health
worker’s level. All levels are summarized in Figure 2.
The international policy level: This is the macro-system level that helped to review and
understand the international policies that govern health care waste (HCW). The review of
international policies was conducted to fulfill the second objective. The review covered how the
policies were developed, who developed them and the contexts in which they were developed.
Exploring international policies governing HCWM was important for understanding the context
and how such policies influenced the formation of policies at the national level.

The national policy level: This is the exo-system level that helped to review and understand
national policies that govern HCWM in South Africa. The review of policies at this level was
relevant to answer objective two. The policies governing health HCW were reviewed including
the context in which they were developed as influenced by the international policy environment.
Exploring these policies helped to understand how they are translated and implemented into
practice by the policy makers and stakeholders.

The policy makers and stakeholders’ level (municipality and community level): This is the meso-
system level where policy maker (the ward councilors) and stakeholders are found. In this study,
the stakeholders were: (1) the community-based care managers who are responsible for running
community-based care organisations in the communities; (2) the area cleansing officers who are
in charge of overseeing HCWM in the community; and (3) the education officers who are
responsible for developing and providing HCWM education in the communities.

15
 The macro level: International policies
on HCWM

The Exo level: National HCWM

policies in South Africa

The Meso level: policy makers and

stakeholders perspectives on HCWM in
CBC

The Micro level: HCWM

practices of CHWs in CBC

Figure 2 Ecological systems theory as applied to this study sourced from (Bronfenbrenner,
1974)

The policy and stakeholders work together with the community members to provide HCWM
services that are needed in the community. This level links to objective number four. This level
helped to explore the experiences of the policy makers and stakeholders about how HCWM
policies are interpreted and implemented in practice, in the communities that they serve. All
challenges and strategies used to address the challenges regarding implementation of HCWM
policies where explored. Understanding how the HCWM policies from the policy makers and
stakeholders’ perspective was necessary to determine how these policies are in line with the
international and national policies on HCWM.

The community health worker’s level: CHWs belong to the micro-system level. They provide
home-based care services to patients in homes within the community. Home-based care

16
involves nursing care activities that are responsible for generating HCW. This level is in line with
objective umber five. This level helped to explain how the HCWM policies are implemented in
practice by the CHWs in the homes of the patients. The challenges confronted, and how these
challenges are dealt with is explained. Understanding the CHWs’ perspectives was important to
determine how HCWM practices are in line with the international and the national policies on
HCWM and also to point out the inconsistencies.

Conclusion
This study assumes that there is consistency among all levels when it comes to policy and practice
of health care waste management (HCWM), meaning that if there are international and national
policies that govern HCWM, policy makers and stakeholders are more likely to implement them
hence the practices of HCWM are improved at the community level by the community health
workers or members.

17
 References

Bronfenbrenner, U. (1974). Is early intervention effective? Early Childhood Education Journal,

2(2), 14-18.

Bronfenbrenner, U. (1994). Ecological models of human development. Readings on the

Development of Children, 2, 37-43. Oxford: Elsevier.

Begon, M. Harper., J.L. & Townsend, C.R. (1996). Ecology: Individuals, Populations
and Communities (3rd.ed). Blackwell Science Oxford.

Weiss-Gal, I. (2008). The person-in-environment approach: Professional ideology and practice of

social workers in Israel. Social Work, 53(1), 65-75.

McLeroy, K. R., Bibeau, D., Steckler, A. & Glanz, K. (1988). An ecological perspective on health
promotion programs. Health Education & Behavior, 15(4), 351-377.

Davis, P. K. (2009). Financing Home and Community-Based Long-Term Care: Adult Children
Caregiver Perspectives. Graduate Theses and Dissertations, 530.

Hangulu, L. (2012). An Exploratory Study of Infection Control Practices in Home-based Care in

Durban, South Africa (Doctoral dissertation, University of KwaZulu-Natal, Durban).

Woodside, A. G., Caldwell, M. & Spurr, R. (2006). Advancing ecological systems theory in
lifestyle, leisure, and travel research. Journal of Travel Research, 44(3), 259-272.

18
 CHAPTER THREE

A SCOPING REVIEW OF TERMINOLOGIES USED TO

DESCRIBE

HCW, CATEGORIES AND CLASSIFICATION OF HEALTH

CARE WASTE

19
 Health care waste in the health care sector: A scoping review

Lydia Hangulu1

Olagoke Akintola2, 3

1. Health Promotion PhD Programme, University of KwaZulu-Natal.

2. Discipline of Psychology, Health Promotion Programme University of
KwaZulu-Natal.
3. School of Human and Social Development, Nipissing University, North Bay,
Canada.

This manuscript has been prepared for submission to Health Research Policy
and Systems.

I Lydia Hangulu [LH] was responsible for the conception and designing of this
study. My supervisor, Dr Olagoke Akintola [OA], provided guidance.
Samantha Moodley [SM] served as a research assistant and assisted with data
searches, assessment of the journal articles and the development of the coding
framework. The three of us worked together as assessors in developing
concepts for the methods section. I drafted the chapter under the guidance of
my supervisor.

20
 Abstract
Background: Health care waste (HCW) is generated during the provision of health care and could
have adverse effects on both the people and the environment if it is not managed properly. There
is lack of uniform nomenclature for waste generated during the provision of health care services.
This could undermine efforts to understand issues relating to HCW in developing and
implementing appropriate policies to address issues relating to health care waste management
(HCWM). The study sought to understand terminologies used to describe HCW, their definitions,
categories and classification. It also sought to explore how the terms are in line with the ones that
are provided in the WHO global manual on health care waste management from health care
facilities. The study first identified terms from the existing literature, conceptually map the
literature and identified gaps and areas of further inquiry.
Methods: We conducted a scoping review using six electronic databases: EBSCOhost, Open
Access, ProQuest, PubMed, Web of Science and Google Scholar. A total of 112 studies were
included in the study. The review selection and characterisation were performed by three assessors.
All studies were mapped based on the source of literature, country focus, study design, academic
discipline, terminologies used to describe HCW, their definitions, categories of and classes under
each category of HCW.
Findings: There was more literature from low-and-middle-income countries (LMICs) with 87.5%
(n=98) and 12.5% (n=14) from high income countries. The largest number of articles were from
the public health discipline with 19.6% (n=22) followed by the discipline of environmental health
with 8.9% (n=10). This scoping review found that HCW, medical waste, clinical waste, biomedical
waste and hospital waste are the five dominant terminologies used to describe HCW both in high
income countries and LMICs. The definition of the terminologies and the categorization and
classification of health care waste were in line with the ones provided in the WHO global manual.
Conclusion and recommendations: Because all different terminologies used to describe HCW
are in line with the WHO manual’s recommendation, there is a need to adopt and use one standard
term the one that is provided by the manual. Further studies must be conducted to explore how
these terminologies are interpreted into practice. This will help to understand how their
implementation aligns with the recommendations contained in the WHO manual.
Keywords: Health care waste, health sector, scoping review.

21
Introduction

The provision of health care such as operative procedures, diagnostic procedures which involve
the administration of injections, medications, drips and surgery among others results in improved
wellness and quality of life for people (Verma, Mani, Sinha and Rana, 2008). However, health
care waste (HCW) generated during the provision of health care could have adverse effects on
both the people and the environment (Pruss et al., 1999; Botelho, 2012). Literature on HCW shows
that large volumes of HCW are produced in health care facilities settings throughout the world
(Alagoz and Kocasoy, 2008) but it is poorly managed especially in the low-and-middle income
countries [LMICs] (Hossain et al., 2011).

The main factors responsible for the poor management of HCW by the governments of many
LMICs are: lack of financial investment and clear policies to manage HCW (Alagoz and Kocasoy,
2008; Sawalem, Selic and Herbell, 2009), low level of knowledge among health care staff on how
to handle HCW (Kumar, Khan, Ahmed, Khan, Magan, Nausheen and Mughal, 2010; Abah and
Ohimain, 2011), lack of segregation of HCW from point of generation to the point of disposal
(Ferreira and Teixeira, 2010) and poor management of dumpsites which leaves room for
scavenging (Leonard, 2005; Mundia and Mbewe, 2006). In addition, there are inadequate
technologies for managing HCW. As a consequence, incineration is the most common method
used (Soliman and Ahmad, 2007; Nemathagaet al., 2008; Hassan et al., 2008; Abd El-Salam,
2010). In many LMICs, HCW is transported together with other goods (Gabela and Knight, 2010);
untrained people and those who are not registered to deal with HCW used as drivers of vehicles
that transport HCW (Mbongwe, Mmereki and Magashul, 2008). Health care waste is also buried
or burnt openly (Soliman and Ahmad, 2007; Mangaa, Fortonb, Moforc and Woodardd, 2011).

Poor management of HCW exposes health care workers to risks of infection with various diseases.
Waste handlers and the community members confront the risk of infections, and exposure to toxins
and injuries (WHO, 2007). In a study conducted in Tripoli, Libya, it was found that exposure to
HCW among waste handlers caused 5% of them to develop hepatitis B virus and 0.3% had hepatitis
C virus (Franka, El-Zoka, Hussein, Elbakosh, Arafa and Ghenghesh, 2009). Exposure to
HCW can cause tuberculosis (TB) infections (Bdour,

22
Altrabsheh, Hadadin and Al-Shareif, 2007), and damage the respiratory, nervous and reproductive
systems of the patients, family members and caregivers, and the general public. HCW have
mutagenic, teratogenic and carcinogenic effects (Blackman, 1993). Exposure to HCW can also
cause diseases like diarrhoea, leptospirosis, typhoid, cholera and HIV (Mato and Kassenga, 1997).

The disposal of HCW into unprotected dumpsites which is an improper practice carried out
especially in LMICs, promotes scavenging in landfills for reusable items for reselling. For example
in India, a study that was conducted by the India Clinical Epidemiology Network on the
management of HCW, revealed that, in almost 10 of the health care facilities in the country, more
than 30% of the 3-6 billion injections that were administered every year were done with used
syringes and needles that were recycled by unskilled scavengers who sold them on the black
market (Harhay, Halpern, Harhay, and Olliaro, 2009). Similarly, in 2009, 240 people in the state
of Gujarat in India contracted hepatitis B because medical care was delivered with previously used
syringes that were acquired through the black market (Solberg, 2009).

While the environmental and health impacts of HCW is well documented, the World Health
Organisation in its global 1999 manual ‘health care waste management from health care settings’
provides guidelines for all issues relating to health care waste’s definition, classification and its
management. The manual uses the term ‘health care waste’ to mean all waste that is generated as
a result of health care activities. The manual further classifies HCW into nonhazardous and
hazardous waste (Pruss et al. (1999). However, different terminologies have been used to describe
HCW by various authors from high income countries and low-and-middle income- countries. For
example some have used the term ‘medical waste’ (Lee et al., 2002; Mato and Kaseva, 1999;
Nemathaga, Maringa and Chimuka, 2008) while the United States Environmental Protection
Agency (EPA) and Bdour, Altrabsheh, Hadadin and Al-Shareif (2007) use the term ‘hazardous
waste’. Diaz, Eggerth, Enkhtsetseg and Savage (2008) used the term ‘biomedical waste’, clinical
waste, ‘hospital waste’ or ‘yellow bag waste’. Given the various terminologies used to describe
HCW, it is not clear how these terminologies align with the WHO 1999 manual. Moreso, we did
not find any scoping review that describes, defines and characterises HCW.

23
A study of health care waste management practices in health care facilities in Botswana found that
the use of the terminology: ‘clinical waste’ to describe HCW confused health care workers and the
general public. For example the health care workers and the people correctly defined clinical waste
as any waste from health care facilities without considering the fact that HCW is further
categorised as non-hazardous and hazardous waste. Failure to categorise HCW into these
categories resulted in improper segregation of the HCW (Mbongwe, Mmereki and Magashula,
2008). This suggests that the lack of uniform nomenclature for HCW could undermine efforts to
develop and implement appropriate policies aimed at addressing health care waste management
(HCWM) practices.

This scoping review aims at exploring the nomenclature that is used by the high income countries
(HICs) and LMICs to describe HCW as well as how HCW is defined, classified and categorised.
Doing so, will help to understand how and to what extent the nomenclature aligns with the ones
that are provided in the HCWM global manual by WHO. This study will also help to identify
inconsistencies. In this scoping review, we sought to answer four specific research questions: 1)
What are the various terms used to describe HCW, and how is HCW defined and categorised in
high-income and LMICs in existing peer-reviewed and gray literature on health care waste
management? 2) In what ways and to what extent does the nomenclature in the literature align with
the WHO manual? 3) What are the gaps and areas for further research with regards to the terms
used to describe, define and categorise HCW?

Methods

Unlike systematic reviews that aim at combining, summarizing and synthesising findings of a
particular research (Chircop, Basset and Taylor, 2014), scoping reviews are conducted for the
purpose of mapping the key concepts underpinning a research area, and the main sources and types
of evidence available (Mays, Robert and Popay, 2001; Arksey and O’Malley, 2005). Scoping
reviews can be undertaken as stand-alone projects in their own right, especially where an area is
complex or has previously not been reviewed comprehensively (Daudt, Mossel and Scott, 2013).
We chose to conduct a scoping review because no such study has been conducted to explore a
large body of literature and summarise the nomenclature used to describe, define,

24
and categorise HCW in HICs and LMICs. We conducted the scoping review using both deductive
and inductive approaches: first we identified search terms from literature. Secondly we used the
search terms that we identified in literature to search for literature from various databases. Thirdly,
the relevant literature was reviewed and selected and finally all the selected literature was mapped.

Identifying search terms

We used an iterative process to conduct the searches. First, we used read the WHO manual in order
to derive the first term ‘health care waste’ for the search. We then used the term health care waste
to search for and conduct a broad but rapid review of the literature. In order to identify terms used
by ordinary policy makers and stakeholders we conducted a rapid review of 20 media news stories
using the search term HCW. The various searches yielded the following terms: *healthcare waste*,
*medical waste*, *clinical waste*, *biomedical waste* and *hospital waste*.

Database search/literature search

The initial search was conducted in September 2015 by two assessors (LH and SM) using six
electronic databases: EBSCOhost, Open Access, ProQuest, PubMed, Web of Science and Google
Scholar (see Appendix 1 for the table of all data bases). These data bases were those available at
the University of KwaZulu-Natal, Durban, South Africa. We chose both grey and peer-reviewed
literature in order to have broader coverage of the literature. From this search, the results hits were
9,735 and we realised that the search was too broad and therefore we put in place the following
inclusion criteria: (1) full texts of both grey and peer-reviewed literature which were available
through the library at the University of KwaZulu-Natal (2) literature must have been within date
limit of 1990 to 2015 because this period had the highest hits (3) literature must be in English (4)
literature must have key search terms in their title and/or their abstracts...

Review and selection of literature

After applying the inclusion criteria, 8468 were excluded and 1,267 studies remained. Thereafter,
two assessors (LH and SM) worked together to develop a set of explicit exclusion criteria. The
exclusion criteria were applied independently by the assessors who met regularly to compare the
assessments and resolve discrepancies. The criteria were applied as follows, studies were

25
removed if they: 1) were duplicate copies; 2) did not define or categorise and classify HCW in
their full texts. Based on the exclusion criteria, 107 duplicates were removed while 1,157 studies
remained. A total of 1,045 studies did not have define, categorise, or classify HCW in their full
text hence they were excluded. A total of 112 studies were included for mapping and these are
summarized in figure 1.

Figure1. A flowchart of study selection process

9735 Original search without

applying any inclusion criteria
8468 records excluded did not
fall between 1990-2015 and
were not full text studies
1267 Studies with key words
in the title and abstract

107 duplicates removed

1 157 full text articles

assessed for eligibility

1 045 full text articles removed

for not defining or
characterising HCW
112 articles included in the
review

The 112 studies that met our criteria covered various topics for example, 44 (39.3%) covered
26
health care waste management practices, 14 (12.5%) discussed knowledge and attitudes of health

27
care staff about health care waste management, 13 (11.6%) covered segregation and quantification
of HCW, 12 (10.7%) covered risks associated with HCWM, 11 (9.8%) focused on HCW treatment
and disposal options, 9 (8.0%) reviewed existing policies on HCWM and 9 (8.0%) addressed
models for HCWM. A list of the included studies is attached in Appendix 3.

Mapping of the literature

In order to extract information about terminologies used to describe HCW, definitions, categories
and its classifications of HCW under each category, we used an extraction form. The extraction
form was developed using both deductive and inductive approaches. First, we used a deductive
approach to develop the extraction form: We used the World Health Organization’s (1999)
guidance manual on safe management of waste from health-care activities by Pruss et al. (1999)
as a guiding framework for developing the extraction form. This framework was used because it
is the most recent global guideline on all issues related to health care waste management. Further,
we drew on the WHO manual to help us determine how and to what extent it is applicable in
various contexts.

Health care waste is the term used to describe HCW in the manual. This term defines HCW as:
‘all waste that is generated by health care establishments, research facilities and laboratories. It
also includes waste from minor or scattered sources such as homes where waste is produced in the
course of health care activities’ (Pruss et al., 1999: 2). HCW is classified into two categories which
are non-hazardous waste and hazardous waste. Nonhazardous waste is defined as waste that does
not contain pathogens that can cause harm to the people or the environment while hazardous waste
is defined as waste that is known to contain pathogens that can cause harm to the people and the
environment (Pruss et al., 1999: 2). The manual further classifies HCW under each category as
follows: Non-hazardous waste comprise all general waste that is comparable to municipal waste
and includes waste such as used boxes, paper and empty tins. Hazardous waste comprises all
infectious, pathological, sharps, pharmaceutical, genotoxic, chemical and radioactive wastes
(Pruss et al., 1999:2).

Next, we used an inductive approach to improve on the extraction form. We developed more
categories after conducting the trial coding of 20 articles (discussed earlier). The categories are
non-pathological waste, pathological waste and biohazardous waste. Thereafter, the two

28
assessors met to discuss the extraction form and reached consensus to add new categories to the
coding list. The extraction form was independently checked by a third assessor (supervisor, OA)
for consistency and accuracy. Domains that were excluded from the extraction were sampling
techniques and names of the authors because they were not part of the objectives of the studies.
All changes that were made to the extraction form by the supervisor were discussed with the two
assessors until consensus was reached before it was applied. We then used the form to extract
information from the full text of all the articles in the sample. The final extraction form included
the following themes: the source of literature, country focus, study design, academic discipline,
and terminologies used to describe HCW, the definitions, categories and classes of HCW (see
Appendix 2 for full coding framework).

Results
Mapping of literature
The 112 articles were then mapped according to source of literature, country focus, study design,
discipline of the study, terminologies used to describe HCW, categories of HCW and classes of
HCW under each category.
Source of literature: The overwhelming majority of the studies that are included in this scoping
review were published in journals (n=100, 89.3%), while only 10.7% (n=12) were student
dissertations.
Country focus: Only 12.5% (n=14) were studies from high income countries (Canada, Croatia,
Japan, United Kingdom, Greece, Poland, Portugal and Italy). Most of the studies focused on
LMICs with the highest number being 43% (n=49) from Asian countries (Bangladesh, China,
India, Lao republic, Malaysia, Pakistan, Philippines, Romania and Thailand), followed by 23.2%
(n=26) from African countries (Algeria, Botswana, Egypt, Ethiopia, Ghana, Libya, Nigeria,
Tanzania and Zimbabwe); 11.6% (n=13) were from Middle East countries (Buhrain, Iran, Jordan
and Palestine); 4.5% (n=5) were from the South America (Brazil) and another 4.5% (n=5) was
from Europe (Turkey).
Study design: The methods of the studies included in the scoping review varied with the most
common being cross-sectional studies (n=22, 19.6%), followed by those that used mixed methods
(n=16, 14.3%), literature reviews (n=13, 11.6%), quantitative surveys (n=13, 11.6%), case studies
(n=11, 9.8%), qualitative studies (n=8, 7.1%), experiments (n=6, 5.4%), document

29
analysis (n=5, 4.5%), commentaries (n=2, 1.8%) and systematic reviews (n=3, 2.8%), in that
order. The source of literature, country focus and study design are summarized in table 1 below.

Table 1: Results of mapping of included studies

Mapping category Number of studies (N=112)
Source of literature
Dissertation 12 (10.7%)
Journal 100 (89.3%)
Country focus
High income countries 14 (12.5%)
Low- and middle income countries 98 (87.5%)
Study design
Case study 11(9.8%)
Commentary 2 (1.8%)
Cross-sectional study 22 (19.6%)
Document analysis 5 (4.5%)
Experiment 6 (5.4%)
Mixed method 16 (14.3%)
Literature review 13 (11.6%)
Systematic review 3 (2.8%)
Quantitative surveys 13 (11.6%)
Qualitative 8 (7.1%)

Disciplines of the studies: Similarly, the studies included were from various disciplines with most
of the studies about public health (n=22, 19.6%), environmental engineering (n=16, 14.3%),
environmental health (n=10, 8.9%), environmental management (n=9, 8.0%), community
medicine (n=7, 6.3%), environmental sciences (n=5, 4.5%), community health nursing (n=3,
2.8%), preventive medicine (n= 2, 1.8%) and public health dentistry (n= 2, 1.8%). The discipline
of a few of the articles (n=8, 7.1%) could not be determined while each of the following disciplines
had one (0.9%) article: administrative science and policy, applied ecology, biotechnology and
bioinformatics, biological sciences, chemistry, community dentistry, environmental and
developmental sociology, energy and environment, environmental resources and development,
forestry and environmental science, forensic medicine, industrial management, laboratory
medicine, law, microbiology, nursing, obstetrics and gynaecology, optometry, ophthalmology,
process engineering and applied sciences, pharmaceutical sciences and rural development. All the
disciplines are summarized in table 2 below.

30
Table 2.A summary of the academic disciplines

Academic discipline Number of studies (N=112

Administrative science and policy Applied 1 (0.9%)
ecology 1(0.9%)
Biotechnology and bioinformatics 1(0.9%)
Biological sciences 1 (0.9%)
Chemistry 1 (0.9%)
Community dentistry 1(0.9%)
Community medicine 7 (6.3%)
Community health nursing 3(2.8%)
Environmental and developmental sociology 1(0.9%)
Environmental engineering 16 (14.3%)
Energy and environment 1(0.9%)
Environmental health 10 (8.9%)
Environmental management 9 (8.0%)
Environmental resources and development 1(0.9%)
Forestry and environmental science 1 (0.9%)
Forensic medicine 1(0.9%)
Environmental sciences 5 (4.5%)
Industrial management 1(0.9%)
Laboratory medicine 1(0.9%)
Law 1(0.9%)
Microbiology 1(0.9%)
Nursing 1 (0.9%)
Obstetrics and gynaecology 1 (0.9%)
Optometry 1 (0.9%)
Ophthalmology 1 (0.9%)
Public health 22 (19.6%)
Preventive medicine 2(1.8%)
Process engineering and applied sciences 1(0.9%)
Pharmaceutical sciences 1(0.9%)
Public health dentistry 2(1.8%)
Rural development 1 (0.9%)
Waste management engineering 7(6.3%)
Not clearly stated 8 (7.1%)

Terminologies used in the study: The included studies used various terminologies to describe
HCW (as summarized in table 3). HCW was the term with the highest number 33.9% (n=38) of
all the articles followed by biomedical waste with 26.8% (n=30), medical waste with 17.9%
(n=20), clinical waste 9.8% (n=11), hospital waste 8.9% (n=10), health care risk waste was 1.8%
31
(n=2) and infectious waste (n=1, 0.9%). All disciplines defined HCW as the waste that is produced
from health care activities whether for humans or animals.

Table 3 terminologies and categories of health care waste

Terminologies used to describe Number of studies Categories of health care Number of studies
health care waste (N=112) waste (N=112)
Biomedical waste 30 (26.8%) Non-hazardous waste 111 (99.1%)

Clinical waste 11(9.8%) Non-pathological waste 1 (0.9%)

Health care waste 38 (33.9%) Hazardous waste 81 (72.3%)

Medical waste 20 (17.9%) 1 (0.9%)

Pathological waste
Hospital waste 10 (8.9%)
30 (26.8%)
Infectious waste 1 (0.9%) Biohazardous

Health care risk waste 2(1.8%)

Categories of health care waste: based on the two categories provided by the WHO: non-
hazardous and hazardous waste, most disciplines categorised HCW as non-hazardous waste 99.1%
(n=111), while the environmental engineering discipline categorises it as non-pathological waste
(n=1, 0.9%). On the other hand, 72% (n=81) of disciplines categorised HCW as hazardous waste
while those in the medical field categorised it as bio-hazardous waste (n=30, 26.8%). Those from
the environmental engineering discipline categorised HCW as pathological waste (n=1, 0.9%).
Under the non-hazardous and hazardous waste categories, HCW is divided into various classes. It
should be noted that both high-income countries and LMICs classify municipal waste under the
non-hazardous or non-pathological waste.

On the other hand, high-income countries have five classes of waste under the hazardous waste
category these are: Group A waste which is all human tissue including blood, animal carcasses,
tissue from veterinary centres, hospitals and laboratories; Group B waste which is all discarded
syringe needles, cartridges, broken glass and any other contaminated disposable sharp instruments;
Group C waste which is all microbiological cultures and all potentially infected
waste from pathology departments such as clinical or research laboratories and post-mortem
31
rooms; Group D waste which is all pharmaceutical products and chemical wastes; and Group E
waste which is all items that are used to dispose of urine, faeces, body secretions and excretions.
Similarly, all the LMICs classify HCW into: infectious waste, pathological waste, sharps,
pharmaceutical, genotoxic, chemical and radioactive waste, as hazardous waste. All this
information is summarised in Table 4 and 5 below.

Table 4. Classification of health care waste by high income countries

Classification of health care waste Examples Number of studies

(N=112
Group A waste: All human tissue This kind of waste includes soiled 14 (12.5%)
including blood, animal carcasses, surgical dressing, swabs, and
tissue from veterinary centres, other soiled waste from treatment
hospitals and laboratories areas

Group B waste: All discarded Any contaminated disposable 14 (12.5%)

syringe needles, cartridges, broken sharp instruments
glass

Group C waste: All microbiological Waste from pathology 14 (12.5%)

cultures and all potentially infected departments such as clinical or
waste research laboratories and post-
mortem rooms
Group D waste: All pharmaceutical 14 (12.5%)
All discarded medicines,
products and chemical wastes
cytotoxic drugs

Group E waste: All items that are 14 (12.5%)

Incontinence pads, disposable
used to dispose of urine, faeces,
body secretions and excretions bedpans, urine containers

32
 Table 5. Classification of health care waste by low-and-middle- income countries

Classification of health Examples Number of studies (N=112

care waste
Infectious waste Waste suspected to contain pathogens 98 (87.5%)
e.g. laboratory cultures; waste from
isolation wards; tissues (swabs),
materials, or equipment that have been in
contact with infected patients; excreta

Human tissues or fluids e.g. body parts;

Pathological waste 98 (87.5%)
blood and other body fluids; foetuses

Sharp waste Sharp waste: e.g. needles; infusion sets; 98 (87.5%)

scalpels; knives; blades; broken glass

Pharmaceutical waste Waste containing pharmaceuticals 98 (87.5%)

e.g. pharmaceuticals that are expired or
no longer needed; items contaminated by
or containing pharmaceuticals (bottles,
boxes)

Waste containing substances with 98 (87.5%)

Genotoxic waste genotoxic properties e.g. waste
containing cytostatic drugs (often used in
cancer therapy); genotoxic chemicals

98 (87.5%)
Chemical waste Waste containing chemical substances
e.g. laboratory reagents; film developer;
disinfectants that are
expired or no longer needed; solvents

Radioactive waste
Waste containing radioactive substances 98 (87.5%)
e.g. unused liquids from radiotherapy or
laboratory research; contaminated
glassware, packages, or absorbent paper;
urine and excreta from patients treated or
tested with unsealed radionuclides;
sealed sources

33
 Table 6. Terms, definition and classification of health care waste
Term and meaning Examples Number of
articles using the
category
Non-hazardous/non-pathological waste is Used paper, boxes, cans 112 (100%)
waste that does not contain pathogens

Hazardous/Biohazardous/pathological
waste is waste that contains pathogens that Human tissue, body parts, chemicals, 112 (100%)
can cause harm to the health of the people expired medicines
and to the environment

1.Health care waste is waste produced from Examples of health care 38 (33.9%)
health care establishments as a result of establishments, laboratories, research
health care activities facilities, minor or scattered sources such
as in homes
2.Biomedical waste is any waste generated Human and animal anatomical wastes, 30 (26.8%)
during the diagnosis, treatment or fluids and secretions from patients,
immunisation of human beings or in contaminated syringes and other "sharps",
research activity contaminated laboratory wastes

3. Clinical waste is any other waste arising Wholly or partly of human or animal 11 (9.8%)
from medical, nursing, dental, veterinary, tissue, blood or other body fluids,
pharmaceutical or similar practices, excretions, drugs or other pharmaceutical
investigation, treatment, care, teaching or products, swabs or dressings or syringes,
research or the collection of blood from needles or other sharp instruments
transfusion
4. Health care risk waste is waste generated Infectious and pathological matter, sharps, 2 (1.8%)
in health care facilities and discarded and expired
pharmaceuticals
5. Hospital waste is any solid waste that is Including but not limited to: soiled or 10 (8.9%)
generated in the diagnosis, treatment or blood soaked bandages, culture dishes
immunisation of human beings or animals and other glassware. It also includes
discarded surgical gloves and
instruments, needles, cultures, stocks and
swabs used to inoculate cultures and
removed body organs.
6. Medical waste is any waste generated Swabs or dressings or syringes, needles or 20 (17.9%)
during medical diagnosis or treatment of other sharp instruments, being waste
humans or animals, in related research, or which unless rendered safe may prove
in the production of biologicals used in hazardous (incl. microbial infectious),
clinical activities pharmacological and/or physical dangers
to any person coming into contact with it

34
Discussion Principal Findings

Various studies (n=112) met inclusion the criteria and formed part of the analysis. This review
shows that there were many journal articles than dissertations. Most of the studies focused on the
LMICs. The studies used various methods employed to research the issue of HCW and these
methodologies range from case studies, commentaries, cross-sectional studies, document analysis,
experiments, literature reviews, systematic reviews, quantitative surveys, qualitative studies and
mixed methods. The studies are spread across different disciplines with the largest number coming
from the public health discipline followed by environmental engineering, environmental health,
environmental management, waste management engineering and lastly community medicine. This
scoping review has also found that both high income countries and LMICs use different
terminologies but they define, categorise and classify HCW in the same way despite using various
semantics.

Study meaning

The study attempted to answer the following questions: what are the various terms used to 1)
describe HCW, and how is HCW defined and categorised in high-income and LMICs in existing
peer-reviewed and gray literature on health care waste management? 2) In what ways and to what
extent does the nomenclature in the literature align with the WHO manual? 3) What are the gaps
and areas for further research with regards to the terms used to describe, define and categorise
HCW? This study, to our knowledge, is the first attempt to conduct a scoping review on HCWM.
Our findings show that health care waste is a multidisciplinary issue with the majority 22 (19.6%)
coming from public health followed by environmental health with10 (8.9%). This means it is of
concern to a wide range of disciplines and these findings are consistent with those of Gabela
(2007), Harhay, Halpern, Harhay and Olliaro (2012) and Njagi, Oloo, Kithinji and Kithinji (2012).

The review also shows that there is more information about HCWM in LMICs with 89.3% than in
high income countries with 10.7%. This could mean that the issue of HCWM is more of a concern
in these countries as described by Kassim and Ali (2006). The information about HCWM being
more available in published articles is an important finding for policy makers

35
because Rutter, Luschen, von Lengerke (2003) argue that, in addition to the evidence that is
derived from the real world, published literature also provides evidence that is used to generate
public health policy models by policy makers. In this case, it is possible for policy makers to able
to use information from published journals in informing policies related to terminologies,
definitions and categories of health care waste.

The findings reveal that terminologies used by various disciplines to describe HCW are:
biomedical waste, clinical waste, HCW, health care risk waste, hospital waste, infectious waste
and medical waste. Notwithstanding which of these terminologies are used, their definitions,
categories and classifications under each category both for high and LMICs remain the same and
are in line with those provided in the global manual for safe management of waste from health care
activities by World Health Organization (Pruss et al., 1999). The findings of this review can be
used to develop an understanding of the terminologies used to describe HCW, the meaning, how
it is categorised and classified by various disciplines.

The studies of HCWM in LMICs are important because it is an issue that has implications for the
well-being of the people and also the environment. The adverse consequences of improper
management of HCW have been documented extensively (Abdulla, Qdais and Rabi, 2008;
Ramokate, 2008). Using different terminologies to describe HCW can cause confusion when it
comes to developing waste management policies by policy makers and can affect the practices of
HCWM by ordinary people who are generators and handlers of HCW. For example, Mbongwe,
Mmereki and Magashula (2008) in their study in Botswana on health care waste management
current practices in health care facilities showed that, the term ‘clinical waste’ is known to mean
all waste that is generated from health care facilities. Because of this definition, most health care
workers and the general public ended up not segregating HCW into non-hazardous and hazardous
waste. Instead health worker disposed of all categories of waste together as hazardous waste in red
bags. The consequence of this practice was the unnecessary use and wasting of red bags, and the
overloading of resources needed for transportation and storage of health care waste.

This scoping review has found that, although different terminologies are used do define, describe,
categorise and classify HCW in literature from LMICs and HICs, their meaning are the
36
same and they align with those of WHO manual. Even if the study by Mbongwe et al. (2008)
cannot be generalized, more of such studies are yet to be found. More importantly, a lesson learnt
from Mbongwe’s study is the need to have a standard term to describe, define, categorise and
classify HCW. Therefore, we recommend that the WHO’s terminology could be adopted since it
is a global manual on health care waste management. A uniform terminology could be beneficial
for the general public who are more involved in implementing policies in that, if they know what
type of waste they are dealing with, they will also know how to manage it appropriately. A standard
terminology could be beneficial to policy makers for designing policies aimed at addressing HCW.

Strengths and limitations

The primary strength of this scoping review is its ability to answer the following questions: what
are the various terms used to 1) describe HCW, and how is HCW defined and categorised in high
income and LMICs in existing peer-reviewed and gray literature on health care waste
management? 2) In what ways and to what extent does the nomenclature in the literature align with
the WHO manual? 3) What are the gaps and areas for further research with regards to the terms
used to describe, define and categorise HCW?. Another strength of the scoping review lies in the
use of transparent methods to conduct the review. Limitations to this scoping review are the fact
that, we only used six databases given the limited resources (at the University of KwaZulu-Natal).
Furthermore, the search only used five key search terms (HCW, medical waste, clinical waste,
biomedical waste and hospital waste) because these are the most dominant terminologies found in
the literature.

Future research

The studies attempted to answer the following questions: What are the various terms used to 1) -
describe HCW, and how is HCW defined and categorised in high income and LMICs in existing
peer-reviewed and gray literature on health care waste management? 2) In what ways and to what
extent does the nomenclature in the literature align with the WHO manual? 3) What are the gaps
and areas for further research with regards to the terms used to describe, define and categorise
HCW?. Further research should be conducted to understand the reasons why various
terms are used to describe, define, categorised and classify HCW were not explored. This

37
scoping review did to explore the extent to which the WHO’s guidelines have been adopted and
implemented in practices by various countries. Such studies could be conducted to provide more
insights into HCW.

38
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 CHAPTER FOUR

A REVIEW OF INTERNATIONAL AND SOUTH AFRICAN NATIONAL POLICIES

THAT ADDRESS HEALTH CARE WASTE MANAGEMENT

42
 A REVIEW OF INTERNATIONAL AND SOUTH AFRICAN POLICIES THAT
ADDRESS HEALTH CARE WASTE MANAGEMENT

Lydia Hangulu1

Olagoke Akintola2, 3

1. Health Promotion PhD Programme, University of KwaZulu-Natal.

2. Discipline of Psychology, Health Promotion Programme University of
KwaZulu-Natal.
3. School of Human and Social Development, Nipissing University, North Bay,
Canada.

I Lydia Hangulu [LH] was responsible for the conception and designing of this study
with guidance from my supervisor (Dr Olagoke Akintola [OA]). I wrote the chapter
under the guidance of my supervisor.

43
 Abstract

Background: To ensure good governance and improved health care waste management practices
across countries, various policies have been developed internationally, nationally and at local
government levels. This chapter will review international and South African policies that address
health care waste management. This will help to know the kinds of policies that are there for
HCWM in CBC.

Results: The WHO’s 1999 manual on health care waste management from health care settings is
the main policy that governs health care waste. The manual classifies community-based care
establishments as minor generators of health care waste (HCW). Professional health care providers
are responsible for providing information on potential hazards of HCW, promoting use of
protective materials, emphasizing the importance of segregation and they are responsible for
providing materials necessary for storing HCW. The professional health care provider must make
necessary arrangement for the HCW to be removed from the home of the patient on a regular basis
or arrangements must be made to have HCW transported to the nearest health care clinic or
hospital.

Conclusion and recommendations: There is no global policy that specifically addresses health
care waste management from community-based care. However, the WHO manual on health care
waste from health care facilities provides bits of information on how HCW from homes should be
managed. Currently, South Africa only has a draft policy on health care waste management. The
SANS CODE 2004 provides all guidelines for HCWM and is a replica of the WHO’s manual on
HCWM. Without the national policy, HCW generators are not obligated to manage HCW
according to the guidelines. There is need to promulgate the policy draft into an enforceable policy.
More importantly, both the WHO manual and the SANS CODE 2004 fail to adequately consider
CBC beyond home treatment and as a result, HCW generated is assumed to be in smaller quantities
that can pose no harm to the people thus except for sharp waste, it is recommended that all other
HCW be disposed of together with domestic waste.

44
Introduction

To ensure good governance and improved health care waste management practices across
countries, various policies have been developed internationally, nationally and at local government
levels. This chapter will review international and South African policies that address health care
waste management. The main aim of this review is to understand the kinds of policies that
specifically govern HCW in community-based care globally and in the South Africa.
Understanding international policies helps to determine the influence they have on the South
African national policies. Together, a review of policies that govern health care waste management
in South Africa will help us understand how they are implemented in practice. The review will
answer the following questions (1) When were the policies developed? (2) What is the context in
which the policies were developed? (3) What do they say about health care waste management
from health care facilities including community-based care?

Methods

This was a desktop study that involved sourcing for international national and South African
national policies that govern health care waste management online using google database. The
following search terms were used to search for policies online; ‘health care waste’ “clinical waste”,
“hazardous waste”, “health care risk waste” “hospital waste”, “infectious waste”, “medical waste”,
“pathological waste”, “pharmaceutical waste”, “sharps”, and “used medical supplies”. The
following websites from the named organisations were searched for policies regarding health care
waste. The World Health Organisation (http://www.healthcare- waste.org),United Nations
Environmental Programmes
(http://www.unep.org/gpwm/Default.aspx?tabid=104478), Department of Environmental affairs
(www.environment.gov.za), South African National Standards
(https://law.resource.org/pub/za/ibr/za.sans.10248.1.2008.), government garzzattes from Sabinet
(http://discover.sabinet.co.za/government_gazettes), the Institute for Waste Management in
Southern Africa (Africahttp://www.iwmsa.co.za/) and South Africa Waste Information Center
(http://sawic.environment.gov.za/?menu=47). There was no limit with date so as to include as
many policies as possible.

45
Review of the policies

We set explicit inclusion criteria for the policy documents. The documents were included if they:
addressed issues relating to health care waste management 2) contain guidelines, policies,
standards, rules, or regulations; 3) were produced by global of international bodies or South
African governmental agencies 4) were produced for use various countries internationally or in the
African region or in South Africa . All the policies that did not meet these criteria were not included
in the study.

Analysis

We reviewed the policies to extract the following information (1) When they were developed (2)
The context in which they were developed (3) the specific provisions relating to health care waste
management from health care facilities, community-based care and other sources. Table 1 below
is a time line for international policies that govern health care waste. A brief background to the
development of these policies will be provided then the details of each policy will be discussed.

Table 1.Timeline for the international policies governing health care waste
Year of Name of regulation Main emphasis The controlling
publication authority
1992 Rio Declaration, principle Requires states to address environmental issues, it United Nations
10 promotes public participation in decision making and
access to information on hazardous material and justice
on environmental matters.
1999 WHO First Edition Manual Its audiences are the medical staff, directors of health World Health
on Safe Management of care facilities, health care workers, infection control Organisation
Waste from Health Care officers and waste workers.
2000 World Bank manual for Awareness of the risks posed by improper management World Bank
resource limited settings of HCW resulting from humanitarian crisis mostly for
World Bank audiences
2003 Technical Guidelines on the It was developed at a time when developed and United Nations
Environmentally Sound developing countries were disposing of health care Environmental
Management of Biomedical waste into landfills without pre-treatment. Program (UNEP)
and Health Care Wastes
2005 Manual with guidelines on It was developed because between the year 2000 and United Nations
health care waste 2004, there was a need to view health care waste Environmental
management practices that management both as a public and an environmental Program and
are appropriate for sub- health issue. World Health
Saharan African countries Organisation

46
2005 Manual on better health It provides manager and technical information that World Health
care waste management: tackles poor health care waste management as part of Organisation
an integral component of their da-to-day programmes (WHO) and the
health investment World Bank
2005 A guide on management of The manual provides guidance to staff working primary World Health
solid health care waste at health –care centres on the most appropriate options Organisation
primary health care centres for managing solid waste from primary health care (WHO)
centres.
2011 Practical tool in routine It is intended as a practical tool in routine management Red Cross
management of hospital of hospital waste in the year
waste, 2011.
2012 Manual for technologies to It was developed because most health care facilities in United Nations
be used for treatment or low and middle income countries do not have adequate Environmental
destruction of HCW in technologies to dispose of HCW. Four major processes, Program (UNEP)
middle and low income thermal, chemical, irradiative and biological, are
countries, provided and explained.
2013 Environmental guidelines It was developed because small scale health care United States
on health care waste facilities still had inadequate HCWM programmes, Agency for
management disposal of HCW with solid waste, appropriate burial of International
HCW, improper operation of incinerators and dumping Development
of HCW into sewage and water systems

Background to the development of health care waste management policies

The Stockholm Declaration on preservation of human environment, 1972: Most international
policies that have to do with the conservation of the environment date back to the Stockholm
Declaration on preservation of human environment made at a conference organised by the United
Nations. The conference was prompted by air and water pollution and hazardous waste concerns
globally. Thus the emphasis of the conference was on solving environmental problems by limiting
human activities that can destroy the planet while considering the social, economic and
developmental factors. The conference also stipulates the environmental protection principals and
their implementation strategies. The conference established the United Nations Environmental
Programme (UNEP) as an intergovernmental institution responsible for dealing with
environmental issues. Since the conference, there have been various international agreements that
have been ratified by various countries and these include but are not limited to the 1979 Geneva
Convention on Long-range Transboundary Air Pollution, the Helsinki Agreement (an agreement
among 21 nations to reduce sulphur dioxide emission) and the Basel Convention on Transboundary
movements of Hazardous Wastes (United Nations, 1972). Among

47
the above mentioned agreements, the Basel convention is the one that addresses health care waste
management issues and it will be discussed next.

The Basel Convention on the Control of Transboundary Movement and disposal of Hazardous
Wastes, 1989.
The Basel Convention is an international agreement that was signed by 100 countries. It is an
international legal instrument on the control of transboundary movement and disposal of hazardous
wastes. In the 80s, due to the constricted environmental regulations in the industrialized countries,
hazardous waste disposal became costly and western countries began shipping hazardous waste to
developing and Eastern European countries. The Convention was created to address concerns
about the management, disposal and transboundary movement of hazardous wastes. The main
principles covered are: the reduction of transboundary movements of hazardous waste consistent
with their environmentally sound management; emphasis on the need to treat and dispose of
hazardous waste close to the point of generation and all hazardous wastes must be reduced at the
point of generation. In addition, the ‘polluter must pay’ principle is emphasised and so is the need
to aim at handling hazardous waste with utmost care and protecting the health of people and
safeguarding the environment in the management of hazardous waste. It also provides a list of all
hazardous and non-hazardous wastes (United Nations, 1989).

The Basel Convention in South Africa was ratified by the African National Congress (ANC)
government in 1994 after the first democratic elections. All countries that signed the Convention,
including South Africa, accepted that only developing countries that lack the facilities or expertise
to dispose of hazardous waste are gazetted to ship such waste to countries that have facilities and
expertise to manage it. Further, all hazardous waste may not be imported or exported from non-
party to the treaty unless a bilateral agreement has been entered into; and that all transboundary
movement of hazardous waste is not to be allowed to parties that have prohibited the import of
such waste. In the year 1999, the Basel Governmental Declaration on Environmentally Sound
Management of Hazardous Wastes was adopted at the fifth conference of the parties (COP-5).
COP-5 outlined main areas of focus from the year 2000 to 2010 these are: increasing partnership,
promoting the use of cleaner technologies and production methods, reduction of movement of
hazardous waste, monitoring and prevention of illegal traffic,
improvement of institutional and technical capabilities and developing regional centres for

48
training and technology transfer. African region centres are Egypt, Nigeria, Senegal and South
Africa (United Nations, 1999). Reaffirming the Stockholm Declaration on Human Environment is
the Rio Declaration on Environment and Development.

The Rio Declaration on Environment and Development, 1992: This is also called the ‘Earth
Summit’ and was hosted by the United Nations. Delegates from more than 130 nations signed an
agreement on Agenda 21 which is an action plan for developing a sustainable planet. Agenda 21
recommends nations to set up measures towards waste management including preventing and the
production of waste, re-using and recycling waste as much as possible, treating waste with
environmentally sound methods and disposing of all waste residues into landfills within the
designated sites. Additionally, the Declaration also requires that all waste producers be responsible
for dealing with waste from its generation point to the disposal point. Communities are encouraged
to dispose of the waste within their boundaries (United Nations, 1992).

The Rio Declaration has 27 principles of which principle 10 is the most relevant to health care
waste management. It encourages participation of all citizens at relevant levels in dealing with
environmental issues. It recommends that individuals at the national level must have access to
information concerning the environment that is held by the public authorities, including
information on hazardous materials and activities in their communities. The Declaration also
requires that communities must have the opportunity to participate in decision making processes
and that all states facilitate and encourage public awareness and participation by making
information widely available. The Rio Declaration obligates all states to provide access to judicial
and administrative, compensation and remedy proceedings (United Nations, 1992). Following the
adoption of this principle, most middle and low-income countries including South Africa have
initiated the processes of strengthening public participation and have made international
agreements on public health issues and issues that deal with the safe management of hazardous
waste as controlled by the Basel Convention which is discussed next. To regulate all health care
waste from health care facilities, the World Health Organization (WHO) developed and released a
manual in 1999. This is the theme that will be discussed next.

49
The global health care waste management policies

The WHO’s first edition Manual on Safe Management of Waste from Health Care Facilities,
1999
This is a global guide to health care waste management that was developed to protect the health of
the public from infections that could be posed due to improper management of health care waste
(HCW). The manual is for medical staff, directors of health care facilities, health care workers,
infection control officers and waste workers. The manual recommends safe, efficient, sustainable
and culturally acceptable methods of treatment and disposal of HCW within and outside health
care establishments. The manual defines and characterises HCW as hazardous and non-hazardous.
Hazardous waste includes all infectious waste, sharp waste, pathological waste, pharmaceutical
waste, genotoxic waste, chemical waste and radioactive waste. All non- hazardous waste is
compared to domestic and it does not pose harm as summarized in Table 2 below.

50
Table 2. Categories of health care waste

Waste category
1.Hazardous waste Description and examples

Infectious waste Waste suspected to contain pathogens, e.g. laboratory cultures; waste from
isolation wards; tissues (swabs), materials, or equipment that has been in contact
with infected patients; excreta or body fluids like dressings, bandages, swabs,
glove, masks, gowns, drapes.

Sharps waste This is waste that consists of used or unused sharps such as needles, auto disable
syringes, syringes with attached needles, infusion sets, scalpels, pipette, knives,
blades and broken glass.

Pathological waste Human tissues or fluids, e.g. body parts; blood and other body fluids; fetuses;
sharps waste, e.g. needles; infusion sets; scalpels; knives; blades; broken glass.

Pharmaceutical waste Waste containing pharmaceuticals, e.g. pharmaceuticals that are expired or no
longer needed; items contaminated by or containing pharmaceuticals (bottles,
boxes).
Genotoxic waste Waste containing substances with genotoxic properties, e.g. waste containing
cytostatic drugs (often used in cancer therapy); genotoxic chemicals.

Chemical waste Waste containing chemical substances, e.g. laboratory reagents; film developer;
disinfectants that are expired or no longer needed; solvents; wastes with
high content of batteries; broken thermometers; blood-
pressure gauges; heavy metals; 51azette51es51 containers; gas cylinders; gas
cartridges; aerosol cans.

Radioactive waste Waste containing radioactive substances, e.g. unused liquids from radiotherapy
or laboratory research; contaminated glassware, packages or absorbent paper;
urine and excreta from patients treated or tested with unsealed radionuclides;
sealed sources.

2.Non-hazardous waste All waste that does not pose chemical, biological, physiological or physical
hazard, for example, paper, cardboards, plastics, discarded wood, metal, glass,
textiles and plastics.

Sourced from WHO safe HCW Guidance manual (Pruss et al., 1999).

51
Page eleven to twelve of the WHO manual identifies two major sources of health care waste: 1)
Major sources include: hospitals, clinics, mortuaries and autopsy centres, animal research and
testing blood banks, and nursing homes for the elderly, 2) Small scale contributors include
physician’s offices, dental clinics, health care establishments with low waste generation and all
home treatment as shown in Table 3 (Pruss et al., 1999).
Table 3. Summary of sources of health care waste
Major Sources Minor Sources

Hospitals Small health-care establishments

University hospital, general hospital, district Physicians’ offices, dental clinics, acupuncturists,
hospital. chiropractors.

Other health-care establishments Specialized health-care establishments and

institutions with low waste generation
Emergency medical care services, health-care
centres and dispensaries, obstetric and maternity Convalescent nursing homes, psychiatric
clinics, outpatient clinics, dialysis centres, first- hospitals, disabled persons’ institutions.
aid posts and sick bays, long-term health-care
establishments and hospices. Non-health activities involving intravenous or
subcutaneous interventions
Transfusion centres, military medical services.
Cosmetic ear-piercing and tattoo parlours, illicit
Related laboratories and research centres drug users, funeral services, ambulance services,
home treatment.
Medical and biomedical laboratories,
biotechnology laboratories and institutions,
medical research centres.

Mortuary and autopsy centres

Animal research and testing, blood banks and

blood collection services, nursing homes for the
elderly.

Sourced from WHO safe HCW Guidance manual (Pruss et al., 1999)

52
Details of health care waste management recommendation by WHO

The manual obligates all countries to develop their own national legislations aimed at improving
health care waste management. It further emphasises that the Department of Health must ensure
that the all legislation is implemented and that the ministry of environment or the national
environmental protection agency must be involved. Additionally, there must be clear designated
responsibilities among institutions responsible for implementation before the laws are enacted. The
manual provides recommendations for developing national plans for managing HCW and it also
provides guidelines on how to manage HCW from the point of generation to the point of disposal.
The manual emphasizes that proper healthcare waste management involves segregation, storage,
transportation, treatment and disposal (Pruss et al., 1999: 60-64). Segregation and storage: The
manual prohibits mixing of HCW. It recommends that HCW must be segregated and must be stored
in red bags marked ‘highly infectious’, with an international infectious symbol. HCW must be
stored in appropriate areas made of hard floor and good drainage and the floors must be easy to
clean and to disinfect, such floors must have water supply for easy cleaning, must be accessible
for staff and waste collectors, must have good ventilation and lighting, must be protected from the
sun, must be inaccessible from animals insects and birds and must not be near food preparation
areas (Pruss et al., 1999: 64-65). All is summarized in table 4

Table 4. WHO recommended storage scheme

Type of waste Colour of container and marking Type of container

Highly infectious waste Yellow, marked “HIGHLY Strong, leak-proof plastic bag, or
INFECTIOUS” with biohazard symbol container capable of being
autoclaved
Other infectious waste, Yellow with biohazard symbol Leak-proof plastic bag or
pathological and container
anatomical
waste
Sharps Yellow, marked “SHARPS” with Puncture-proof container.
biohazard symbol
Chemical and Brown, labeled with appropriate Plastic bag or rigid container
pharmaceutical waste hazard symbol
Radioactive waste Labelled with radiation symbol Lead box

General health-care Black Plastic bag

waste
Sourced from WHO safe HCW Guidance manual (Pruss et al., 1999)
53
Transportation of health care waste within and to off-site facilities: The guidelines further
stipulates that within health care facilities, HCW must be transported by means of trolleys,
containers and carts and transported to off-site facilities by a licensed driver. It is recommended
that all off-site transporters must adhere to the national regulations (Pruss et al., 1999).
Requirements for the driver: Drivers driving vehicles containing HCW must have appropriate
training about handling and labelling, waste classifications and risks involved and spillage
procedures, and they must be declared fit to drive the vehicles. All drivers must be vaccinated
against tetanus and hepatitis A and B and such vaccination records must be recorded by the
supervisor. Drivers must carry a consignment note for the vehicle carrying HCW and must specify
the class of waste, waste sources, pick up date, waste destination, driver’s name, name of the
container and the volume of waste. After completing the transportation of the health care waste,
the driver must return the consignment note to the HCW generator as proof of treatment. All
vehicles used for transporting HCW must be washed with soap and disinfectants daily after use
(Pruss et al., 1999).

Treatment and disposal of HCW: It is recommended that all treatment and disposal of HCW must
be chosen based on the national and local situation. For example sharps can be incinerated or
autoclaved, and anatomical waste may be incinerated or buried based on culturally appropriate
methods. HCW can also be disposed of in a controlled landfill. It is recommended that for all health
care facilities, major sources, small sources, private practitioners and nursing that do not have on-
site treatment facilities, a private contractor be hired and must be responsible for collecting,
transporting, treating and disposal of the HCW (Pruss et al., 1999).

Treatment and disposal of HCW from home: It is said that HCW from homes is very small and
only consist of items contaminated by blood such as incontinence pads, dressings or syringes and
hypodermic needles. Therefore, it is recommended that sharps used by the diabetic patients must
be packed in small puncture-proof containers or boxes for hypodermic needles and must be
disposed of with general refuse. Patients must be provided with such boxes which they must return
to the physician in charge of the treatment when they are full. HCW other than sharps must be
double-packed in plastic bags and then disposed of with household refuse. The HCW generated
by chemotherapy treatment must be packaged safely and transferred to the treating

54
physician (Pruss et al., 1999:56). All the disposal methods for various waste are summarized in
table 5 below.

Table 5. Summary of categories of wastes and their disposal methods

Category of waste Treatment and disposal method

Human anatomical waste: Human tissues, organs, body parts Incineration/deep burial

Animal waste: Animal tissues, organs, body parts, carcasses, fluid, Incineration/deep burial
blood, experimental, animals used in research, waste generated by
veterinary polyclinics

Microbiology and biotechnology waste: Waste from laboratory Autoclave/microwave/ incineration

cultures, stocks or specimens of micro-organisms, live or attenuated
vaccines, human and animal cell cultures used in research, infectious
agents from research and industrial laboratories, waste from
production of biologicals, toxins, dishes and devices used to transfer
cultures

Waste sharps: Needles, syringes, scalpels, blades, glass, etc. capable Disposal in secured landfills
of causing punctures and cuts. This includes both used and unused
sharps Disinfection (chemical treatment)
autoclaving/ microwaving and
mutilation/shredding

Discarded medicines and cytotoxic drugs: Waste comprising Incineration/ destruction of drugs
outdated,
contaminated and discarded drugs and medicines

Contaminated solid waste: Items contaminated with blood fluids Incineration/autoclaving/ microwaving
including cotton, dressings, soiled plaster casts, linens, bedding

Solid waste: Disposable items other than the waste sharps, such as Disinfection by chemical treatment
tubing, catheters, IV sets etc. autoclaving/ microwaving and
mutilation/shredding

Liquid waste: Waste generated from laboratories, washing, cleaning, Disinfection by chemical treatment and
housekeeping and disinfection activities discharge into drains Disposal in
municipal landfill

Incineration ash: Ash from incineration of any medical wastes Chemical treatment and discharge into
drain for liquids and secure

Chemical waste: Chemicals used in production of biologicals,

disinfection, insecticides, etc.

Sourced from WHO safe HCW Guidance manual (Pruss et al., 1999)

Due to that fact that many countries are aware of the potential health and environmental effects
of HCW, the WHO revised the first edition manual on safe management of waste from health
55
care facilities (WHO, 1999). The (2014) second edition includes a wide audience that has interest
in the safe management of health care waste. The new audiences are environmental bodies,
environmental health practitioners, regulators, policy makers, development organisations,
voluntary groups, advisers, researchers and students. Although the audiences have changed, the
information about proper HCWM from various health care facilities including homes has not
changed (WHO, 2014). Besides the WHO’s manual on health care waste management, the World
Bank also developed its own manual.

Health Care Waste Management Guidance Note World Bank, 2000

Using the WHO 1999 manual on safe management of health care waste, the Word Bank developed
this manual for resource limited settings mostly for World Bank audiences. It was developed after
realizing that most health care sectors in resource limited countries rely on international donor
assistance when there is a humanitarian crisis or a natural disaster. As a result, the need arose to
manage all the leftover HCW that is generated. The goal of the manual is to provide awareness of
the risks posed by improper management of HCW and to emphasise the need to manage it. The
guidelines provide a definition and classification of HCW. The classes of HCW are the same as
those of the WHO (Pruss et al, 1999). The manual offers practical guidance on ways to assess and
improve HCWM (Johannssen, Dijkman, Bartone, Hanrahan, Boyer and Chandra, 2000).

Other manuals that address HCWM and have similar guidelines to those of WHO
The following manuals target health care facilities and they tend to focus more on major facilities
especially hospitals. Their guidelines about health care waste management are a replica of the
WHO 1999 manual however; they do not provide information about HCWM in homes in
community-based care. These manuals are (1) Technical guidelines on the environmentally sound
management of biomedical and health care waste, developed by the United Nations Environmental
protection [UNEP] (2003), (2) A guidance manual on preparation of national health care waste
management plans in sub-Saharan African countries (UNEP and WHO, 2005),
(3) Manual on better health care waste management: an integral component of health investment
by WHO and the World Bank (Rushbrook and Zghondi, 2005), and (4) A guide on management
of solid health care waste at primary health care centres (WHO, 2005). (5) Red Cross practical

56
tool in routine management of hospital waste, 2011. It is intended as a practical tool in routine
management of hospital waste in the year 2011 (Red Cross, 2011). (6) UNEP manual for
technologies to be used for treatment or destruction of HCW in middle and low income countries,
2012. It was developed most health care facilities in low and middle income countries do not have
adequate technologies to dispose of HCW. Four major processes, thermal, chemical, irradiative
and biological, are provided and explained. (7) USAID’s sector environmental guidelines on health
care waste management, 2013. It was developed after realizing that small scale health care facilities
still had issues with HCWM, like inadequate HCWM programmes, disposal of HCW with solid
waste, inappropriate burial of HCW, improper operation of incinerators and dumping of HCW into
sewage and water systems. The guidelines provide possible environmentally sound designs of
managing HCW in small scale health facilities in resource limited settings (USAID, 2013).

Health care waste management policies in South Africa

After South Africa got its first democratic election in 1994, the African National Congress (ANC)
government ratified the Basel convention that same year to prohibit importation into the country.
Prior to democratic rule, the South African local government administration provided unequal
services in the communities (Nyalunga, 2006). After the democratic elections, the new constitution
which aimed at providing the South African citizens with equal access to service, was drafted and
promulgated in the year 1996. The South African 1996 constitution brought change to local
government administration and removed disparities in service delivery and also integrated the
segregated societies (Fakoya, 2014). The National Health Care Risk Waste Management (Draft)
which was gazetted in the year 2012 is the only legislation that governs HCW in South Africa yet
it is still a draft. This means that after the democratic elections, HCW in the country has been
regulated by various pieces of regulations including the South African Constitution (Act 108 of
1996), the National Environmental Management Act, the National Health Act and the
Occupational Health and Safety Act 85 of 1993. Due to lack of a national policy regulating HCW
in the country between 1994 and 2012, the South African National Standards Authority developed
guidelines for managing HCW in the country. Additionally, the Gauteng and Western Cape
Provincial Governments developed their own regulations to govern HCW. The Acts will be
discussed first, second the provincial regulations, after which the

57
National Health Care Risk Waste Management will be discussed. Table 6 is a timeline of health
care waste management policies that will be discussed.

Table 6. A timeline of South African health care waste management policies

Year of Name of regulation Main emphasis The controlling

publication authority
1994 Basel convention ratified in Emphasises the reduction of transboundary United Nations, 1989
South Africa by the the African movements of hazardous waste consistent with
National Congress (ANC) their environmentally sound management
government in 1994 after the
first democratic elections
1996 Constitution of South Africa Provides a right to a safe and clean Republic of South Africa
environment for every person.
1993 Occupational Health and Safety Provides guidelines on worker health safety Department of Labour
Act 85 of 1995 and training.
1998 The National Environmental Provides that the polluter must pay principal Department of
Management Act 107 of 1998 and regulation for establishing the Environmental
environmental impact assessment (EIA). Affairs
2003 The National Health Act, 61 of Compels the province, municipality and health Republic of South Africa
2003 districts to deliver quality health care services
including ‘municipal health services’ under
which waste management and environmental
pollution are listed.
2004 South African national Standards that provide for the safe and Republic of South Africa
standards, SANS 254 effective management of health care waste
aimed at reducing risks to humans and the
environment.
2004 Gauteng Integrated Strategy Aims at improving health care waste Gauteng Provincial
and Action Plans for management in the province. Government
Sustainable Health Care Risk
Waste
2004 The Western Cape Aims at improving health care waste Western Cape Provincial
Management Draft Bill management in the province. Government

2008 Draft Health Care Risk Waste HCW generators are responsible for putting in Department of
Management Regulations of place measures necessary to prevent pollution. Environmental
Affairs
2008 KwaZulu-Natal Health Care Risk Aims at improving health care waste KwaZulu-Natal
Waste Management policy management in the province. Provincial government

The South African Constitution (Act 108 of 1996)

To ensure good governance and improved HCWM practices in South Africa, the South African
Constitution (Act 108 of 1996) is a framework for environmental governance in the country.
Section 24 of The Constitution of the Republic of South Africa states that every person has a
58
right to a safe and clean environment and the government has an obligation to pass legislation that
prevents pollution and ecological degradation, promote conservation, secure ecologically
sustainable development and use of natural resources while promoting justifiable and social
development. Schedule 4, of the South African constitution states that, the government at the
national level is responsible for providing health services and protecting the environment.
Departments that play a role in ensuring that HCW is managed properly are the Department of
Environmental Affairs and Tourism, the Department of Health, the Department of Labour and the
Department of Agriculture and Land Affairs. In schedule 5 (B), the constitution states that the
local government has authority to govern and pass by-laws regarding air pollution issues,
municipal health services, refuse removal, refuse dumps and solid waste disposal among others
(Republic of South Africa, 1999). Considering the fact that various organs of states are involved
in regulating health care waste management in the country, it is possible for such organs to suffer
from lack of collaboration and cooperation. This could also delay the implementation process.
Waste is also addressed in the White Paper on Integrated Pollution and Waste Management which
is the theme that is turned to next.

The White Paper on Integrated Pollution and Waste Management for South Africa, 2000
This is a policy that was developed in partial fulfillment of the requirements of Agenda 21 of the
Basel 1992 Rio Conference. It was developed at a time when there were fragmented and
uncoordinated waste management plans and there were insufficient resources and monitoring of
all legislations governing waste in the country. The policy does not cover any issue about HCW;
it is relevant to HCWM because it addresses prevention of pollution, waste, impact management
and remediation. The policy encourages partnerships between government and the private sector.
The policy defines sustainable development as that which includes social, economic and
environmental factors. It also states that sustainable development is an appropriate approach to
ensuring resource management. It is an approach that establishes environmental sustainability in
policy and practice (Department of Environmental Affairs and Tourism, 2000). The other relevant
regulation to HCWM is the National Environmental Management Act.

59
The National Environmental Management Act 107 of 1998 (NEMA)
The NEMA was developed to give legislative effect to the White Paper on a National
Environmental Management Policy for the country and it is a framework for protecting the
environment. The Act provides sections that are relevant to HCW. Chapter 1, 2(1) mandates all
organs of state to work together to ensure that the environment is protected through establishing
guidelines for decision masking in relation to the issues affecting the environment, establishing
institutions that will implement and monitor compliance with the developed principles. Section 2
of the Act provides two principals: (1) in any environmental initiative, people must be protected
and their interest must be served equitably, (2) any development must be socially, environmentally
and economically sustainable. Chapter 7: part 1, 28(1) state that the polluter must take measures
to prevent such pollution. The Act also requires all relevant organs of state to develop
environmental implementation plans. This principle implies coordination in the development of
HCWM plans, policies and regulations. In chapter five, NEMA also provides legislation on
environmental impact assessment (EIA) through developing of tools and systems to manage the
impact of activities on the environment (Department of Environmental Affairs, 1998). Another
Act of importance to HCWM is the National Health Act.

The National Health Act, 61 of 2003

The National Health Act was promulgated to erase health inequalities of the past apartheid
government with the aim of improving quality of life. It is an overall framework for a structured
and uniform health system in the country. The Act in chapter 12 p. 11, defines a health
establishment as any place where health care services are rendered. From this definition it is clear
that community-based cares are health establishments. Chapter 6 of the Act provides mandate to
the minister of health to classify a health care establishment based on its role and function within
the health care system, the size and location of the communities it serves, level of health services
provided, geographical location and reach, and whether it is private or not. The Act gives power
to the minister to make regulations related to medical waste (Republic of South Africa, 2004). The
Act uses the term ‘medical waste’ but it does not define it. In the absence of a definition, it is not
clear if medical waste could also mean HCW, highlighting a gap that needs to be addressed. The
Act further compels the province, municipality and health districts to address

60
health policy questions and delivery of quality health care services including municipal health
services which include waste management. It is not clear as to whether waste management under
‘municipal health services’ implies HCWM. Such lack of clarity could cause confusion. The Act
also compels public and private health professionals to cooperate and share responsibility within
the context of national, provincial and district health (Republic of South Africa, 2004). HCWM is
important to protect the health of the environment and the people. The Occupation Health and
Safety Act will be discussed below.

The Occupational Health and Safety Act 85 of 1993

The Act regulates all health and safety matters. It provides regulations about the safety of workers
in a work place where biological agents are produced, used, handled or transported. The Act
provides information, training for employees and the duties of people who might be exposed to
risks. In addition, it provides information for risk assessment, medical surveillance and the
provision of protective clothing, and sets regulations on the establishment of an occupation health
and safety advisory council and its functions. In 4.1(a), it states that any person who is in charge
of management and control of a health care facility is a chief executive officer (CEO), thus in 4.7.1
reveals that the person in charge must explain to the employee about all the expected hazards at
any place of work. Sections 4.2(f) and 4.6.2 indicate that if there is an accident at a place of work
resulting in injuries, such incidences must be reported to the person in charge. The person in charge
has the responsibility of keeping all the records of such incidences and investigations (Department
of Labour, 2004). All these regulations are relevant to community-based care because they are also
health care establishments.

Health care waste at the national level: The SANS CODE, 2004
The South African National Standards Authority developed the code SANS: 2004 as a quick
regulation on HCW at the national level. The guidelines provide the definition of health care
facilities and HCW that are in line with the WHO manual on HCWM. To reduce potential risks to
humans and to the environment, the guidelines provide minimum standards for the safe and
effective management of all HCW that is generated in health care facilities. It covers the ‘cradle to
the grave’ concepts at all stages of waste management. The standards require proper
Identification, classification, segregation, storage, transportation and disposal of HCW as
61
prescribed by the HCWM manual by WHO. In chapter 7, the guidelines give the responsibility to
the waste generator to segregate all the waste. In section 7.1 to 7.3.5, the guidelines give the
responsibility to the head of a health care facility to train all HCW handlers on how to segregate
waste (Republic of South Africa, 2004).

Packaging: The SANS code stipulates that all general HCW must be packaged in black, beige or
transparent plastics that do not easily tear during handling or transportation. In addition, all
infectious waste must be stored in red packaging with a hazard symbol labelled ‘Infectious Waste’.
The packaging must be tied with non-Poly Vinyl Chloride (PVC) plastic sealing tags that are self-
locking made specifically for sealing HCW. Closing of plastics by stapling is not allowed. All
sharps must be stored in yellow puncture and leak proof containers labelled ‘Danger,
Contaminated Sharps’. The standards require that all HCW must be stored in storage facilities far
away from the operation areas to prevent contamination (Republic of South Africa, 2004).
Requirements for storage areas: All storage areas must be sheltered from sunlight, have good
ventilation, have enough lighting, have water facilities to facilitate cleaning and be vermin proof.
The facility must be locked to prevent access to animals or birds. The time limit for storing HCRW
is 72 hours; for all sharps it is 90 days.
Collection of HCW: All collection of HCW on the site must be made at the point of generation.
All waste within the health care facility must be transported with trolleys, wheeled containers or
carts that are easy to clean, easy to load and must be without sharp ends (Republic of South Africa,
2004).

Waste management team: The guidelines in chapter 8 require all health care facilities to have a
waste management team that should oversee waste management activities from the point of
generation to the point of disposal. The team must plan for all waste management programmes in
the facility (Republic of South Africa, 2004). Members of the team must include a waste
management team officer who should be responsible for overseeing all protective materials,
ensuring sufficient containers and clean operational storage facilities and must also have a schedule
for transportation of all HCW to on and off-site facilities. Other members of the team include:
heads of department, an infection control officer, a chief pharmacist, a radiation officer,

62
a senior nursing manager and health and safety manager, a maintenance engineer or manager, a
financial manager, a procurement manager, a waste management contractor, regional managers or
union representatives (Republic of South Africa, 2004). The HCWM team is responsible for
recommending a waste contractor who will be responsible for the collection, transportation,
treatment and disposal of HCW.

Requirements of the waste management contractor: Section 8.3 of the guidelines stipulates that
the contractor that has the contract with the health care facilities must provide their own
documentation and those of a sub-contractor, treatment and disposal procedures and facilities that
are licensed. The contractor must have a permit and must have all the requirements provided by
the waste management team. The contract must be in writing and must provide the types and
volumes of waste to be collected and to be disposed of, the type of treatment methods used,
methods of accounting for the HCW collected by the contractor, physical verification of the
packages received for treatment and disposal and the potential risk of the hazards and safety
measures to be implemented. The contractor must have a back-up plan of providing transport for
HCW to off-site treatment and disposal facilities. The waste management company must provide
proof of treatment of waste to the waste management officer who must also monitor the contractor
to ensure compliance. Chapter 10 of the guidelines provides guidelines for the disposal of HCW.
The recommended methods for disposal of HCW are incineration and landfilling of the residues
for hazardous waste. The relevant organs of state must carry out an environmental impact
assessment to ensure compliance of such facilities (Republic of South Africa, 2004).

Disposal of health care waste from minor generators: All minor generators are responsible for
managing their own waste. A manager of the health care facility is responsible for training of all
staff regarding the identification, classification, handling, packaging and storage of all HCW. In
the homes of the patients, those that assist to provide health care must be trained on the correct
wearing of protective materials, classification, segregation, handling and storage of HCW,
including proper disposal methods by a health care professional. All HCW must be identified,
classified, handled, packaged, stored, labeled and transported in accordance with the South African
National Standards. All the guidelines applicable to the major generators are also

63
applicable to the minor generators. SANS 2004, section 11, 1.2 prohibits minor generators from
using domestic waste collection services provided by the local authority or a private contractor to
dispose of any HCW that may pose harm to the people and the environment. The guidelines also
stipulate that all minor generators can provide justifications of hiring their own waste contractor
without such justifications; they must make arrangements to deliver the waste to the local hospital.
All the waste transported to the hospitals must be stored in locked leak proof containers which
must be disinfected after delivery and such information must be recorded (Republic of South
Africa, 2004).

Disposal of health care waste from private dwellings: The guidelines in SANS 2004, section
11.3 states that the HCW generated in private dwellings is very small. It gives the responsibility
to the professional health care provider to educate the family members about the proper
management of the HCW and must provide waste disposal packages. The professional health care
provider must make arrangements with the waste contractor to collect the waste from home on a
regular basis. Alternatively, arrangements must be made for the waste to be delivered to the local
clinic or pharmacy where a professional health provider will take inventory of its disposal. The
guidelines regard sanitary pads, home-made bandages, bandages and condoms to pose low risk,
hence they are allowed to be disposed of in the domestic waste stream (Republic of South Africa,
2004).

The provincial regulations on health care waste management

The Constitution of the Republic of South Africa entrusts various legislative powers including
those regarding HCWM to the national and provincial levels of government (Bethlehem and
Goldblatt, 1997). To regulate HCW in Gauteng province, regulations were developed, and these
will be discussed below.

The Gauteng Health Waste Management Regulations, 2004: This policy was passed in the year
2004. The policy applies to all HCW generators and HCW service providers in the Gauteng
province. The policy provides definitions, classification of all HCW and classification of HCW
generators; the responsibilities of the waste generators; emphasises the need to segregate waste;
correct storage and transportation of HCW; and the importance of wearing protective clothing by
64
handlers, that are consistent with those provided by the WHO. The policy classifies private homes
as minor generators of HCW and it obligates the municipality to provide a safe collection service
for all the HCW that is generated in homes. The policy gives power to the department of health to
provide tenders to the most suitable waste contractors who meet the requirements. The policy also
requires the waste transporters to apply with the department of health to keep audit reports and
tracking documents of all HCW transported. All transporters are prohibited from transporting
untreated waste with other goods (Gauteng Provincial Government, 2004).

The Western Cape Management Draft Bill, 2004: The bill was published for comments in the
year 2004. It was developed to address illegal dumping of HCW in the province. Consistence with
the WHO manual on the safe management of health care waste, the bill provides for the effective
handing, storage, collection, transportation, treatment and disposal of HCW by all waste
generators in the province. The bill obligates the provincial minister to regulate all HCWM in the
municipality to conduct audits of HCW generators to ensure compliance (Western Cape Provincial
Government, 2004)

KwaZulu-Natal Health Care Risk Waste Management Policy, 2008

The policy was developed at a time when incineration was the most common method for the
treatment and destruction of HCW in most low-and-middle-income countries including South
Africa. There was global environmental pressure for countries to ban incineration due to the effects
it contributed to air pollution through the production of particulates, dioxins, furans and heavy
metals. The policy was developed to phase out incineration of HCW in favour of alternative
incineration technologies. The policy provides guidelines on the safe management of HCW from
the point of generation to the point of disposal with the aim of protecting the environment and the
health of the people in KwaZulu-Natal. The policy applies to all public health care establishments
and all health care risk waste services provided that are contracted by the department of health. A
contractor is responsible for supplying of containers, providing off- site transportation, treatment
and disposal of all the residues. The contents of the policy are similar and in line with the Draft
Health Care Risk Waste Management Regulations of 2008 (KZN Department of Health, 2008).

65
The National Health Care Risk Waste Management Regulations of 2008
This is a policy draft that regulates all HCW in the country and was gazetted in 2012. Please note
that HCW is referred to as health care risk waste in this policy and other guidelines in South Africa.
It is required that this policy be implemented together with the South African National Standards
(SANS: 2004). The national health care waste draft (page 6) defines a health care facility as any
place that provides health care services whether for humans or animals and includes places that
carry out medical research. These places are hospitals, clinics, laboratories, rehabilitation centers,
old aged homes, hospices, funeral homes, day clinics and mobile clinics. Although the definition
is well articulated, the list of health care facilities does not include ordinary homes where patients
are cared for (South African Government, 2012).

Further, the regulations categorise HCW into two groups: (a) health care general waste to mean all
waste which is not hazardous; (b) health care risk waste: all waste that is hazardous. Hazardous
waste is the waste that has potential to cause health effects on the general public and the
environment. This kind of waste includes waste from laboratories, anatomical waste,
genotoxic/cytotoxic waste, infectious waste, sharps waste, sanitary waste, nappy waste, low-level
radioactive waste and pharmaceutical waste. It obligates the HCW generators to be responsible for
HCW management from the point of generation to the point of disposal, in a way that protects the
environment and the health of the people. Pages 5-6 of the policy categorises health care risk
generators into two groups: 1) the major generator: one who generates more than 20 kilograms of
health care risk waste – including nappy waste (nappy waste is used diapers) – per day that is
calculated monthly as a daily average; 2) the minor generator: one that generates more than 150
grams and less than 20 kilograms of health care risk waste and also less than 10 kilograms of nappy
waste per day both calculated monthly as a daily average (South African Government, 2012). In
part 2 of the policy, no person is allowed to mix the HCW with any general waste at the point of
generation or disposal of all untreated HCW into the environment. It is required that all HCW must
be segregated, packaged, labeled and stored according to the SANS: 2004 standards. Part 1,(11)
(1), emphasises that, a manager or a transporter must not accept any HCW major or minor
generators that have not been segregated or packaged according to the standards (South African
Government, 2012). This policy provides the definition, classification of HCW and categories of
HCW generators that are the same as those provided by

66
the WHO manual. Thus going by this policy, community-based care clearly falls under the
category of minor generators.

Discussion and conclusion

The WHO manual on health care waste from health care facilities provides global guidance for
managing health care waste. Currently, South Africa’s main piece of legislation on HCWM is still
a draft. HCWM is governed by the SANS CODE, 2004 and it’s a replica of the WHO guidelines
on HCWM. The SANS CODE, 2004 guidelines recommends that professional health care
providers assume the role of educators of potential hazards of HCW, use of protective materials,
importance of segregation and must provide materials necessary for storing HCW. The SANS
CODE further obligates professional health care providers to make necessary arrangements for the
HCW to be removed from the homes of the patient on a regular basis, or make arrangements for
the HCW to be transported to the nearest health care clinic or hospital. Despite the provision of
SANS CODE guidelines, they cannot be enforced in the absence of a national policy. There is
need to promulgate the policy draft into an enforceable policy.

More importantly, even if the SANS CODE has adopted the exact guidelines that are provided in
the WHO manual, the adequacy of these guidelines is questionable. Firstly, CBC is referred to as
‘home treatment’ and does not define what this means no explain what it entails. This terminology
is too broad and it is possible to assume that ‘home treatment’ may only mean taking medication
from home. The ambiguity in the terminology also could mean that patient care by nurses and
caring provided by family members are excluded. Yet these activities could be responsible for
generating HCW.

Furthermore, the WHO manual recognizes CBC as minor generators whose HCW is in small
quantities and include used syringes, needles, incontinent pads and bandages therefore such waste
is recommended to be disposed of with domestic waste. In practice, the assumed ‘smaller quantities
of HCW with inability to cause ‘harm’ is a debatable issue. Although there are no studies that have
been conducted to determine how much HCW is produced in CBC, it is a fact that CBC in the
African and South African context is relevant and addressees the social effects of the HIV/AIDS
pandemic on families and on the health care system (Akintola, Gwelo, Labonte

67
and Appadu, 2015; De Maesenneer and Flinkenflogel, 2010; Van Pletzen et al., 2014). For
example, more patients are receiving nursing care at home that could potentially generate
minimum quantities of HCW just like in nursing homes. Even if the HCW that comes from CBC
is assumed to be in ‘smaller quantities’, it is still HCW and whether in smaller quantities or large
quantities, it remains harmful to the people and the environment. Further studies must be conducted
to explore the quantities of HCW produced in CBC. This will assist in revising the manual and
provide adequate guidelines regarding HCWM in CBC for specific contexts.

68
 References

Bethlehem, L., & Goldblatt, M. (1997). The bottom line: Industry and the environment in South
Africa. IDRC.
Chartier, Y., Emmanuel, J., Pieper, U., Prüss, A., Rushbrook, P., Stringer, R., Townend, W.,
Wilburn, S., & Zghondi, R. (2014). Safe Management of wastes from health-care activities 2nd
edition. World Health Organisation
Fakoya, M. B. (2014). Carbon tax Policy implications for economic growth and unemployment
rates in South Africa: a Conceptual thought. Environmental Economics, 5, 93-98.

Gauteng Province Department of Agriculture, Conservation and Environment. (2004). Gauteng

Health Care Waste Management Regulations, 2004. Gauteng Province.

ICRC (2011). Medical Waste Management. Geneva: International Committee of the Red Cross.
Retrieved from https://www.icrc.org/eng/assets/files/publications/icrc-002-4032.pdf

Johannessen, L., Dijkman, M., Bartone, C., Hanrahan, D., Boyer, M. G., & Chandra, C. (2000).
Healthcare Waste Management guidance note. World Bank.

KwaZulu-Natal Department of Health (2008). KwaZulu-Natal Health Care Risk Waste

Management policy. KwaZulu-Natal Province

Nyalunga, D. (2006). The revitalisation of local government in South Africa. International NGO
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Prüss, A., Giroult, E., & Rushbrook, P. (1999). Safe management of wastes from health-care
activities. Geneva: World Health Organization.
Republic of South Africa (1993). Occupational Health and Safety Act (No. 85 of 1993). Cape
Town. Government Printers.

Republic of South Africa (1998). The National Environmental Management Act (No. 107 of
1998). Pretoria: Government Printer.

Republic of South Africa (2004). National Health Act (No. 61 of 2003). Pretoria: Government
Printer

Republic of South Africa (2012). National Environmental Management: Waste Act (50/2008):
Draft Health Care Risk Waste Management Regulations. Cape Town: Government
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Republic of South Africa, Department of Labour. (1993). Occupational Health and Safety Act
No 85 of 1993. Pretoria: Department of Labour.

Republic of South Africa. (1996). Constitution of the Republic of South Africa, Act 108 of 1996.
Government Gazette, 378.

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Republic of South Africa. (2000). White paper on integrated pollution and waste management
for South Africa. A policy on pollution prevention, waste minimisation, impact
management and remediation. Pretoria: Government Printer.

Rushbrook, P., & Zghondi, R. (2005). Better Health Care Waste Management. World Health
Organization, Regional Office for the Eastern Mediterranean Regional Center for
Environmental Health Activities (CEHA), Jordan, Amman.

SABS (2014). South African National Standard: Management of healthcare waste. Standards
South Africa.

UNEP & WHO (2005). Preparation of National Health-Care Waste Management Plans in
SubSaharan Countries: Guidance Manual. Geneva: World Health Organisation. Retrieved
from http://apps.who.int/iris/bitstream/10665/43118/1/924154662X.pdf?ua=1

UNEP (1992). Rio Declaration on Environment and Development 1992. Retrieved from
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UNEP (2003). Technical guidelines on the environmentally sound management of biomedical

and healthcare wastes. Geneva: United Nations Environment Programme. Retrieved
from http://archive.basel.int/pub/techguid/tech-biomedical.pdf

UNEP (2012). Compendium of Technologies for Treatment/Destruction of Healthcare Waste.

Osaka: United Nations Environment Programme Retrieved from
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r uction_of_Healthcare_Waste_2012.pdf

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Nations Publications. Retrieved from http://www.un-documents.net/aconf48-14r1.pdf
USAID (2013). Healthcare Waste Sector Environmental Guidelines. Retrieved from
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l thcare%20Waste.pdf

Western Cape Province, Department Environmental Affairs and Development Planning (2004).
Western Cape Health Care Waste management draft bill.
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Decision-Making Guide. Geneva: World Health Organisation. Retrieved from
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f

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 CHAPTER FIVE

PRINT MEDIA REPORTING OF HEALTH CARE WASTE MANAGEMENT IN

SOUTH AFRICA

71
 PRINT MEDIA REPORTING OF HEALTH CARE WASTE
MANAGEMENT IN SOUTH AFRICA

Lydia Hangulu1

Olagoke Akintola2,3

1. Health Promotion PhD Programme, University of KwaZulu-Natal.

2. Discipline of Psychology, Health Promotion Programme University of

KwaZulu-Natal.
3. School of Human and Social Development, Nipissing University, North
Bay, Canada.

This paper was prepared for submission to the Journal of Health Research Policy and
Systems.

I, Lydia Hangulu [LH] was responsible for the conception and designing of this
study. My supervisor, Dr Olagoke Akintola (OA), provided guidance. Cassidy-Mae
Shaw (CS) conducted data searches and assisted with assessment
of the newspapers. The three of us worked together as assessors in developing
concepts for the methods section. I drafted the chapter under the guidance of my
supervisor.

72
Introduction: Media has the ability to frame issues in a way that affects the attitudes and
behaviour of the public in responding to policy issues. Given the ability of the media to frame
issues in a way that influences policy-making and decision making more generally, an
understanding of how the media frames issues relating to health care waste in CBC, South Africa
could help inform policy-making about health care waste management in South Africa. However,
it is unclear how the media frames issues related to health care waste in South Africa. We found
no single published study on this theme. This study therefore aimed at exploring how print media
reports on issues related to health care waste in South Africa. We sought to answer the following
questions: 1) How does the print media frame problems related to health care waste management
2) How does the media frame options related to health care waste management.

Methods: Using the South African media database, a total of 189 news stories were retrieved from
20 newspapers. Analysis was conducted using thematic analysis.

Results: The media frames revealed health care waste management problems as caused mainly by
government even if the main perpetrators are waste contractors. There is blame on the government
for delaying in developing a national HCWM policy and for having inadequate HCW disposal and
treatment facilities in the country. As a result, options for addressing the issue of illegal dumping
were directed at the government. Options proposed include, developing of policies and providing
HCW treatment and disposal facilities in the country. The most intriguing thing about the media
frames is that, there was no mention of health care waste from homes. This raises questions as to
whether HCW from homes is even considered as a policy issue in South Africa.

Conclusion: Failure of the print media to propose options that includes waste contractors who are
the main perpetrators of illegal dumping and stockpiling could lead to half solutions that masks
the real problem and focuses on palliatives instead of focusing on all levels of society: mainly the
government policy makers and implementers; government agencies; waste contractors; health
facilities; individual health care workers; health care professionals; waste workers and cleaners in
the health facilities that contribute to this problem.

73
Introduction

Health care waste (HCW) results from health care activities in major health care settings like
hospitals, doctors’ private practices, pharmaceutical manufacturing plants, research laboratories,
nursing homes and minor sources such as ordinary homes where there is care of a patient (Pruss
et al., 1999). There are two categories of HCW: (1) hazardous waste which poses risks to the
environment and the health of people. This comprises infectious waste, sharps waste,
pathological, pharmaceutical, genotoxic, chemical and radioactive waste, and (2) non-hazardous
waste, which is waste which does not pose harm to the environment or people. Non-hazardous
waste comprise of packaging material like cud boxes, office paper, cans and leftover food from
kitchens (Hossain, Santhanam, Norulaini and Omar, 2011). Proper management of HCW involves
segregation, collection, storage, transportation, treatment, disposal, managing and monitoring of
waste management practices (Pruss, et al., 1999).

HCW management is a global concern and was addressed in the Rio Declaration, Principle 10,
which required all States to address environmental issues, promote public participation in decision
making and access to information on hazardous materials and justice on environmental matters
(United Nations, 1992). The major international policies that govern HCW are the WHO manual
on the safe management of waste from health care facilities (Pruss et al.,1999), the technical
guidelines on environmentally sound management of biomedical and HCW (UNEP, 2003), and a
guide on management of solid HCW at primary health care centers (UNEP and WHO, 2005) [see
Table1].

Many low-and-middle-income countries (LMICs) have developed their own policies to govern
HCW. In line with international standards, South Africa has various policies that govern HCW.
Prior to democratic rule which began in 1994, environmental management was neglected and was
not seen as an environmental health nor a priority policy issue (Cock, 2007). However, the South
African government’s approach to HCWM changed after the democratic government of the
African National Congress assumed power. HCW has been regulated by various pieces of
legislations such as the Constitution of the Republic of South Africa (Act 108 of 1996), which is
the main guiding policy aimed at preventing environmental pollution and improving health
74
(Republic of South Africa, 1996), the National Environmental management: Waste Act, 2008
(Act No.59 of 2008), which governs all waste in the country with the aim of protecting the health
of the people and the environment, the Occupational Health and Safety Act 85 of 1993, which
protects the safety of all health care providers and HCW handlers (Department of Labour, 1993),
and the National Health Act, 61 of 2003 (Republic of South Africa, 2003).

As of the year 2000, South Africa did not have any national policy governing HCW but the
Constitution of the Republic of South Africa entrusts legislative power to the national and
provincial levels of government (Bethlehem and Goldblatt, 1997). Thus, in the absence of a
national policy, most of the provincial governments in South Africa took some initiatives to
develop regulations that address HCW. These include the Gauteng Health Waste Management
Regulations passed in 2004 and the Western Cape Management Draft Bill which was published
for comments in 2005. Additionally, the South African Standards Act of 2008 mandates the
establishment of a national body that develops, maintains and promotes the standardisation of
services for the management system, product testing and certification in the country. The South
African Bureau of Standards was established in 1945. The Bureau of Standards developed some
standards (SANS 10248) in the year 2004 to help regulate HCW in the country (Republic of South
Africa, 2004). However, it was not until four years later in 2008 that the National Health Care
Waste Management policy was drafted (Department of Environmental Affairs, 2012). Since then,
this policy which is still a draft document has been the main legislation that governs HCW
management in the country and it is supposed to be implemented together with the various South
African National Standards (SANS) codes of practice for managing HCW (Republic of South
Africa, 2004) as summarised in Table 1. In line with the national policy, KwaZulu-Natal province
developed its own Health Care Risk Waste Management Policy in 2008 (KwaZulu-Natal Health
Department, 2008).

In spite of the existence of the regulations that govern HCWM in South Africa, Van Schalkwyk
(2013) argues that HCWM in hospitals and clinics is a growing problem. These health care
facilities lack funding for HCWM programmes to manage the 45,000 tons of HCW that is
generated annually in South Africa. As a result, HCW is removed, transported, treated and
disposed of by private sector services (contractors).
75
 Table 1: Key health care waste management policy developments relevant to South
Africa

Date Key policy developments

1989 United Nations developed the Basel Convention which is an international legal instrument on the control of
transboundary movement and disposal of hazardous wastes.

1993 Department of Labour developed the Occupational Health and Safety Act 85 of 1995 which provides
guidelines on worker health safety and training.

First democratic elections; Africa National Congress (ANC) government assumes power and ratifies the
1994 Basel convention

South Africa adopts a new constitution that provides a right to a safe and clean environment for every
1996 person.

Department of Environmental Affairs adopts the National Environmental Management Act 107 of 1998
1998 which provides that the polluter must pay principal
World Health Organisation develops a First Edition Global Manual on Safe Management of Waste from
Health Care facilities

1999 Department of Environmental Affairs mandates the provinces, municipalities and health districts to deliver
quality health care services including waste management

2003 United Nations Environmental Program introduces Technical Guidelines on the Environmentally Sound
Management of Biomedical and Health Care Wastes

The South African Bureau of standards develops Standards ‘SANS CODE’ that provides for the safe and
2003 effective management of health care waste aimed at reducing risks to humans and the environment.

Gauteng Provincial Government develops a Gauteng Integrated Strategy and Action Plan for Sustainable
2004 Health Care Risk Waste

Western Cape Provincial Government develops The Western Cape Management Draft Bill aimed at
2005
improving health care waste management in the province.

2005 United Nations Environmental Program and World Health Organisation introduces a Manual with
guidelines on health care waste management practices that are appropriate for sub-Saharan African countries

2007 Promulgation of a Western Cape Health Care Waste Management Act at improving health care waste
management in the province.

2008 Department of Environmental Affairs promulgates a Draft Health Care Risk Waste Management Regulation
of 2008

2008 KwaZulu-Natal Provincial Government develops a Health Care Risk Waste Management policy for
improving health care waste management in the province.

76
Erasmus, Poluta, and Weeks (2012) explain that, the management of HCW by contractors makes
it difficult to have tangible statistics on HCW in South Africa and makes it difficult to provide
proper HCW management practices. To support this argument, research has shown that there is
improper management of HCW from point of generation to the point of disposal in the country
(Nemathanga, Maringa and Chimuka, 2008; Simonsen, Kane, Lloyd, Zaffran and Kane, 1999). In
addition, there are insufficient technologies for managing HCW and as such HCW is burnt in the
open and buried (Raphela, 2014; Abor, 2007). Other problems identified in the literature are the
lack of training for health care providers and handlers (Akiter, 2000; Van Schalkwyk, 2013) and
in fact waste handlers lack proper protective gear (Gabela and Knight, 2010).

Improper management of HCW has adverse impacts on the health of the people and affects animals
and the environment (Erasmus et al., 2012). Most polices on HCWM in South Africa only
emphasise proper management of HCW from major health facilities such as hospitals and clinics
but do not address how HCW should be managed from minor sources such as homes where there
is care of a patient. Yet the majority of the people living with HIV/AIDS and TB as well as other
chronically ill patients receive care at home with the help of community health workers (Akintola
et al., 2015; Young and Busgeeth, 2010; De Maesenneer and Flinkenflogel, 2010). The current
scaling up of community-based care (CBC) services as part of the government’s primary health
care re-engineering initiative calls for researchers, policy makers and stakeholders to pay more
attention to the HCW that is generated in homes.

The mass media is a podium that facilitates the public’s opinion and expectations about policies.
It acts as a channel between the government and the public (Kingdon, 1995; Collins, Abelson,
Pyman and Lavis, 2012). It can inform the public about government’s actions and policies and can
also help convey the attitudes of the public to government officials (Entman, 2007). Through
framing, the media decides what specific issues to cover at the expense of others (Akintola, Lavis
and Hoskins, 2015). Framing is a process where the media defines and constructs a political issue
or public controversy. The media can get and sustain the attention of the public over policy debates
through framing or using rhetoric. Media framing aims at persuading particular audiences (Nelson,
Clawson and Oxley, 1999). The media can use frames to identify
77
policy problems, their causes, consequences and policy solutions to be sought, in a way that
changes the attention paid to such issues (Entman, 1993; Harrington, Elliot and Clarke, 2011). For
example, Daku, Gibbs and Heymann (2012) in their study on Muilti-Drug Resistant and
Extensively Drug Resistant Tuberculosis (MDR and XDR, TB), found that media frames of blame
on the patients for spreading MDR and XDR in South Africa, ignored the role of social drivers in
the spread of MDR and XDR. They argue that, such media framing of blame on an individual
could only influence policy makers to develop policies that are person centered ignoring the
environment/society where the individual comes from. The news media can also decide to frame
issues in a way that draws attention to the players who are involved in the policy process and can
also highlight their role in the decision making process (Jha-Nambiar, 2002).

Therefore the media can play a role in setting policy agendas by focusing on specific social issues
at the expense of others in such a way that influences politicians, policymakers and other policy
actors to adopt particular options at the expense of others (Soroka, 2002). Of interest to our study
is the ability of the media to frame issues in a way that affects the attitudes and behaviour of the
public in responding to policy issues (Kingdon, 1995; Boaz, 2005; Collins et al., 2012). Given the
ability of the media to frame issues in a way that influences policy-making and decision making
more generally, an understanding of how the media frames issues relating to health care waste in
CBC, South Africa could help inform policy-making about health care waste management in South
Africa. However, it is unclear how the media frames issues related to health care waste in South
Africa. We found no single published study on this theme. This study therefore aimed at exploring
how print media reports on issues related to health care waste in South Africa. We sought to answer
the following questions: 1) How does the print media frame problems related to health care waste
management 2) How does the media frame options related to health care waste management.

Methods

We used the South African media database, which is the only media database available at the
University of KwaZulu-Natal, to search for news stories for our analysis of print media framing of
HCWM. The South African media database is compiled and maintained by the institute for

78
contemporary history (INCH) located at the Free State University. The institute collects and scans
newspaper cuttings and periodicals daily and then categorises and indexes them into Afrikaans and
English, before uploading them on the database. The media database contains various South
African newspaper articles from the year 1978 onwards.

Newspaper search and selection strategy

We (LH and CS) developed a search strategy in order to help us retrieve newspapers from the
South African media database that were relevant to our study. Using an iterative process that
involved brainstorming and trial searches of the South African media database, we developed a set
of explicit inclusion criteria, which are that all newspapers to be included in the study must be: 1)
classified as a South Africa newspaper, and 2) published in English and 3) cover a health care
waste issue. A total of 20 newspapers met the inclusion criteria (see Table 2) and were included in
the study. The search covered all news stories that were available in the South African media
database from 1 January, 2004 to 31 December, 2014, a ten-year period.

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 Table 2: Characteristics of newspapers covered in analysis
Geographical circulation Newspapers Frequency Publisher
of newspapers
National newspapers
Citizen Monday-Friday CTP/Caxton

City Press Sunday Media24

Mail & Guardian Weekly M & G Media Ltd

Johannesburg
New Age (The) Daily
TNA Media

Star (The) Monday-Saturday

Independent
Sunday Independent (The) Weekly Newspapers,
Johannesburg

Sunday Times Weekly Independent

Newspapers,
Sunday Tribune Weekly Johannesburg

Times (The) Weekly Avusa Media Ltd,

Johannesburg

Independent
Newspapers,
Johannesburg

Avusa Media Ltd,

Johannesburg

Provincial Newspapers
Eastern Cape Daily Dispatch Monday-Saturday Avusa Media Ltd,
Johannesburg
Herald (The) Monday-Friday
Avusa Media Ltd,
Weekend Post Weekly Johannesburg

Avusa Media Ltd,

Johannesburg

80
 Gauteng Pretoria News Monday-Saturday Independent
Newspapers,
Johannesburg
Sowetan Daily
Avusa Media Ltd,
Johannesburg
KwaZulu-Natal Business Day Daily BDFM Publishers
(Avusa Media Ltd)
Daily News Daily
Independent
Independent on Saturday Saturday Newspapers,
Johannesburg
Witness Daily
Independent
Newspapers,
Johannesburg

Media24

Western Cape Cape Argus/Argus Weekend Monday-Sunday Independent

Newspapers,
Johannesburg
Cape Times Daily
Independent
Newspapers,
Johannesburg

Search strategy for news stories

We searched for news stories from the 20 newspapers using specific terms related to health
HCWM in South Africa. News stories that had specific terms/concepts related to HCW
that are mainly used in the literature on HCWM in South Africa were included in our
sample. Because we wanted to include a wide range of news stories on HCW, we searched
for news stories that had used the keywords/search terms both in their titles and full texts.
Relevant stories that were covered from all sections of newspapers were also selected if
they met the explicit inclusion criteria. Two broad categories of concepts for the search
were used. The first being “healthcare waste”, the broad concept that is widely known for
describing waste that results from health care activities and the second involved using the
common terms from literature that are used in various contexts to refer to healthcare waste.
These terms are “clinical waste”, “hazardous waste”, “health care risk waste” and its
variant spellings and acronyms: “hospital waste”, “infectious

81
waste”, “medical waste”, “pathological waste”, “pharmaceutical waste”, “sharps”, and
“used medical supplies” (see Appendix 1 and 2 showing news stories retrieved using
various search terms).

Selection and analysis of news stories

We retrieved a total of 901 news stories from 20 South African newspapers (see Appendix
1). In order to remove news stories that were not relevant to the study, we developed a list
of explicit exclusion criteria. First, from a total of 901 news stories, we removed 74 news
stories that were published in languages other than English and 827 remained. Second, we
excluded 105 news stories that were published in non-South African newspapers, like the
Nigerian publication, This Day, and the Namibian publication, and The New Era. After
removing non-South Africa news stories, 722 news stories remained. Third, we removed
360 news stories that did not cover HCW and a total of 362 news stories remained. Fourth,
we removed 64 news stories that did not have a focus on HCW in their main text and 298
news stories remained. Fifthly, from the 298 news stories, 109 articles overlaps –same
news stories retrieved using various search terms - were removed. A total of 189 news
stories were left and analysed the summary is provided in Figure 1.

Data analysis

The two assessors (SM and LH) analysed both newspapers and 189 news stories in our
sample. We adopted an approach to data analysis that struck a balance between a more
structured deductive approach that uses pre-set themes and categories derived from
existing theories, and an inductive approach that starts with immersion in the data and
allow themes to emerge strictly from the data. This was done because we were interested
in the policy and public health relevance of media reporting of issues relating to health
care waste management in South Africa.

82
 Initial search
901

Remove 74 articles not published

in English

English articles
827
Removed 105 articles not published
in SA newspapers

Articles printed in SA newspapers

722
Removed 360 articles that did not
cover health care waste

Articles focusing on health care waste in

their title and abstracts 362

Removed 64 articles without

focus on HCW in their full texts

Articles that focused on health care

waste in the full texts
298
Removed 109 articles that were
overlaps

Articles that formed part of analysis 189

Figure 1: Flow chart showing sample selection process analysed for basic characteristics

As such, we chose to draw on literature related to policy and public health systems to
help develop concepts that could sensitise and guide us while conducting thematic
83
analysis. Our analysis proceed in two phases: In the first phase, we drew on existing
literature on policy and health systems; in particular, Kingdon’s conceptualization of policy
problems in the agenda setting process (Kingdon, 2003) and literature about the health
policy process more generally (Lavis et al., 2012) to develop sensitizing concepts that
served as prompts for our thematic analysis that followed in the second phase.

Two groups of concepts were derived from this process and were agreed upon by the two
assessors and reviewed by the third assessor (OA) for accuracy. The first group of concepts
dealt with issues related to the nature of health policy problems (eg. what problems are
identified and how are the problems being framed to motivate different stakeholders
including policy makers; and how did it come to attention), and at what level are the
problems being defined (eg who or what level of governance is responsible or should be
held accountable for the problem). The second group included concepts related to the
nature of policy options proposed by the news stories to address the problems identified
(eg. What are the options being proposed and how are the options being framed, and at
what level are the options being framed or defined?).

In the second phase, we used the two concepts derived in the first phase as organizing
categories for our data and proceeded to analyse the news stories following the six steps
of thematic analysis proposed by Braun and Clarke (2006). Firstly, we read news stories
in order to familiarise ourselves with the data. Secondly, the news stories were read again
to identify and categorise the data into the three organizing concepts: problems and their
causes, options and implementation considerations. In the third stage, codes were
identified and generated. In the fourth step, all subthemes were identified from the codes.
In the fifth stage, the sub-themes were grouped together and in the sixth stage, all themes
were grouped together and presented in the results section. The analysis was conducted in
an iterative manner by the two assessors and a third assessor (OA, the supervisor) helped
in resolving discrepancies where the assessors could not reach consensus and in checking
for accuracy.

84
Results
Characteristics of the newspapers and news stories
As shown in Table 3, more news stories 107 (56.6 %) were published by national newspapers than
by provincial newspapers (82, 43.5%). Of the 189 news stories published in national and provincial
newspapers, the largest grouping was published in newspapers in the Eastern Cape 56 (29.6%)
followed by newspapers in KwaZulu-Natal province with 23 (12.8%), the Western Cape provincial
with newspapers 21(11.1%) and Gauteng provincial newspapers had 7 (3.7%). Of the total number
of news stories published in both the national and provincial newspapers, Daily Dispatch had the
highest number of news stories (29, 15.3%) followed by the Star and The Herald with 24 (12.7%)
each.

85
Table 3. Characteristics of news stories on health care waste (N=189)
Variable Sub-variable Total %
Newspaper source
National newspapers 126 42
Citizen 18 6.0 3.0
City Press 9 2.7
Mail & Guardian 8 0.7
New Age (The) 2 11.0
Star (The) 33 5.3 7.3
Sunday Times 16 0.7
Sunday Tribune 22 4.7
Sunday Independent (The) 2 0.7
Times (The) 14
Sowetan 2
Provincial newspapers 174 58%
Eastern Cape newspaper 71 23.6
articles Daily Dispatch
Herald (The) 42 14.0
Weekend Post 26 8.7
3 1.0
Gauteng newspaper articles 12 4.0
Pretoria News 12 4.0

KwaZulu-Natal newspaper 43 14.3

articles
Business Day 7 2.3
Daily News 18 6.0
Independent on Saturday
(The) 3 1.0
Witness (The) 15 5.0
Western Cape newspaper 48 16.0
articles
Cape Argus/Argus Weekend 34 11.3
Cape Times 14 4.7

86
The news stories covered in this study were published between 2004 and 2014 as shown in figure
2. The number of news stories on health care waste fluctuated between 2004-2006. However, there
was a steady increase from 2007 with a peak in 2010 and a sharp decline in 2011 and a gradual
decline in the number of news stories was observed from 2011 to 2014.

N=189
50
45
40
Number of news stories

35
30
25
20
15
10

2004' 2005' 2006' 2007' 2008' 2009' 2010' 2011' 2012' 2013' 2014'

Year of publication

Figure 2. Number of news stories and year of publication

Presentation of the news stories

The news stories will be presented under the two broad themes 1) the problems related to health
care waste management and their causes; 2) the options proposed for dealing with the problem.
The summary of themes and sub-themes are presented in Table 5.

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 Table 5: Summary of the themes generated from the news stories
Problem and causes Options
Problems causes Proposed solutions What is already being done
to the problems about problems
1. Illegal dumping of health a. There is lack of a national 1. Government should a. Development of a health care waste
care waste health care waste management develop regulations or management Bill in Eastern Cape
policy; existing ones are review the existing ones b. Development of disposal sites and a
fragmented and not implemented. 2. Government should waste management team was
b. Insufficient treatment facilities established in KwaZulu-Natal
open more disposal
c. Lack of capital to handle HCW
sites. c. Education awareness programmes
by government
e. Corrupt tender processes
f. Incompetence of contractors to
handle health care waste
2.Illegal storage and stock a. Lack of capacity for storage of 3. Government should 1. Raids: are conducted on the premises
pilling of health care health care waste by contractors monitor health care of the contractors. 2.Inspections and
waste b. Contractors face Stiff waste management. audits are conducted in hospitals
competition and end up not
honoring their contracts
3. Financial impropriety Not mentioned
by department of health
4.No personal protective a.Incompetence of contractors to
equipment for the waste afford PPE for their workers
handlers
5. Lack of segregation of a.Incompetence of hospitals to
health care waste. segregate health care waste
6.Use of inappropriate a.Incompetence of contractors to
transport by contractors afford appropriate transport
7.Re-use of HCW a.Incompetence of contractors
containers

Problems and causes

This theme will discuss the problems that are identified in the news stories, the level at which the
problem is defined and who is blamed for the problem. The theme comprise nine sub themes,
illegal dumping of HCW, illegal storage of HCW, HCW management operating without permits,
corrupt tender processes, financial impropriety by the department of health, lack of personal
protective equipment for waste handlers, news stories identified lack of resources for health care
waste management, lack of segregation of HCW, use of inappropriate transport for HCW and re-
use of HCW containers. These problems come to the attention of the media mainly through “tip
offs’ that are provided by people who work in these sectors. The problems are discussed in detail
below.
Illegal dumping of health care waste by waste management companies: This was a problem that
was reported by the overwhelming majority of news stories. Dumping of HCW waste is done on
privately owned land, on the streets, in open veld, in municipal landfills, in residential
areas and near school premises. Residents are represented as heroes, whistle blowers who
88
discover the acts and alert the media, the Health Department and the Municipality. Most
newspapers attributed various negative consequences such as infestations of disease-causing
organisms such as rats, flies and cockroaches to illegal dumping. The stench produced by the HCW
is another effect highlighted by the media and children were represented as being at risk of poor
health because they were said to have been seen playing with HCW. Illegal dumps near homes
were also framed as affecting landlords who claimed that prices of their properties went down due
to the existence of illegal dumps close to their properties. Illegal dumps in residential areas were
framed as attracting scavengers who also used such places for toileting. Waste scavengers were in
turn seen as responsible for house break-ins in the residential areas.

The print media framed the issue of illegal dumping as caused mainly by the lack of a national
policy to regulate HCW management in the country. The government is blamed for taking long to
develop a national policy and for ‘dragging its feet’ on passing the national health care waste
management draft policy into law. The blame on the government largely originates from the
Democratic Alliance (DA), the main South African opposition party to the governing African
National Congress (ANC). Further, news stories also emphasise that HCW is governed by
provincial laws which are fragmented thereby causing a lack of uniformity in the implementation
of the laws.

“The problem that we have as a country is that, currently, policies for medical
waste are individually driven by nine provincial governments causing a substantial
overload of regulation for service providers!…There is inconsistencies in
implementing health care waste management laws in the country…”(The Saturday
Weekend, 7th March, 2009)
The second cause of illegal dumping according to the news stories is a lack of financial and human
capacity for HCW management at the national level. This was attributed

“The total amount of waste generated in South Africa amount to 42200 tons per
year but available commercial treatment facilities could only handle 31,690 tons
per year…We do not have the financial capacity or skills to obtain more
incinerators that cost millions of Euros…” (The Saturday Weekend Argus, 7th
March, 2009)
The news stories recognized that large amounts of HCW are produced in the country yet there are
only five incinerators available for treating HCW. The incinerators are only available in the Free
State, Western Cape and Gauteng provinces. Therefore the provinces that do not have
89
incinerators transport the HCW to these provinces with the incinerators. One news story quoted a
chairperson of environmental activist group who said:

“The fact that medical waste incinerators are failing is neither surprising or
news…in provinces such as KwaZulu-Natal, North West, Limpopo, Mpumalanga,
and Northern and Eastern Cape where no incineration capacity exists…health care
risk waste is transported to Free state, Western Cape, or Gauteng to be
incinerated” (The Sunday Tribune 6th March, 2011)

The news media reported that only recently, one incinerator was built in KwaZulu-Natal province.
Further, because the government lacks financial capital to provide facilities needed for treating and
disposing of HCW, it relies on private waste companies (contractors) to manage all HCW in the
country. The government is also blamed for not having human resources in the Department of
Health and the Department of Environmental Affairs and Tourism that can help to
offer advice on how to handle and manage HCW. Hence the healthcare waste management sector
is seen as being in ‘a national waste crisis’ (The Star 12th February, 2010). In emphasising the
problem of lack of human resource, one news story reports:

“South Africa generates more medical waste than it can handle. This is a disaster!
The government insists that waste must be handled properly yet there are few or
no officials in the provincial departments with the expertise to offer advice on how
the industry works.” (The Cape Argus, 14th October, 2009)
Thirdly, most news stories reported that the other cause of illegal dumping is corrupt tender
processes. The news stories accused officials in The Department of Health who are responsible for
awarding contracts on waste management to the private companies of corruption. The news stories
framed the issue of corruption as very serious and wide spread, and as caused by lack of standards
for awarding tenders to the waste management companies. They indicated that as a result, tenders
are awarded based on the price that the waste management companies are willing to bid other than
on their capabilities to provide HCWM services. One news story indicated:

“…Policy oversights…dodgy tenders and the milky delineation of responsibility

between the government and the government departments are the root of the
problem (of illegal dumping)…” The Business Day, 14th, October, 2009)
“Members of the forum (the tender board) have been approached by waste
disposal contractors who say: we will give you bigger margin if you bring the
waste to our plant; there is a lack of compliance...” (The Sunday Tribune, 28th
February, 2010)

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It is also reported by a few news stories that due to lack of standards for awarding tenders by the
Department of Health, there have been disputes between the waste management companies and
the Department of Health. Some waste management companies have taken the department of
health to court because of tender irregularities and in most cases the department has lost several
court cases thereby wasting a lot of money which could have been invested in the HCWM sector.
The news stories also claimed that because of the corrupt tender process, the companies that are
awarded the contracts do not possess the requisite competencies and capacity to treat or dispose of
waste appropriately.

“It costs millions to set up a plant… many of those contractors who submit
contracts to process health care waste lack the capacity to do so legally…to survive
you end up getting pulled into the web and it becomes a cartel with a big spider at
the top” (28th February, 2010)
Illegal storage and stockpiling of health care waste by waste management companies

Most news stories framed this issue of illegal storage and stockpiling as a serious and rampant
problem. Stories of illegal dumping are reported to the media by workers. Most newspapers also
indicate that some contractors pile HCW for several weeks or months in warehouses which
produce a strong stench and affect the workers. One news story revealed a particular waste
company whose truck drivers told the news crew about the health and social impact of exposure
to HCW:
“The smell of rotting human bodies is so potent; it had penetrated my skin and
body. I go home at night and smell so bad that my wife makes me sleep in another
room…” (The Star, 23rd February, 2009)

The news stories blamed the problem of illegal storage of HCW on the lack of incinerating or
capacity to process HCW and lack of sufficient funds to own appropriate HCW storage facilities.
As a consequence some of them rent and store HCW illegally in warehouses. The waste
companies do not have treatment facilities of their own and therefore they rely on the government
facilities which are few and sometimes non-functional. As a result of non- functional facilities,
there are backlogs with HCW treatment processes causing the contractors to stock pile the HCW.

91
 “Waste companies were being forced to stockpile dangerous medical waste
because the country’s legal incinerators couldn’t cope…” (29th November, 2009).

Some news stories also had frames about some waste management companies failing to pay their
landlords the rents for the warehouses that they use to store waste and as such, they are evicted
from the warehouses. The evicted companies end up stockpiling the HCW in their own trucks that
are meant for transporting purposes. The trucks are hardly cleaned and when they are cleaned, the
cleaning is done from the provincial hospitals without using any disinfectant. In the Northern Cape,
there was a report about an instance where the vehicles used for storing waste was used to transport
liquor to a end of year function.

“The trucks for the contractors are hardly ever washed. And when they are
washed, it takes place at the provincial hospital without using any disinfectant to
clean and sanitize the vehicles. At one stage the contractors used one of the trucks
to collect liquor at a liquor store in Kimberly to have it transported for the end of
year function.” (The Mail and Guardian, 9th June, 2011)

Most stories have framed this problem of stockpiling as caused by stiff competition among
HCWM companies. As a result, they find it difficult to survive in the industry and end up failing
to honour their contracts.

“The bigger problem with waste management by the contractors is that the
smaller emerging companies many of whom have won tenders by the Department
of Health are squeezed by the well established players who have dominated the
industry…so the smaller companies feel the heat…some of them have invested
millions to set up specialist disposal plants but stiff competition makes them use
short cuts and do illegal things.” (The Sunday Times, 2nd December, 2007)

Financial impropriety: A few newspapers also reported financial impropriety by the department
of health (DOH). The DOH is responsible for awarding tenders and paying the contractors who
are responsible for removing, transporting and disposing all HCW from health care facilities
around the country. Although no cause was identified as responsible for this problem, it is further
reported that the department of health fails to pay the waste contractors who in turn find it
92
difficult to keep their operations running. For example, it is reported that there have been instances
when the waste management companies have stopped collecting waste from all hospitals in protest.
Such acts have been said to cause backlogs with waste management processes in most health care
facilities. Some waste companies have been reported to be on the verge of closing down due to the
fact that the department did not pay them for several months. One news story revealed:

“We have not been paid since November and have been told we will only get the
money in mid-April. The department promised payment of the debt.”(The Sunday
Star, 17th April, 2010)

Lack of personal protective equipment (PPE) for workers: One news story also reported
that some workers that are hired by some waste management companies are not provided
with any PPE such as masks and gloves for use when handling waste. As a result, such
workers felt that they were at risk of infections because they were pricked by needles.
Others claimed that they had become accustomed to the stench produced by the rotting
waste:

“We have to use our bare hands to pick up everything that we find here and handle
dangerous waste from hospitals…since I started here I have never been given
anything [protective equipment] to wear. Initially it was difficult for me to
withstand the stench but I am now used to it.” (The Star, 25th May, 2005)

Lack of segregation of health care waste: Some news stories reported that most hospitals in South
Africa do not segregate waste. Most newspapers reported that such cases come to the attention of
the public through anonymous ‘tip offs’ that are made to the media by ‘insiders,’ those working
for the companies. The problem of lack of segregation was framed by one news story (the Daily
News, 3rd of February, 2012) to be more prevalent in KwaZulu-Natal province where 12 out of the
14 hospitals were said to be guilty of this practice. However, most news stories framed this
challenge as caused by incompetent waste management companies who give hospitals unmarked
containers for storing HCW.

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 Hospitals are complaining about unmarked (waste) containers that were delivered
to them by waste management companies” (Mail and Guardian, 9th June, 2011)

These news stories also report that due to lack of proper segregation of waste in hospitals,
there have been cases where dead babies have been found by scavengers among general
waste while another case of a leg floating in an abandoned and flooded boiler room was
reported at one hospital. Another news story framed this issue as a big problem affecting
all hospitals in the Eastern Cape Province. It is reported that the hospital administrations
were trying to save money by rationalising services. There were many instances when the
hospitals were never cleaned, wards and toilets were filthy and HCW was uncollected and
seen lying around causing stench:

“The Livingstone Hospital has become a ‘ghost hospital’ which is ‘half closed’ because services
there have been streamlined significantly.” (The Weekend Post, 17th September, 2005)

It is further reported that some nurses became fed up with unhygienic working conditions,
and therefore went or a protest:

“Today the cleaners did not pitch for work, the floors and the wards are dirty. It is depressing.
Our young doctors are refusing to work in the conditions and are leaving the country.” (The
Weekend Post, 17th September, 2005)

Use of inappropriate transport: A few news stories reported that lack of use of appropriate
transport by waste management companies was a problem. Most of the waste management
companies used open vans to transport HCW. The news stories framed the problem of use
of inappropriate transport by waste companies to transport HCW as caused by lack of
finances to purchase recommended vehicles. It was reported that HCW was found on the
highways, which is suspected to have fallen from moving vehicles and was causing
obstruction to the motorists.

94
…”The companies that are awarded tenders do not have the right vehicles. The vehicles
are not clearly identified as carrying hazardous waste, a legal requirement!” (The Mail
and Guardian, 9th June, 2011)

“…Hazardous waste which fell from a moving truck along Port Elizabeth’s freeways shock
motorists by causing obstruction…” (The Herald, 2nd February, 2004)

Reuse of containers for storing and transporting of anatomical waste: One news story
reported that some contractors reused buckets containing anatomical waste which are
supposed to be incinerated. They framed this issue as caused by incompetence of the waste
management companies who do not have the appropriate materials equipment for
managing HCW.

Options proposed or provided to address the problems

The news stories identified three solutions to the problems of health care waste
management. These are the need for government to develop regulations or review the
existing ones, opening up of disposal sites and to monitor health care waste management.
These themes are discusses together with the options that the government is providing to
address the problems and these are: development of a health care waste management Bill
in Eastern Cape, establishment of disposal sites a waste management team in KwaZulu-
Natal, education awareness programmes, raids, inspections and audits.

The government should develop regulations or to review the existing regulations: Most
news stories proposed solutions to deal with the issue of improper management of HCW
across the country. The news stories framed this option as doable by the government. To
address the problem of illegal dumping in the Western Cape, news story (The Cape Time,
26th November, 2007) reported that a bill on HCWM (draft) in the Western Cape was
initiated by the provincial government in 2005 in response to an incident where 40 children
pricked themselves with discarded needles found in HCW that was illegally
dumped in residential areas.

95
 “The ‘years in making’ Western Cape Health Care Waste Management Act that
will make dumping of medical waste a criminal offence will be signed by the
Government. This legislation was initiated when more than 40 children had to go
for an HIV test in 2005 for injecting themselves with discarded needles in Delft
and Mitchells Plain…” (The Cape Time, 26th November, 2007)

After the bill on HCWM (draft) in the Western Cape was released for comments by the
public in 2005, it was promulgated into law in 2007 and now it is called the Western Cape
health Care Waste Management Act of 2007.

“This act will change the way in which the HCW in managed in the province…for
the first time… there will be a uniform provincial standards for managing HCW…”
(26th November, 2007)

To address the issue of insufficient treatment and disposal facilities: the government
opened disposal sites in KwaZulu-Natal province.

“The EnvironServ Company will now install a state-of- the-art facility using a
thermal process…the decision to establish was made, because if such facilities
were not established, HCW would continue to be transported to other provinces
increasing the risk of exposure to communities…” (The Sunday Tribune, 22nd July,
2007)

Some news stories revealed that, to address the issue of illegal dumping of HCW, some
partnerships between the governmental departments and environmental activist groups
were formed. Awareness campaigns are held to educate community health workers about
HCWM and the implications for its improper disposal. A few newspapers also indicated
that conferences and meetings were held to put together a HCWM strategy to regulate
HCW in South Africa.

To address the problem of lack of segregation in the KwaZulu-Natal Province, one

newspaper (the Daily News, 3rd February, 2012) indicated that the Department of Health
created the waste manager posts. Additionally, medical waste management strategy
document was also developed, HCWM committees were established and there was

96
incorporation of transportation of HCW from clinics into the waste management strategy
service contract to ensure compliance. All tenders for waste management contractors are
published to ensure transparency.

The government should monitor health care waste management: It was suggested that
the government should monitor all the HCW that is produced in the country.

“The government must create a specialised agency to oversee medical waste

management which will be responsible for regulating medical waste disposal
chain; it would enforce laws, create clear guidelines and keep records of medical
care waste management activities.” (The Business Day, 14th October, 2009)

In order to ensure that waste management companies comply with the standard waste
management procedures, most news stories report that random raids at the warehouses of
the waste management companies are conducted by the Green Scorpions (the
environmental management inspectors). Those that are found operating without permits
are given 24 hours to shut down their operations and are fined. Companies that fail to pay
the fines and persistent offenders are imprisoned for five to ten years, and those who
stockpile are ordered to remove and dispose of the HCW within 24 hours. Companies that
are found guilty of illegal dumping are given 24 hours to clean up. In situations where the
offenders are not found, clean up sessions are organised by the government through the
health unit in the municipality. The government officials also fence and monitor such areas
after cleaning up. Some waste companies have had their contracts terminated by the
Department of Health due to non-compliance.

“Wasteman, a waste management company that was allegedly responsible for

being the South Africa’s biggest medical waste dumper, was raided by the South
African watch dog the ‘Green Scorpions’ in the last two weeks and has been
ordered to shut down; the chief executive director has been arrested and charged
for being a persistent offender.“ (The Saturday Star, 17th April, 2010)

97
Inspections and audits by the Department of Health are carried out in hospitals to ensure
that they comply with proper procedures of HCWM from point of generation to the point
of disposal.

“Provincial Health Department spokesman expresses shock about problems at

Livingstone hospital. ‘We promise inspections and audits will be carried out in all
hospitals to ensure that this problem does not persist,’ said the provincial Health
Department spokesperson.” (The Weekend Post, 17th September, 2005)

Discussion

This study explored how the media frames issues relating to problems and options about HCW
management in 20 newspapers in South Africa. Although the implementation of policies occurs at
the provincial level in South Africa, there were a few more national newspapers reporting issues
relating to HCWM than were provincial newspapers. This might reflect the concern that HCWM
is generating among policy-makers and various stakeholders and actors at the national level; as
National newspapers might therefore be interested in covering these issues in order to influence
policy makers (Entman, year, Daku et al, 2012). It is striking that most of the news stories were
from the Eastern Cape and were reported by the major Eastern Cape newspapers: The Daily
Dispatch and The Herald. The Eastern Cape is one of the five provinces that does not have a
provincial policy on HCW management and a treatment plant for health care waste. It is possible
that it has more HCW management issues or concerns due to a lack of a provincial policy on HCW
and waste treatment plants. Of the five provinces, Eastern Cape is the only one with more
newspapers in our sample. Unfortunately, we are unable to compare this figures with that of other
provinces with similar HCWM challenges since we do not have newspapers from the other four
provinces in our sample.

We note a steady increase in the frequency of news stories from 2007 to 2010 with a peak in 2010.
It is also interesting that there was a gradual decline in the number of news stories from 2011
onwards. While some news stories discussed the publishing of the Western Cape Waste
Management Policy in 2007, none of them discussed the national health care waste draft policy
which was published for public comments in 2008. It is not clear what is responsible for the spike
in the number of news stories on HCW in 2010 as no policy documents were published in
98
2010. During this period, most of the news stories discussed the problems of health care waste
management, linking it to the lack of a national policy and/or a failure to implement existing
policies. The gatekeeping literature suggests that newspapers choose what issues to report based
on the newsworthiness of the issue (Soroka, 2012). It is possible that the various policy
developments which took place from 2004 to 2008 helped to sensitise the media to health care
waste management issues in the country to the extent that media organizations considered it
newsworthy. At the same time stakeholders might be have been sensitized by these draft policies.
These two factors may have contributed to an increase in the number of reports relating to health
care waste management.

The most dominant representation in the new stories was on illegal dumping by HCW waste
companies/contractors. The WHO global health care waste manual (Pruss et al., 1999) and the
South African National Standards on HCW (the SANS 10248 (Republic of South Africa, 2004)
prohibits illegal dumping of HCW due to its environmental and public health effects. While many
studies have found that illegal dumping is widespread in South Africa (Gabela and Knight, 2010)
and other low-and-middle-income countries (Mundia and Mbewe, 2006; Bendjoudi, Taleb,
Abdelmalek and Addou, 2008; Sawalem, Selic and Herbell, 2009; Mangaa, Fortonb, Moforc and
Woodardd, 2011), there is no literature on the perpetrators of illegal dumping. We are therefore
unable to assess the accuracy of this frame. Therefore, this issue warrants empirical research that
seeks to gain a deep understanding of illegal dumping of health care waste. The media portrayed
the waste management contractors as out of control because of their illegal practices. The
contractors were portrayed in most of the news stories as engaging in illegal dumping and illegal
storage and stockpiling of HCW, using inappropriate vehicles to transport health care waste and
re-using containers used for anatomical waste which is supposed to be incinerated. The print
media’s representation of contractors is that of villains whose activities have gone unchecked by
government structures that are portrayed as ‘looking the other way’ while the contractors
perpetrate their dastardly acts. Their activities were also represented as causing health hazards for
the environment, residents of communities close to the sites where the illegal dumping of HCW
occurs, and their own workers who are not provided with protective devices when handling health
care waste.

99
Interestingly, the overarching dominant frame of the cause of the problems of health care waste
management in South Africa was the government’s lack of proper oversight and control of the
waste management sector. The contractors were presented as operating in a very difficult
environment that was disenabling. The news stories blamed the problem on the governments’
inability to create the necessary enabling environment for proper health care waste management
and for contractors to do their jobs properly. Given the manner in which the cause of the problems
of health care waste management was framed, the options for dealing with the problem were
focused mainly at the level of government [namely the Department of Health and Department of
Environmental Affairs]. News stories constructed the contractors’ actions as being left to go
unchecked and therefore proposed the development of appropriate regulations that will set up an
agency to monitor contractors and enforce laws and regulations on the entire health care waste
management chain.

While the framing of solutions may sound logical and sensible, some news stories, at the same
time, ironically portrayed contractors as victims of a system that was not conducive for them to
carry out fair and proper waste disposal practices. They were portrayed as ‘victims’ of
circumstances created by governments’ lack of funding of the health care waste management
sector. This it was said led to inadequate financial and human capacity for developing disposal
sites and effectively managing the industry as a whole respectively. Government departments were
accused or financial impropriety and waste contractors were said to be owed money by government
which hampered their ability to comply with regulations. As a consequence, the options proposed
were those designed to increase capacity for the incineration of health care waste across the country
which most news stories said were only able to process only about 75% of the large volume of
health care waste that is generated in the country and sometimes not functional. There were also
proposals for government to purchase modern technology for the treatment of health care waste.

In addition government was blamed for corrupt tender processes which led to the appointment of
incompetent contractors. Government was also vilified for financial impropriety which led to
delays in the payment of contractors which in turn further exacerbated their woes. There are

100
studies that have found corruption as a major challenge that has dodged procurement processes in
the public sector in South Africa (Ambe, 2012; Jeppesen, 2010; Abadenhorst-Weiss; 2012). The
authors of these studies argue that corruption in the government sector in South Africa is as a result
of decentralization of public procurement. Although news stories constructed the issue of
corruption as widespread in the health care waste management sector, there is no empirical
research evidence on corruption in the health care waste management sector. Research that seeks
to explore this issue would be a welcome contribution to knowledge on health care waste
management.

By identifying the illegal and unprofessional practices of waste contractors but blaming
government for their reprehensible activities and proposing options that focus mainly on the
government, the print media creates a situation that indirectly absolves waste companies. While
some news stories mentioned the need to monitor contractors closely, this was not the dominant
frame. Further, rarely did the print media emphasise the legal and contractual as well as moral
responsibility of the contractors as corporate entities to comply with existing laws and regulations.
Instead, there was a strong emphasis on the need for government to do more for contractors and
the industry. The SANS 10248 (2004) prohibits illegal dumping of health care waste and
recommends that specific HCW must be disposed of in a specified manner. For example,
anatomical waste must be dumped at a class A dumpsite where it must be burnt in a controlled
manner. While the dominant representations of problems vilify both the contractors and
government, the dominant representations of options have the potential to justify the malpractices
of the contractors albeit indirectly thereby tacitly encouraging them to break the law.

Stockpiling by waste management companies is in contravention of the law in terms of the

National Environmental Management Waste Act 59 of 2008 (Republic of South Africa). The
dominant media frame could lead to a fixation with narrow solutions that focuses on government’s
failures and responsibilities while neglecting the legal and contractual obligations, and moral
responsibilities of waste companies to deliver services within the confines of their contracts and
the laws of the country which prohibit their illegal activities (SANS, 2004; Republic of South
Africa, 2008). The dominant media representations of government as the

101
cause of the problem in the industry perhaps largely reflect the views of the opposition party – the
Democratic Alliance which dominated the coverage of the problems contained in the news stories.
As Nelson and Oxley (1999) argue, a frame could marginalize other frames of understanding. The
frames used by the news stories in our sample could undermine the development of comprehensive
solutions that holds the main perpetrators of the illegal activities to account for their actions.

Another dominant representation in the media is that of lack of a national health care waste
management policy which has led to a fragmentation or provincialisation of policies A review of
policy and literature shows that there is no national policy governing HCWM in South Africa
(Akiter, 2000; Nemathanga, Maringa and Chimuka, 2008). The current national guiding document
on health care waste management has been in draft form since 2008. Recent studies by Van
Schalkwyk (2013) and Erasmus, Poluta, and Weeks (2012) argue that a lack of a national policy
and the fragmentation of policies (i.e. development of policies by various provinces) on HCW
management makes it difficult to have uniform implementation in the country and to quantify and
monitor HCW. The way the media frames the problem of fragmentation in policy on HCWM is
consistent with empirical evidence on this issue. This media representation could potentially help
influence and policy makers to take appropriate action (Entman, 1993; Akintola, et al., 2015). But
as noted earlier, the problem of health care waste management cannot be focused on the
government’s policies alone but must include other levels of society that contribute to the problem.
We now turn to the other levels contributing to the problem of waste management in the country
as described by the news media.

The other dominant frame in the print media is the lack of segregation of HCW by health care
facilities. The media frames this as an institutional (health care facilities) problem. The WHO
policy, the SANS 10248, the South African Constitution and all South African provincial policies,
puts the responsibility on all waste generators of HCW to segregate waste. Health care institutions
are given the responsibility to oversee all health care waste management activities in order to
ensure that HCW is properly managed (Pruss et al, 1999; Republic of South Africa, 1996).
Evidence from low-and-middle-income countries (Sawalem, Selic, & Herbell, 2009; Magdy &
El-Salam, 2010; Ferreira & Teixeira, 2010; Libya ;Mangaa, Fortonb, Moforc, &

102
Woodardd, 2011) and specifically in South Africa (Leonard, 2005; Muswema , 2005; Gabela &
Knight, 2010) suggest that health care facilities do not segregate HCW. The reasons for lack of
segregation of HCW are that waste generators and handlers do not have skills to do so due to lack
of training. However, the media rarely discussed the specific factors or individuals to be held
accountable for this problem at the health facility (institutional) level. Some of the news stories
blamed the waste companies for not supplying the hospitals with the appropriate facilities for
segregating waste.

However, they did not identify who should be held accountable for non-segregation at the
institutional level. It was not clear from the reports whether the problems of lack of segregation
was caused by medical professionals, cleaning staff, the hospital management or contractors
responsible for waste management. Factors like the level of knowledge and skills about segregation
of health workers or waste handlers or the availability of the appropriate facilities needed for
segregation at the facility level were rarely discussed. This makes it difficult to judge how
consistent the news media frames are with the literature and could send confusing signals to policy-
makers who are influenced by news media frames (Daku etal., 2012). A few of the news stories
blames non-segregation of waste on the contrators for not supplying appropriate facilities. By
blaming the problem of non-segregation on the waste companies, the media deflects the
responsibility for segregation to the companies. This is inconsistent with the provisions of the
Constitution of the country, and all other policy and standards on HCWM (SANS, 2004). This
might absolve the hospitals and health professionals and lead to solutions that are not
comprehensive enough for the dealing with the problem.

Completely absent from the media frames is a discussion of issues relating to HCW that emanates
from homes in community based care. The primary health care re-engineering model in South
Africa which aims at providing basic home treatment, community assessment and campaigns on a
national scale (Naledi, Barron & Schneider 2011) will inevitably lead to an increase in the amount
of nursing and care activities such as bathing patients, changing soiled nappies, cleaning and
dressing their wounds, washing soiled clothes and beddings in the homes. These activities could
potentially lead to an increase in the amount of HCW generated. While a previous analysis of the
South African print media coverage of primary health indicate that the print media has covered the
primary health care re-engineering initiative extensively (Akintola et

103
al, 2015), our study shows that the issue of health care waste management in primary and
community health care was not covered by any news story. This raises questions as to whether
HCW at the primary health care and community health care level is seen as an issue of concern by
stakeholders and whether the print media considers this issue newsworthy (Lewin, 1950; Soroka,
2012).

The gate-keeping literature suggests that news that does not meet the criteria set for
newsworthiness by media organizations are either not covered in the first place or discarded during
gatekeeping process thereby helping to influence policy agendas by determining the news that is
elevated and therefore that will get the attention of the policy-makers and stakeholders (Lewin,
1950; Soroka, 2012; Akintola et al., 2015). The lack of coverage of health care waste management
in community-based care portrays health care waste management as an issue that is solely at the
level of health facilities level.

Conclusion

The media framing of health care waste management problems as caused mainly by government,
results into failure of the print media to propose options that includes waste contractors who are
the main perpetrators of illegal dumping and stockpiling could lead to half solutions that masks
the real problem and focuses on palliatives instead of focusing on all levels of society mainly the
government policy makers and implementers; government agencies; waste contractors; health
facilities; individual health care workers; health care professionals; waste workers and cleaners in
the health facilities that contribute to this problem.

While there is a lot of media reporting on health care waste management from hospitals in South
Africa, nothing is mentioned about HCW that emanates from community-based care (CBC). This
raises questions as to whether HCW from CBC is seen as important. Seeing that media is a podium
for communicating policy issues, it could be used as a podium for sensitizing people about health
care waste that comes from homes. For example, through awareness programmes collaborated by
CBO managers, community health workers, the waste handlers and community members and the
municipality in the communities, people in the community will know the importance of HCW that
originates from homes therefore, such awareness programmes could get

104
the attention in media which in turn, media could be a podium used to get the attention of policy
makers regarding policy initiatives for governing HCW from CBC.

Strengths and limitations

This study used rigorous and transparent methods throughout the entire process. The use of the
South African media database allowed us to have a broad search strategy. The key terms that we
used to search for the newspaper articles were reviewed thoroughly. The limitations of this study
are: (a) most researchers (Akintola, Lavis and Hoskins, 2015; Cheung, Lavis, Hamandi, El- Jardali,
Sachs and Sewankambo, 2011; Mountcastle et al., 2003) that have conducted media analysis on
health issues have used LexisNexis to identify newspapers for news stories. In this study,
LexisNexis was not used because it was not accessible by the University of KwaZulu- Natal at the
time of the research. The South African media database was the only reliable database at the time
of research; (b) this study is only limited to the print media; other types of media like the television,
radio and social media were not used but could also play a role in reporting issues related to
HCWM; (c) this study only focused on news stories that were covered in English and excluded
those in the local languages which may be an important source of information.

105
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Appendix 1: Number of news stories retrieved using various search terms (n=
298)
Search Term 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Total
1. Chemical 0 0 0 0 0 1 0 0 0 0 0 1
waste

2. Clinical waste 0 0 0 0 0 0 0 0 0 0 0 0

3. Hazardous 3 5 1 5 0 7 3 3 1 0 1 29
waste
4. HCRW 0 0 0 0 0 1 1 0 0 0 0 2
5. Health care 0 0 0 1 1 2 1 2 2 1 0 10
risk waste
6. Health care 0 2 0 2 2 5 1 0 1 1 0 14
waste
7. Healthcare 0 0 0 0 0 2 0 2 0 0 0 4
risk waste
8. Health-care 0 0 0 1 1 2 1 2 2 1 0 10
risk waste
9. Healthcare 0 0 0 2 0 3 2 1 0 1 0 9
waste
10. Health-care 0 2 0 2 2 5 1 0 1 1 0 14
waste
11. Hospital 0 2 0 0 1 1 1 0 0 0 1 6
waste
12. Infectious 1 0 0 0 0 3 0 0 0 1 0 5
waste
13. Medical 10 18 2 15 18 34 46 18 11 10 4 186
waste
14. Pathological 0 0 0 0 0 0 0 1 0 0 0 1
waste

15. 1 0 0 0 0 0 0 0 0 0 0 1
Pharmaceutical
waste
16. Sharps 0 1 0 1 0 1 1 2 0 0 0 6
Total 15 30 3 29 25 69 58 31 18 16 6 298

110
 Appendix 2: No. of news stories retrieved from various newspapers using various search
terms
Search Terms 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 Total
l
Newspaper
Citizen 0 0 2 0 0 2 0 0 2 2 0 1 9 0 0 0 18
City Press 0 0 0 0 0 0 1 0 0 0 0 0 7 0 0 1 9
Mail and 0 0 1 0 0 0 0 0 1 0 0 0 5 0 0 1 8
Guardian
New Age (The) 0 0 1 0 0 0 0 0 0 0 0 0 1 0 0 0 2
Star (The) 0 0 4 0 0 0 1 0 0 0 2 0 23 1 1 1 33
Sunday 0 0 0 0 0 0 0 0 0 0 0 0 2 0 0 0 2
Independent
Sunday Times 0 0 2 0 0 0 0 0 1 0 0 1 10 0 1 1 16
Sunday Tribune 0 0 1 0 2 2 0 2 1 2 0 0 11 0 0 1 22
Times (The) 0 0 1 0 0 0 1 0 1 0 0 0 11 0 0 0 14
Daily Dispatch 0 0 2 0 1 2 0 1 0 2 2 1 30 0 0 1 42
Herald (The) 0 0 0 0 0 0 0 0 0 0 1 0 23 0 0 0 24
Weekend Post 0 0 0 0 0 0 0 0 0 0 0 0 3 0 0 0 3
Pretoria News 1 0 1 0 1 0 1 1 0 0 0 0 7 0 0 0 12
Sowetan 0 0 0 0 0 0 0 0 0 0 0 0 2 0 0 0 2
Business Day 0 0 1 0 0 1 0 0 1 1 0 0 3 0 0 0 7
Daily News 0 0 2 1 3 1 0 3 0 1 0 0 7 0 0 0 18
Independent on 0 0 1 0 0 0 0 0 1 0 0 0 1 0 0 0 3
Saturday
Witness (The) 0 0 0 0 1 1 0 1 0 1 0 0 11 0 0 0 15
Cape Argus 0 0 6 1 2 3 0 2 0 3 1 2 13 0 1 0 34
Cape Times 0 0 2 0 0 2 0 0 1 2 0 0 7 0 0 0 14
Total 1 0 29 2 10 14 4 10 9 14 6 5 186 1 3 6 298

111
 CHAPTER SIX
HEALTH CARE WASTE MANAGEMENT IN COMMUNITY-BASED CARE IN
SOUTH AFRICA: PERSPECTIVES OF POLICY-MAKERS AND
STAKEHOLDERS

Lydia Hangulu1

Olagoke Akintola2, 3

1. Health Promotion PhD Programme, University of KwaZulu-Natal,

Durban, South Africa.
2. Health Promotion Programme, Discipline of Psychology, University of
KwaZulu-Natal, Durban, South Africa.
3. School of Human and Social Development, Nipissing University,
North Bay, Canada.

This paper was prepared for submission to the Journal of Development Studies.

I was responsible for the conception and designing of this study with guidance from
my supervisor (Dr. Olagoke Akintola). I collected data and was assisted by Noloyiso
Dlilanga, a research assistant who conducted the interviews with Zulu speakers
(IsiZulu, the local language in the study area). I drafted the chapter under the
guidance of my supervisor.

112
 Abstract

Background: In South Africa, a new primary health care (PHC) re-engineering initiative aims to
scale up the provision of community-based care (CBC). A central element in this initiative is the
use of outreach teams comprising nurses and community health workers to provide care to the
largely poor and marginalised communities across the country. The provision of care will
inevitably lead to an increase in the amount of health care waste (HCW) generated in homes and
suggests the need to pay more attention to the HCW that emanates from homes where there is
patient care. CBC in South Africa is guided by the home-based care policy. However, this policy
does not deal with issues about how HCW should be managed in CBC. This study sought to
explore health care waste management (HCWM) in CBC in South Africa from the policy makers’
and stakeholders’ perspective.

Methods: Semi-structured interviews were conducted with 9 policy makers and 21 stakeholders
working in 29 communities in Durban, South Africa. Interviews were conducted in English and
were guided by an interview guide with open-ended questions. Data analysis was conducted using
the six steps of thematic analysis suggested by Braun and Clarke.

Findings: The Durban Solid waste (DSW) unit of the eThekwini municipality is responsible for
overseeing all waste management programmes in communities. Lack of segregation of waste
and illegal dumping of waste were the main barriers to proper management practices of HCW at
household level while at the municipal level, corrupt tender processes and inadequate funding
for waste management programmes were identified as the main barriers. In order to address these
issues, all the policy makers and stakeholders have taken steps to collaborate and develop
education awareness programmes. They also liaise with various government offices to provide
resources aimed at waste management programmes.

Conclusion and recommendations: HCW is generated in CBC and it is treated as domestic

waste and is poorly managed. With the rollout of the new primary health care model, there is a
greater need to consider HCWM in CBC. There is need for the Department of Health to work
together with the municipality to ensure that they devise measures that will help to deal with
improper HCWM in the community.

113
Introduction

Following the Alma Ata Declaration on Primary Health Care in 1978, many low-and middle-
income countries (LMICs) have made it a policy priority to shift the care of chronically ill patients
from hospitals to the community (Schneider et al., 2008). The World Health Organization (WHO)
has also promoted home and community-based care (CBC) and the concept of task-shifting to
deal with health worker shortages in LMICs (Akintola, Lavis and Hoskins, 2015). In recent years
considerable increases in the funding for HIV/AIDS/TB and the need to meet the millennium
development goals have led to a renewed focus on CBC in many LMICs (Schneider et al., 2008;
Akintola et al., 2015).

In sub-Saharan Africa, community based organisations (CBOs) are a key element in the provision
of primary health care services in poor and marginalised communities (Akintola, Gwelo, Labonte
and Appadu, 2015; De Maesenneer and Flinkenflogel, 2010; Van Pletzen et al., 2014). In the
HIV/AIDS sector for example, CBOs often provide care and resources to marginalised
populations like sex workers, drug users, gay men, the aged, the poor and the homeless (Wilson,
Lavis and Guta, 2012; Akintola, Labonte, Gwelo & Appadu, 2015). CBOs are relevant in
providing health care because they understand their local communities and they are linked to the
populations that they serve (Chillag et al., 2002). They serve as a link between the health care
system, decision makers, and stakeholders in developing health policies and programmes
(Oxman, Lewin, Lavis and Fretheim, 2009). CBOs are involved in research development that
aims at informing policy (Bhan, Sign, Upshur, Singer and Daar, 2007) and they also help to
facilitate the involvement of communities in planning and implementation of health care in order
to achieve ‘health for all’, a key principle for primary health care (Wilson, Lavis and Guta, 2012).

CBC in South Africa is guided by the home-based care policy that was developed in 2001 which
is still a draft document. The main thrust of the policy is the provision of CBC in the homes of
the patients. The policy encourages community members to participate in the provision of care to
the ill people (South Africa Department of Health [DOH], 2001). However, this policy does not
deal with how health care waste (HCW) should be managed in CBC. The WHO defines HCW as
all waste that is generated in health care facilities, research centres, and laboratories

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that are related to medical procedures. It also includes waste produced from health care activities
in minor and scattered sources including in homes where there is recuperative care, self-
administration of insulin and dialysis (Pruss et al., 1999). HCW management (HCWM) involves
segregation, collection, storage, treatment, transportation, safe disposal (Ananth, Prashanthini and
Visvanathan, 2009) and monitoring of these activities (Pruss et al., 1999). When HCW is not
properly managed, it could transmit infectious diseases such as HIV/AIDS and hepatitis B and C
to the public, and could cause death (Akter, 2000; Magdy and El-Salam, 2010). HCW could also
reduce environmental aesthetics (Phorano et al., 2005), cause social contagion (Kassim and Ali,
2006) and the breeding of disease-causing vectors such as cockroaches, flies and rodents
(Drackner, 2005; Ramokate, 2008).

In South Africa, a new primary health care (PHC) re-engineering initiative aims to scale-up the
provision of CBC. A central element in this initiative is the use of outreach teams, comprising
nurses and community health workers, to provide care to the largely poor and marginalised
communities across the country (Naledi, Barron and Schneider 2011). The provision of care will
inevitably lead to an increase in the amount of HCW generated in homes and suggests the need
to pay more attention to the HCW that emanates from homes where there is patient care (Hossain
et al., 2011).

In KwaZulu-Natal province where this study was conducted, some challenges with HCWM have
been documented. For example, a study was conducted in 30 clinics in iLembe health district, the
findings of which revealed that HCW was frequently not segregated from the point of generation
to the point of disposal; it was sometimes transported together with goods and passengers, and
the vehicles were driven by people who are untrained, unequipped and not registered to handle
HCW (Gabela and Knight, 2010). Given the recent policy direction of the department of health
to promote home and community-based care on a national scale, the perspectives of policy-
makers and stakeholders could help shed light on particular issues relevant for policy decision
making on health care waste management in community-based care. Regrettably, little is to be
found about the perspectives of policy makers and stakeholders regarding HCWM in community-
based care in South Africa. In this study, we sought to answer the following questions: What are
policy makers’ and the stakeholders’ perceptions regarding HCWM in community-based care?
How do policy makers and stakeholders describe the

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challenges regarding HCWM in CBC? How do policy makers and stakeholders address the
challenges related to HCWM in CBC?

Methods Research design

This was a descriptive qualitative study (Ulin et al., 2012) that helped to provide in-depth insights
into stakeholders’ perceived challenges with HCWM and their causes as well as descriptions of
how challenges with HCW were addressed.

Study setting and context Background

This study was conducted in 29 resource-scarce communities located on the outskirts of Durban,
KwaZulu-Natal, South Africa. Of these communities, 21 were peri-urban communities. Peri-
urban communities are segregated communities that were created by the apartheid government in
the 1950s and 1960s and were racially structured to stabilise black labour in the industrial
economy. These communities are characterised by the presence of small sized houses named after
the reconstruction and development programme (RDP) that was initiated by the government in
1994 to promote service delivery. The RDP houses are for the poor who earn less than R3500 per
month (Gilbert, 2004). Currently, because the government provides low subsidies for developing
these houses, RDP houses are usually built on cheap land located away from economic
opportunities. The minibus taxi industry provides community members with transport which links
dwellers to the cities to access economic opportunities. Because most people in these communities
do not work and/or have an unsteady income, they tend to build ‘back rooms’ which are
extensions of the main house. They rent the backrooms out to people who are still waiting for
RDP houses as a way of earning themselves a living. Some households rent out the RDP houses
and opt to live in the backrooms (Gardner, 2010).

Furthermore, three of the communities that were included in the study were informal settlements.
Informal settlements consist of houses that are illegally built on private land, government owned
land or tribal land. People who live in informal settlements travel from various places such as
rural areas or peri-urban communities and some are foreign nationals who are in search of formal
housing and employment. Informal settlements have a high rate of unemployment, food insecurity
and poverty (Crankshaw, 2008; Del Misto and Hensher, 2009).

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Five were rural communities: these are areas that are in between, they are neither peri-urban nor
informal settlements. The communities are settlements usually located far from economic centres
and affordable transport is limited and expensive. They are occupied mainly by the older
populations that have retired and rely on subsistence agriculture, social grants and allowances
from family members who work in cities (Hunter and Posel, 2012). All the 29 poor resource
communities are characterised by high rates of unemployment and poverty; there is a lack of
quality social services such as education, health and transport services. Municipal services such
as water, sanitation and electricity are basic and free (Molefe, 1996; Allen and Brennan, 2004;
World Bank, 2013). These communities are serviced by the eThekwini Municipality of KwaZulu-
Natal

Participants

Four kinds of participants were included in our sample: nine ward councillors who are policy
makers, five area cleansing officers, ten managers of CBOs and six education officers who are
stakeholders in charge of overseeing general waste management activities in the communities.
The range of service in the community was one to 13 years as described in Table 1 below.

Table 1: Roles and demographic characteristics of policymakers and stakeholders

Post of the Role in the community Total Range of
official number of years of
participants service of
participants
Ward These are policy makers who are employed by the 9 4-6
councillors government at the municipality level. They are community
representatives who provide leadership and guidance to the
community and facilitate communication between the
community and the government at the municipality level.
Area cleansing These are stakeholders and are government employees at the 5 4-5
officers municipal level. They supervise waste management
contractors, inspect communities to ensure that waste is
collected and they oversee garbage bag distribution within
the communities.
CBO These are stakeholders who manage non-profit organisations 10 8-13
managers that provide community-based care programmes in the
communities.
Education They are stakeholders who are employed by the government 6 1-3
officers at the municipal level. They develop and facilitate education
programmes on waste management in the communities.

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Sampling procedure for the participants

CBO managers were selected using snowball sampling. We contacted two CBO managers known
from previous research. These managers provided contact details of the other managers that they
knew. From the contact details provided, eight CBO managers from different communities were
recruited purposively if their organisations offered home-based care services. CBO managers were
included in the study because they oversee CBC programmes that are responsible for generating
health care waste. The CBO managers were chosen if they were willing to participate in the study.
Ten CBO managers (one per organisation) participated in the study while three were not available.
Contact details of the ward councillors, area cleansing officers and education officers who served
the 29 communities were obtained from CBO managers. The ward councillors, area cleansing
officers and education officers were chosen if they were willing to participate in the study and if
the CBOs fall within their jurisdiction. Ten ward councillors served the thirteen communities (one
per community). However, only nine of them participated in the study, the remaining one declined
to participate in the study. Five area cleansing officers and six education officers participated in
the study because the thirteen communities fell within areas of their jurisdiction. All participants
were selected if they worked for a period of six months because respondents with such length of
work experience were in a better position to provide insight to the study.

Data collection procedure

Ethical approval for this study was obtained from the Humanities and Social Science Research
Ethics Committee of the University of KwaZulu-Natal, South Africa (See appendix 1). Semi-
structured interviews were conducted with nine policy makers and twenty-one stakeholders and
these were guided by an interview schedule with open-ended questions (see Appendix 3). The
interview schedule covered three main themes: 1) the policy makers’ and the stakeholders’
perspectives regarding health care waste management in community-based care 2) the policy
makers’ and stakeholders’ perceived challenges regarding health care waste management in
community-based care 3) strategies employed by policy makers and stakeholders to address the
challenges related to health care waste management in community-based care. Participation in the
study was voluntary and anonymity was achieved through the use of titles and not names.

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The objectives of the study were explained to the participants; informed consent was sought and
all participants gave both written and verbal informed consent (see appendix 2 for consent form).
Permission to record all interviews was sought and granted. All interviews were conducted in
English in the participants’ offices and they lasted from 40 to 60 minutes. Data collection took
place from August 2014 to March 2015.

Data analysis

All the recorded data was transcribed verbatim in English by the research assistant (ND). Data
analysis was conducted using the six steps of thematic analysis suggested by Braun and Clarke
(2006). The first step involved familiarisation with data through reading all the transcribed scripts.
I (LH) read all the transcribed scripts to familiarise myself with the data. At the second stage, I
read the scripts, and identified and generated some themes. For the third step, I re-read the
transcripts and I identified and generated some codes. At the fourth stage, I read the scripts again
and generated themes from the codes. Fifth, I read the scripts again, identified and grouped all the
main themes and sub-themes that I identified. After which I presented all the themes and subthemes
that I generated to my supervisor. We discussed each of the themes and sub-themes. We reached
consensus as such all grouped main themes and sub-themes are presented in the findings below.

Results

The following themes were derived from the data: Perceived HCWM practices in community-
based care by policy makers and stakeholders, and the perceived challenges, the perceived causes
of the challenges and strategies used to address the challenges of HCWM practices in community-
based care by policy makers and stakeholders. All the major themes are in bold while minor
themes are italicised in bold.

The perceived health care waste management practices in community-based care

Participants were asked to state who was responsible for managing HCW in the communities that
they served. They all explained that the Durban Solid waste (DSW) unit of the eThekwini
Municipality is responsible for overseeing all waste management programmes in their
communities. All participants indicated that health care waste is mixed, treated as domestic

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waste and is removed together with domestic waste from all homes. They further explained that,
DSW has garbage trucks and waste collectors that remove all domestic waste which is mixed with
health care waste from suburbs. While waste management services are free for those in rural, peri-
urban communities and informal settlements, because they are subsidised by the government. The
ward councillors indicated that, as a way of empowering communities, the municipality awards
tenders to community members. The selected community members work as waste management
contractors whose jobs are to remove all waste from homes to the disposal sites. Ward councillors
and area cleansing officers indicated that all tenders are advertised in the media and the most
competent contractors are offered the tenders. Contractors sign contracts with DSW and they are
given rules and regulations on how they should operate:

“Yes they sign a contract document that binds them on how to work. It is a very
thick document which constitutes what they are supposed to do and how and what
is expected of them and their staff.” (Area Cleansing Officer 1)

All participants were asked to give an account of how HCW is managed in the communities that
they served. The CBO managers explained that they advised their community health workers
(CHWs) who provide home visits to the patients to dispose of the HCW in black garbage bags or
in any other plastic bag. They also advised CHWs to tie the plastics containing HCW to prevent
spillage. Contrary to what the CBO managers said, most area cleansing officers were defensive
when they were asked to explain how HCW is managed and removed from homes in the
communities that they served. They said that they were not aware of any HCW that was produced
in homes:
“The thing is we do not know that there is a problem like that, if we knew of a house
that has a patient, then maybe we can make an arrangement.” (Area Cleansing
Officer 5)

Area cleansing officers emphasised that there is a private company responsible for removing HCW
from hospitals and clinics, yet nothing was mentioned about who is responsible for removing HCW
from homes where there is patient care. They insisted that their main role is to ensure that all
domestic waste and not HCW, from homes is removed by community waste management
contractors:

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 “A private company collects all the waste for the hospitals and the clinics, but us
in the DSW unit we only collect domestic waste.” (Area Cleansing Officer 2)

Only two area cleansing officers and all education officers were willing to openly discuss the issue
of HCW. The two acknowledged that they are aware that HCW is generated in homes and is
usually treated and removed together with domestic waste. The two area cleansing officers
explained that they handle HCW as domestic waste because it is not in large quantities unlike at
the hospitals. One of them said:

“Such cases are few that we have health care waste… so because it may be only
one residence that has a patient, we encourage such people to put everything
(HCW) in a plastic bag and tie it up, then place it in the house bin, because there
is no other way. Unless if there is a lots of people, then we can refer them to those
that deal with medical waste in the clinics and the hospitals, they have their own
special truck that collects medical waste.” (Area Cleansing Officer 3)

All participants were asked to describe the challenges related to HCWM in the communities that
they served as well as their perspectives about the causes of these challenges. The challenges are
discussed at the household/community and the municipal levels. At the household level, the main
themes that emerged are lack of segregation of waste by households and illegal dumping and these
are discussed in detail below.

The perceived challenges with health care waste management practices in community- based
care at household level
This theme will discuss the challenges that impede health care waste management practices in
CBC, the causes and the strategies used to deal with the challenges. The themes are presented at
the community level and municipality level. At the community level, challenges ranges from lack
of segregation of HCW by households to illegal dumping. At the municipality level the challenges
range from corrupt tender processes to and inadequate funding for general waste management. A
wide range of causes of the challenges and strategies used to deal with the challenges are provided
and all themes and sub-themes are summarized in Table 2 and will be discussed in detail.

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Table 2. Summary of the challenges, causes and solutions to the challenges of health care
waste management
Sources of the Problems Causes of the problems Solution provided
problems to the problems
The community 1.Lack of segregation o Lack of knowledge about o Collaboration of
level of health care waste segregation of health providing
2. Illegal dumping care waste. education about
o Laziness to take out waste
health care waste on the management in
day of collection general
o Negative attitudes about o Liaising with
waste management. government for
o Irregular collection of adequate
health care waste by resources
waste
o Lack of sufficient
garbage bags.
o Lack of participation of
community members
The municipality 1.Corrupt tender regarding waste
level processes management
2. Inadequate programmes.
funding for the waste o The presence of back
management in rooms.
general o Long distance between
the waste storage
facilities and homes in
the informal
settlements.
o Slow change in the rural
areas

Lack of segregation of waste in homes by households

All participants revealed that generally, waste segregation is a responsibility of the households and
that waste collectors are responsible for collecting the waste from homes and transporting it to the
landfill. They also explained that households do not separate the HCW and as a result, waste
collectors ended up collecting and transporting the unsegregated HCW to the landfill. There were
incidences of waste collectors being pricked by needles while collecting waste from homes.
Participants revealed that, such incidences were investigated and the pricked individuals sought
medical attention.

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 “Another thing is, needles which people use when they have diabetes or anything,
they just throw them away. We have had incidences where our workers have been
pricked by them because even if you give them gloves a needle is a needle, it goes
through. But such incidences are thoroughly investigated.” (Education Officer 1)

All participants felt that the possible cause of lack of segregation of waste by the household
members was lack of knowledge about waste segregation. They believed that there was a need
for community members to be educated on how to handle HCW. One area cleansing officer said:

“…Communities must be taught to at least wrap a needle with a tissue or something

before disposing it…Just for them to learn simple things like that for now.” (Area
Cleansing Officer 5)

Illegal dumping
All respondents felt that all communities were facing challenges with illegal dumping. Community
members disposed of HCW together with domestic waste illegally in the bush, roads and in
streams.

“There is litter all around. You go to the roads, rivers and streams you find that
they are full of litter. People throw dirty diapers and other things there…” (Ward
Councillor 7).

All participants said that illegal dumps are a hazard to children who make these dumps their
playgrounds and scavenged for used items. One CBO manager said:

“With these illegal dumps that are right next to our homes, you find that children
go to these areas and play there! It is dangerous!” (Manager C)

Ward councillors believed that illegal dumps created a leeway for criminal activities in the
community. One councillor narrated a story where they found women’s bodies that were burnt in
an illegal dump in the bush. They said that another woman was beaten up and left to die at a
dumpsite. Participants said that they found foetuses at the illegal dumps and they believed that
they were from illegal abortions by young girls in the community. They also felt that illegal

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dumpsites were a hiding place for boys who used injectable drugs and disposed of the needles
illegally at the illegal dumps.

The perceived causes of challenges with health care waste management practices in
community-based care at the household level

All respondents revealed that illegal dumping of HCW was the main challenge. The reasons
provided were ranged from laziness to lack of space in the communities.

Laziness and negative attitudes towards waste management: All participants thought that
community members were illegally dumping HCW because they were too lazy to take it out on a
particular day of waste collection. They reported that community members disposed of HCW
illegally because they believed that they were creating jobs for the waste collectors. This kind of
misconception angered all education officers and the area cleansing officers who felt that these
acts undermined their work because their superiors think that they are not doing their jobs
effectively. One area cleansing officer, with an angry tone, said:

“The mind-set of the people is terrible! Their attitude towards waste management
is unacceptable! Throwing away litter! Anywhere and everywhere! Because they
believe that they are ‘creating jobs’! Who does that? Really? (Area Cleansing
Officer 4)

Irregular collection of health care waste by contractors: All participants agreed that irregular
collection of HCW caused the creation of illegal dumps. For example, CBO managers and ward
councillors explained that there were several instances when HCW was left uncollected from the
communities for several days without any notices from the waste contractors. They revealed that
uncollected HCW is scattered by animals that tear up the garbage bags to scavenge for food. To
ensure that waste management services continue, area cleansing officers seek permission to use
the DSW trucks (meant to serve suburbs) to collect all waste from the communities. The education
officers and the area cleansing officers revealed that they have the power to fine and penalise the
contractors who fail to adhere to the contracts. Those that do not deliver the required services or
pay the fines are reported to top management so that their contract can be cancelled and their
services terminated.
“We report those that do not pay the fines and those who continually fail to deliver
services according to the stipulated contract. We recommend to the top
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 management that they should not be paid the full amount or their contracts should
be cancelled.” (Area Cleansing Officer 4)

Insufficient garbage bags: Education officers and area cleansing officers provided more insights
about this issue because they are directly involved with waste management and related issues.
They explained that households in peri-urban, rural areas and informal settlements receive only
two garbage bags per week while those in the suburbs received two months’ supply. The cause of
the discrepancy according to the education officers is that most households in the suburbs adhere
to proper waste management practices and they use the garbage bags for the intended purposes,
while those in peri-urban, rural areas and informal settlements use the garbage bags for other
purposes such as storing clothes, committing crimes such as storing dead bodies or storing foetuses
resulting from illegal abortions.

Education officers also felt that they were protecting the community members, especially children,
from playing with the plastics to avoid fire accidents which could result in burning of the houses.
Most area cleansing officers said that two garbage bags per week were not sufficient to
accommodate the HCW that is generated on a daily basis. They said that this was an issue beyond
their control and there was nothing they could do to rectify the problem because they work with a
given budget which was limited. They also said that they are in contact with their superiors, having
dialogue to find a possible solution regarding budget increments. One area cleansing officer said
that they negotiated with their superiors in management for several years to offer households at
least a three months’ supply of garbage bags but nothing has been changed.

“There is nothing we can do because it is something we have raised with the

management, saying that people should be given a three month supply as it happens
with the suburb... They said that they have problems relating to budget and the
money is not adequate for buying garbage bags for households…” (Area Cleansing
Officer 2)

Lack of participation in waste management programmes: Education officers stated that with the
help of community leaders and ward councillors, they organise clean-up campaigns in the
communities aimed at removing all illegal dumps. They hold workshops with community

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members and teach them about the importance of keeping the environment clean. During the
campaigns, education officers encourage community members to take ownership of the problem
(illegal dumping). After that they chose a day for cleaning and removing all the illegal dumps in
the communities. Education officers said that they felt disappointed because community members
do not commit to such programmes. They indicated that many community members do not show
up for clean-up sessions. They believed that such acts are a drawback to their work.

Back rooms in peri-urban communities: Area cleansing officers blamed some households for
creating enabling environments for illegal dumping in the community. They revealed that some
households have illegal backrooms. They said that backrooms are structures that most households
build as an extension of their own house in peri-urban communities. Residents rent out these rooms
to tenants as a way of earning a living. Area cleansing officers revealed that when such structures
are built, no toilets or refuse bags are provided to the tenants, because they are not legal occupants.
They said that occupants of such back rooms are also expected to share all the sanitation facilities
with the landlords but many of them dump their HCW illegally.

“The refuse bag distributors know that they should give one plastic bag to each
household, but then there are houses with 4 or 5 tenants. Tenants also need refuse
bags, but they do not get them because the people who give bags don’t know them,
they are not appearing on their database so they are staying illegally.” (Area
Cleansing Officer 1)

All area cleansing officers suggested that government must take responsibility for addressing this
problem because it has to do with service delivery.

Long distance between homes and waste storage facilities: Ward councillors and area cleansing
officers revealed that in informal settlements, roads are inaccessible for the waste collectors. As
such, waste collection points are built close to the main roads. All households are expected to
remove their waste from homes and store it in these facilities on a daily basis. They explained that
the long distance between the homes and the waste disposal facilities was a disincentive for
community members which negatively affected their use of such facilities. Area cleansing officers
said that this issue is beyond their control and felt that it is a service delivery issue that is supposed
to be addressed by the government.

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Slow change in rural areas: This was an issue that was raised by only one education officer. The
education officer believed that change in rural areas is slow. Households in rural areas still buried
HCW even if they were educated about its negative impacts. In response to this challenge, she said
that all education officers continue to offer education about proper management of waste. The
education officer also believes that there is a need for the municipality to put extra effort into
monitoring waste management activities in these areas.

Perceived challenges with health care waste management practices at the

municipality level

Ward councillors, area cleansing officers and education officers are government
employees whose duties are to serve the communities and mediate between the
community and government at the municipal level. They all felt that there are challenges
at the municipal level that hamper proper management of waste in homes in the
communities. They identified corrupt tender processes and insufficient funding for waste
management services as problems at the municipal level.

Corrupt tender processes: All participants believed that the service delivery issue was not within
their purview and is an issue that they could not address. All area cleansing officers were saddened
by the process involved when choosing contractors responsible for managing waste in the
communities. They felt that the tender process was corrupt and lacked transparency. The area
cleansing officers revealed that most contractors got their tenders because they had political
connections with the tender board. They complained that they are not involved in the selection of
the contractor even though they are in a better position to do so because they work directly with
the people and are able to know their capabilities. They criticised the process and were sure that
this interfered with waste management services in the communities. They observed and believed
that the contractors that are offered the tenders are incompetent and unskilled to handle waste in
general. They said that some waste contractors used open vans when collecting HCW and domestic
waste:
“You find that they use open vans and staff in the same vans to collect the
waste.” (Area Cleansing Officer 5)

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The education officers revealed that the contractors’ trucks constantly broke down and as
a result, HCW is left uncollected from communities for several weeks:
“I won’t lie, there are times when the trucks break down and waste is left
uncollected. When we ask them they say they are doing something about it.
They delay to replace the trucks.” (Education Officer 2)

Area cleansing officers and education officers felt the constant breakdown of the
contractors’ trucks caused households to resort to illegal dumping. They also said that they
have powers to fine and terminate the contracts of the offending contractors. However,
area cleansing officers felt that their powers were undermined by the tender board that
turned down their recommendations. They indicated that such acts caused conflict
between them and the contractors. Area cleansing officers believed that most contractors
lost respect for them and undermined their job.

“Most of the contractors are politically connected. Sometimes you report

and recommend that the contractor’s contract should be cancelled because
he or she is not performing but you find that they have been rewarded with
a tender again. Then we look like we are bad people and contractors
cannot respect us anymore, they do what they want, you know! We end up
dealing with one problem that is not getting solved.” (Area Cleansing
Officer 4)

Inadequate funding for health care waste management programmes: Ward councillors,
area cleansing officers and the education officers believed that generally, all waste
management issues compared to housing issues, were not seen as a priority issue by the
government. They gave an example of insufficient funding towards waste management by
the government. These participants felt that this was the reason why the municipality was
supplying insufficient garbage bags to community members. Two education officers felt
that the municipality was not willing to provide sufficient funds for clean-up sessions
because it was not a priority issue to the government.
“Collection trucks and resources for clean-ups are costly. One of the
challenges is funds. There are limited funds for clean-ups.” (Education
Officer 1)

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One education officer said that insufficient funding has a negative impact on human
resources. He said that the job of an education officer requires more human resources due
to the fact that they inspect all communities and also attend meetings. Some meetings were
held on the same day and same time, and as such it is hard for them to prioritise where to
go because all meetings are important and require their attendance. Even though they are
each assigned to attend various meetings, they are still unable to attend all of them.

“There are 18 meeting rooms and only three of us and the challenge is that
sometimes there are multiple meetings on the same day due to a lot of war
rooms. We then have to separate ourselves between the war rooms but we
cannot make it. There is so much demand and we are few.” (Education
Officer 3)

On the other hand, ward councillors revealed that general waste management issues were
not a priority on a list of their community development programmes. They revealed that
the top developmental issue is housing, then unemployment. They also indicated that even
community members do not listen to any waste management issues because they are more
concerned with housing and employment issues.

“People are hungry, they want jobs and houses. So when you talk about
waste no one will listen they all leave you because they are not interested.”
(Ward Councillor D)

Strategies used to deal with health care waste management challenges in community-based
care combined at the household and municipality levels

All participants indicated that, they do not provide programmes directly related to health care
waste management. All programmes that are provided aim at managing waste in general and these
strategies are discussed below.

Collaboration: Education officers said that they have taken some steps to address the problem of
lack of segregation of waste in general, illegal dumping and lack of participation by community
members. This includes working with CBO managers, community leaders, ward

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councillors and area cleansing officers, who said that they collaborate with Departments of
Health, Housing, Environmental Affairs and Environmental Health to provide various education
programmes to community members. They offer door to door education on general waste
management and distribute pamphlets that have information on waste management. They also
hold monthly ‘Masakhane road shows’ where the public is educated on the separation of various
waste. Education trucks (mobile classrooms) are provided on site to schools and organisations, to
offer training on waste minimisation. Enviro-forums are conducted with the business owners,
health organisations, community members and councillors that aim at having effective
coordination on issues regarding the protection of the environment. Special days are set aside to
raise issues on the environment and the importance of managing general waste.
Weekly landfill site tours that cover general waste management topics, financial issues, recycling
and conservancy management are conducted. Lastly, buy back and drop off centres are advertised.
These are recycling initiatives where community members can drop of recyclable products in
exchange for money at buy back centres and also drop off recyclable products for non-
reimbursement at drop off centres.

Education officers also indicated that they hold clean-up sessions. In instances where community
members do not show up, they reschedule such sessions and continue to mobilise the community
members. They collaborate with the Environmental Health Department and hold workshops with
the community members to educate them about the importance of the managing various kinds of
waste.

“We postpone it. We do not just give up at the first point. We call another meeting
and we involve the ward councillors and the environmental health department so
that they advise the community on the hazards that come with a dirty place.”
(Education Officer 3)

Education officers also encourage people to adopt a spot. This is usually done after cleaning the
area that was an illegal dump. Various people are encouraged to adopt and own such spots to use
them as gardens or a play park. Names of the owner (the adopters) are displayed on those spots
and are published in community newspapers. Annual competitions are held and prizes are given
to the adopters that manage and sustain the spots. This is a way of encouraging people to
participate in the clean-up sessions. They also indicated that they focus more on providing
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education in schools to target children. They do this with the hope that the children would
implement what they learn at school in their homes. They also hoped that the households would
learn from the children.

“What we do is increase the levels of education in schools. So we won’t need a lot

of money. Therefore, the more people are aware about proper waste
mismanagement, the more they take initiative and the less money spent.”(Education
Officer 3)

Reporting and liaising with government: All ward councillors, area cleansing officers and
education officers felt powerless to address issues about corrupt tender processes. They said that
these are issues beyond their control because they are involved with politics. However, to address
issues regarding distance between homes and waste storage they said that the only way possible is
to report the matter to the Department of Human Settlements that is in charge of housing issues.
On the other hand, all ward councillors, area cleansing officers and education officers explained
that to deal with the insufficient funding for clean-up sessions and for garbage bags, they are still
negotiating with the government to increase its budget:
“We do have meetings where we present all our challenges. So it is in these
meetings that we try and negotiate with our superiors that we need resources for
waste management, for example they must provide more garbage bags for the
households…” (Ward Councillor A)

Discussion
Previous studies show that HCW is improperly managed in hospitals and clinic settings
(Mbongwe, Mmereki and Magashul, 2008; Magdy and El-Salam, 2010; Ferreira and Teixeira,
2010; Gabela and Knight, 2010; Mangaa, Fortonb, Moforc and Woodardd, 2011; van Schalkwyk,
2013). Our study provides nuanced qualitative findings on HCWM in CBC which illustrates that
HCW is also not properly managed in CBC. This finding contributes to the body of knowledge on
HCWM. The finding that the municipality is in charge of overseeing all domestic waste
management in the communities including HCW is consistent with the
requirements by South African National Standards (SANS, 2004) on HCWM. Going by the
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SANS (2004) standards, HCW that is generated in homes as a result of care for a patient is assumed
to be in small quantities hence SANS (2004) requires municipalities in charge of managing
domestic waste to handle, transport and treat this waste before its disposal. However, the findings
reveal that HCW is treated as domestic waste which contravenes the SANS (2004) requirements.

Furthermore, it is intriguing to find that HCW that is generated in homes as a result of care for a
patient is assumed to be in small quantities yet, South Africa has the highest HIV prevalence in the
world and has about 5.6 million people living with HIV (Statistics South Africa, 2014). Most the
HIV/AIDS patients receive care at home (Akintola and Hangulu, 2014). South Africa also has the
largest number of TB incident cases in the world (WHO, 2015). Given that the standards were
developed in the year 2004, it therefore does not take into account subsequent policy events that
have led to the rise in the home-based care activities in South Africa (Akintola et al., 2015). These
include the recent primary health care re-engineering initiative which aims to scale-up the
provision of home health care services to communities across the country through outreach teams.
The existing and new policy developments highlight the need for policy makers to revise the policy
on HCWM in CBC.

Area cleansing officers provided conflicting claims about the management of waste in the homes.
While some claimed that they are not aware that HCW was being generated in homes, others
acknowledged that it is mixed with domestic waste. This indicates that HCW from homes is not
treated as it should. The fact that it is assumed that the volume of HCW generated in homes is
small, this does not change the risks that it poses on the environment and the people. Moreover,
this shows a misunderstanding about how HCW from homes must be handled by the stakeholders
in the municipality. The SANS (2004) requires that all HCW from homes be treated as HCW and
not as domestic waste. The standards further require the health care providers who are assigned to
the patients to provide containers for storing sharp waste specifically for diabetic patients. As for
the other infectious HCW besides sharps, it is recommended that private arrangements with
hospitals or clinics should be made for the collection and disposal of HCW from homes by
contractors responsible for collecting HCW from hospitals and clinics.

132
It was clear from our study that health care providers do not provide storage facilities for HCW to
the households where there are patients being cared for. Additionally, no private arrangements are
made for the collection of HCW from homes of the patients in CBC. Participants did not seem to
know whose responsibility it was to provide these facilities. These findings highlight a need for
the Department of Health to develop policies that will govern HCW from CBC and other minor
sources as is the case with hospitals, clinics and other facilities. Further the Department of Health
and the Durban solid waste unit (DSW) should develop formal partnerships that will help delineate
responsibilities relating to the provision of storage facilities for HCW and the disposal of these
facilities.

Stakeholders in this study indicated that separation of HCW in homes is a responsibility of

households. Mixing of HCW with domestic waste makes treatment of such waste difficult
(Schalkwyk, 2013). Improper segregation of HCW exposes family members to injuries resulting
from sharp waste and exposes them to infections (Diaz, Savage and Eggerth, 2005). Although
education officers indicated that they provide education and awareness programmes to community
members in the communities, it is clear from our findings that this has not yielded the desired
results. There is need for the Department of Health to work with the area cleansing officers to
develop mechanisms for identifying and providing households that have patients with HCW with
storage bins as recommended by the SANS (2004). There must also be mechanisms put in place
to monitor HCWM activities in homes to ensure sustainability.

From the policy makers’ perspectives, the main reason for illegal dumping by community members
is the lack of sufficient allocation of budgets for HCWM which results in shortages in the supply
of garbage bags specifically for domestic waste. The area cleansing officers stated that they are in
constant negotiation with their superiors for adequate allocation of budget. We found that most
households are poor and rely solely on government to provide them with houses and basic services
including waste management services. As a consequence, some households in peri-urban
communities build backrooms to generate income. Occupants of the backrooms are illegal
occupants and they contribute to the problem of illegal dumping of HCW which causes air, land
and water pollution (Adewole, 2009). There is need for the Department of Housing to

133
develop and tighten enforceable housing laws to prohibit building of illegal structures. Steps must
also be taken to deter defaulters.

Furthermore, illegal dumping was caused as a result of irregular collection of waste by waste
collectors. Both irregular collection of waste and insufficient supply of garbage bags are a problem
of poor service delivery. All participants in this study revealed that these problems were caused
by inadequate funding. The issue of inadequate funding is common in the service delivery
literature in sub-saharan Africa. Odaro (2012) and Briceno-Garmendia, Smits and Foster (2008)
explain that governement taxies, usage fee revenues and aid are the main source of funding for
water, sanitation and electricity in sub-saharan Africa and yet the allocation of funding for these
services is only 0.5% of the gross domestic product (GDP). Mdlongwa, (2014) argues that, besides
lack of finances as a cause of poor service delivery in South Africa, municipalities also lack skilled
people in the local government to run services delivery programmes adequately; the process of
rolling out services to the communities is slow and hampers the quality and efficiency. Poor
allocation of funding for waste management programmes could mean such services are not a
priority to government. Waste on the environment has the ability to cause environmental pollution
and pose public health risks. The government must make sanitation programmes as one of the
priority issues for protecting the health its citizens. Adequate funding should be allocated.

Our study reveals a lack of cooperation from community members in the removal of waste from
homes and also during clean-up sessions in the community. The education officers revealed that
they provide various education programmes in the communities and clean-up campaigns that aim
at changing people’s attitudes towards waste management. Clean-up campaigns are really
important and that can they give community members a sense of ownership not only of community
goods but also of community problems. Clean ups can also serve as deterrents to improper waste
disposal. If participants know that they will be called out to clean up then they might be less likely
to dispose waste improperly and also likely to discourage those who do so. However, it can be
noted that, lack of cooperation from community members could be as a result of lack of place
attachment which is a bond that exist between people and places (Altman and low, 1992). This is
expressed by their lack of interest with waste management issues but housing

134
issues. Further, Perkins and Long (1995) argue that people do not feel a sense of community just
by sharing a common neighborhood space. Instead, they feel a sense of community if they share
history, interests or concerns. A sense of community and place attachment both serve as a
motivation for people to participate in community improvement efforts (Manzo and Perkins,
2006).

Research has shown that corruption is a persistent issue facing public service institutions in LMICs
(Davis, 2004). This study reveals that corrupt tender processes for waste contractors affected
service delivery. Mpehle (2012) conducted a study on service delivery in South Africa and found
that most municipal officials in charge of awarding tenders were corrupt and were only interested
in enriching themselves. Furthermore, policies on fighting corruption were not implemented and
this led to misappropriation of funds among municipal officials without any accountability. Our
study shows that incompetent contractors were hired to provide waste collection services in the
communities and this undermined waste collection which had negative ramifications for the
community as a whole. Further, Bruce (2014) argues that, corruption in South Africa is an outcome
of a weak and unaccountable government. One of the reasons of failure to confront corruption is
the fact that there is political patronage. Most political party control usually translates into control
of the local council and ultimately controls the local government. Moreover the corrupt individuals
are at the top management and are protected because of their political influence. Considering that
issues of corruption are not broader and cannot be dealt with one clear cut solution, we recommend
that efforts to solve the problem of corruption related to health care waste management must be
aligned with wider interventions on corruption at the national level..

Conclusion
This qualitative study provides new knowledge by demonstrating that community-based care
contribute to the generation of HCW. The study also shows that the waste generated in community-
based care is poorly managed. The HCW that is produced in homes cannot be assumed to be in
small quantities owing to the fact that South Africa has the highest HIV and TB prevalence in the
world. With the rollout of the new primary health care model, there is a greater need to consider
HCWM in CBC a priority issue. Home-based care policies must be revised to include waste
management practices. HCWM is important because it is a strategy of maintaining

135
hygiene and sanitation and plays a role in preventing diseases for the general public thereby
improving their well-being and achieving health for all.

Strengths and Limitations

The major strength of this study lies in its method. The qualitative approach illuminates how and
why HCW is improperly managed in CBC. The policy makers and stakeholders were the
appropriate participants who provided insight into the issue of HCWM. The main limitation of the
study was the fact that the perspectives of the people overseeing HCWM at the Department of
Health were not explored. Their perspectives would have added more insight into waste
management policies and practices at the level of the department.

Areas for further research

More research could be conducted to find out how much waste is produced in CBC. Further
research could be conducted with the Department of Health to find out its perspectives about
HCWM in homes. Research could be conducted with households and waste collectors to
understand their challenges with handling HCW. This could also assist to understand the actual
health risks posed by HCW to the households and waste handlers. Waste handlers could also be
interviewed to understand how they handle, transport and treat HCW from homes. This could
provide wider perspective on how HCW is managed from homes to the point of disposal.

136
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141
 Appendix 1: Introducing the study to the policy makers and stakeholders

Good morning/afternoon, my name is Mrs Lydia Hangulu. I am a student at the School of

Applied Human Sciences. I am doing my PhD in Health Promotion and Communication
(Student number: 210546147) at the University of KwaZulu-Natal, 4041, Durban, South
Africa. I am conducting a study on policy and practice of home care waste management
in community-based care organisations. I would like to speak to you only if you agree to
speak to me.

The discussion will take about 40 minutes to one hour. I will ask you about health care
waste management practices in the community, the kinds of challenges that you perceive
and the kinds of strategies that are used to deal with the challenges. I will need your
permission to use audiotape recorders to capture our discussion. All information that you
give will be kept confidential and only my supervisor guiding me on this research will
have access to it. Information will be used for research purposes alone and raw data will
be destroyed as soon as the study is completely over. Also, we will not use your actual
name or designation in reporting the findings of the study but will use disguised names to
make sure that no one links the information you have given us to you. You will not be
given any monetary payments for participating in the study but your organisation,
communities and the government will benefit from this study immensely. The results will
help us to understand the challenges encountered by your organisation in accessing
support for homebased care especially with regards to health care waste management.

Your participation in this study is voluntary and you have the right not to participate if
you do not want to. If you agree to take part in the study, I will ask you to sign a form as
an indication that you were not forced to participate in the study. Please note that you will
not be at any disadvantage if you choose not to participate in the study. You may also
refuse to answer particular questions if you don’t feel comfortable answering them. You
may also end the discussion at anytime if you feel uncomfortable with the interview. In
case you want to withdraw information given after the interview, you can call me on: cell:
073 335 6091 and email: lydiahangulu@yahoo.com and my supervisor Dr O. Akintola on
031-2607426 or Akintolao@ukzn.ac.za

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Appendix 1: Introducing the study to the policy makers and stakeholders (the Zulu
version)
Sawubonaigamalamingingu Mrs. Lydia Hangulu ngifunda e Nyuvesiya Kwa- Zulu Natal , ngenza
I PhD yami kwezokuthuthukiswa Kwezempilo ‘’Health Promotion’’ (inombolo yomfundi :
210546147). Ngenza ucwaningo ngemigomo nemithetho mayelana nezokuqoqwa kwadoti
weziguli ezinakekelwa yizinhlangano.Ngingathanda ukuxoxa nawe uma ungangivumel.

Lengxoxo izothatha imizuzu engamashumi amane kuya kwi hora.Ngizokubuza ngemigomo

nemithetho emayelana nokuhlelwa nokulahlwa kuka doti weziguli, ngizobuza nangolwazi eninalo
ngodoti wazempilo neziguli.Ngizonibuza nangezigqinambi enibhekana nazo mayelana nokuqoqa
nokulahlwa kwalodoti, nokuthi nizixazulula kanjani lezo zinkinga.

Ngizodinga imvume yakho yokuku rekhoda nokugcina ingxoxo yethu. Yonke imininingwane
ozonginika yona izoba imfihlo , izogcinwa yimi ne superviser yami, akekho ozokwazi ukuyithola.
Lemininingwane engizoyithola kuwe izosethsenziselwa ucwaningo kuphela futhi, imininingwane
izosuswa eminyakeni emihlanu.Ngeke sisebenzise igama lakho langempela ngesikhathi sibhala
imiphumela yalolu cwaningo.

Angeke unikezwe mali kulolu cwaningo, noma izipho, umphakathi nomongameli bazozuza
kakhulu ngalolu cwaningo. Imiphumelo izosisiza ngokwazisisa ngokwazi izinkinga
enihlangabezana nazo, nokuthi imiphakathi nezinhlangano zizozuza ekwazini kabanzi ngosizo
abangaluthola kwi home-based care/ enhlanganweni yenu.

Kukuweukuthiuyalenzalolucwaningo, unaloilungelolokungaphenduli uma ungathandi.

Uma uvumaukubaingxenye yalolu cwaningo
kuzomeleungwaliseamaphephaukuzekucaceukuthiasizangesikuphoqeukuthiwenzelolucw
aningo. Ngicelakucaceukuthiakumeleuphenduleimibuzoongafuniukuyiphendula, futhi
ungayekaukuqhubekauphendule uma ungathandi noma ungazwisisi, uma
ufunangingawusebenzisiumniningwanengithintekulydiahangulu@yahoo.com my
supervisor Dr O. Akintola on 031-2607426 Akintolao@ukzn.ac.za

143
 Appendix 2: Consent Form

I have read the information about this study and understand the explanations of it given to
me verbally. I have had my questions concerning the study answered and understand what
will be required of me if I take part in this study.

Signature Date

Zulu version

IncwadiYemvume

Mina, Sengfundile mayelana nokuqukethweinhlolovo noma

ngiyaqondaizincazelozenhlolovonjengobangazisiwe futhi
ngachazelwangazongomlomo.Isiphenduliweimibuzo yami
ngalenhlolovo, ngakhongiyagondaukuthiiyiniebhekekekimina uma
ngibayngxemyeyalenhlolovu

Signature Usuku:

144
Appendix 3: interview guide for the education officers

 What is the role of your office or your position in this organisation?

 What are your duties in this community?

 What kind of education do you offer to community members?

 Please name the people that you work/collaborate with when doing your work.

 What are the duties/roles of these people?

 What kind of education do you offer with regards to waste management?

 What do you focus on?

 What materials do you use?

 Who develops these materials?

 What influence do you have in developing these materials?

 Is it possible to have a copy of this material?

 From your observation, how do people view waste?

 Do they see it as something serious?

 From your observation, how do people react to your education about waste?

 How do you assess your education programme?

 What challenges do you face while doing your work?

 What could be the cause of these challenges?

 How do you deal with these challenges?

 What do you think could be done about these challenges?

 How many wards do you serve? Name the wards  How do you like your work?

 What are some of the best moments of your work?

 How long have you been working in the organisation?

145
Appendix 3: interview guide for the area cleansing officers

 What is your post in this organisation?

 What does your job entail?

 How is waste handled in this community?

 How often is the waste collected from these communities?

 Why not everyday?

 Are people provided with garbage bags? If not, why, and what do they use?

 What kind of garbage bags?

 How many per house and why?

 Who is supposed to separate this waste from homes?

 Are people supposed to put all the garbage in that plastic given to them?

 What kind of rules do you follow regarding management of waste? Briefly what do they
say?

 Do you have any copies of these rules/guidelines?

 Is it possible for us to have these copies?

 What influence do you have in developing these rules?

 How and where can we get these rules and guidelines?

 Who is in charge of developing these rules/guidelines?

 How are these rules developed?

 How do you feel about these rules/guidelines? How do they help you?

 In your view, are these rules working?

 What is stopping them from working?

 What makes them work?

 What challenges do you face while managing waste in this community?

146
 What could be the causes of these challenges regarding waste in this community?

 How do you deal with these challenges?

 What do you think is the importance of handling waste properly?

 What could be done to improve handling of waste in this community?

 What efforts have you made to address these challenges?

 What have been the successes of the efforts that you have made?

 What challenges did you face in trying to make efforts?

 How did you deal with these challenges?

 How do you feel about how these challenges are dealt with?

 How would you like these challenges to be addressed?

 Is there a specific way in which waste from patients is handled, e.g. diapers, gloves,
needles?

 What are those ways?

Appendix 3: interview guide for ward councillors and community-based care

managers
 What is your role in this community?

 What are your duties in this community?

 What are your major focus areas of development?

 Please name the people that you work/collaborate with when doing your work.

 What are the duties/roles of these people?

 From your observation, how do people view waste?

 Do they see it as something serious?

 What is your role with regards to waste management in this community?

 From your observation, what are the challenges that this community are having
regarding waste?

 What could be the cause of these challenges?

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 How do you deal with these challenges?

 What do you think could be done about these challenges?

 How many wards do you serve? Name the wards  How do you like your work?

 What are some of the best moments of your work?

 How long have you been working in the organisation?

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Appendix 3: interview guide for the education officers (Zulu version)
 Udlalayiphiingxenyelaphakulelihhovisi, futhi

isiphiisikhundlasakho?

 Wenzamuphiumsebenzikulomphakathi?

 uhlobolunilemfundoolufundisaamalungaomphakathi

 Yishoabantuenisebenzisananabokulomsebezi?

 Labobantubadlalayiphiindimakulomsebenzi?

 Hlobolunilemfundoenilunikezaumphakangokuqoqwa nokuhlelwa kwadoti?

 Nigxilakephi?

 Nisebenzisaziphiizintozokusebza?

 Ubanionakhela lezo zintozokusebenza?

 Unamuphiumtheleloekwakheniizintozokusebenza?

 Celaungikhombisalokhoenikusebenzisayo?

 Ngokubonakwakhoabantubawubona kanjani udoti? Bawuthathanjengentoephusile?

 Ngokubhekakwakhoabantubayalwamukelayiniulwaziobaphalonamayelanodoti?

 Uluhlola kanjani uhlelolemfundiso?

 Iziphiizingqinambaobhekana nazo?

 Yiniimbangelayalezozingqinamba?

 Ubhekana kanjani nalezizingqinamba?

 Yiniengenziwangalezizingqinamba?

 Nisizaizigcemeezingaki, celauwabale?

 Uwuthandakangakananiumsenenziwakho?

 Iziphiizikhathiezikuthokozisangomsebenziwakho?

 Ususebenzeisikhathiesingakananikulenkampani?

149
Appendix 3: interview guide for the area cleansing officers (Zulu version)
 Isiphiisikhundlasakho?

 Kulomsebeziwenzani, yinioyenzayo?

 Udotiuphathwa kanjani kulopmphakathi?

 Udotiuqoqwakangakikulomphakathi?

 Yindabaungaqoqwanjalo?

 Abantubayanikezwaoplastiki?,umabengekbhobasebenzisani?

 Abanjanioplastikibadoti?

 Nitholaabangakioplastiki, futhi ngobani?

 Obaniobahlukanisayolaboplastikibadoti?

 Kumeleyiniabantubahlangiseudotikuplasti lo owodwaabasukebenikezwewona?

 Iyiphiimigomoeniyilandelayo mayelana nodoti?,ithinileyomgomo?

 Celaungikhombiselemigomo uma unayo?

 Ningakwaziukungikhombisalemigomo?

 Imiphiimitheleloeninayoekusungulenilemigomo?

 Singayitholakuphi futhi kajanilemigomo ?

 Ubaniobhekenenokusungulalemigomo?

 Yakhiwa kanjani lemigomo?

 Uzizwa kanjani ngalemigomo, nimilandelo, inisiza kanjani?

 Ngokubonakwakholemigomoiyasebenza?

 Yinieyenzaingasebenzi?

 Yinieyanzaisebenze?

 Iziphiizingqinbambiobhekana nazo ngokuhlelwa kwadoti?

 Yiniengabaimbangelayalezozingqinambiemphakathini?

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 Nibhekana kanjani nalezozingqinambi?

 Yiniebalulekilengokuphathaudotingendlela?

 Yiniengenziwaukundlondlobalisaukuphathwa kwadoti laphaemphakathini?

 Umuphiumdlandlaowenzileukubhekananalezizingqinambi?

 Yimiphiimizamoeniyenzileukubhekananalezizingqinambi?

 Yiniziphi izinkinga enibhekana ekuzameniukuxazulula lezo zingqinambi?

 Nizixazulile kanjani lezizingqinambi?

 Uzizwa kanjani ngendlelalezi zinkinga ezaxazululwangayolezo enabhekana nazo?

 ngathandazixazululwe kanjani lezi zinkinga?

 Ikhonayiniindlelaenilahlangayoudotilweziguli?,ngengamanabukeni , nemijovo?

 Iziphiizindlela lezo?

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Appendix 3: interview guide for ward councillors and community-based care managers
(Zulu version).
 Udlalayiphiingxenyekulomphakathi?

 Kulendima yakho wenzani?

 Ugxilakuyiphiingxenyeekuthuthukiseniizindabazodoti?

 Celaungibaleleosebenzisananabo?

 Badlalayiphiindimalabobantu?

 Ngombonowakhoabantubazizwa kanjani ngodoti?

 Bawubonanjengentoebalulekileudoti?

 Udlalayiphiingxenyekulomphakathikwezokuhlelwakukadoti?

 Ngokubona kwakhoiziphiizingqinambiezibheke umphakathi mayelana nokuhlelwa

kukadoti?

 Yiniimbangelayalezizingqinambi?

 Uzixazulula kanjani lezi zinkinga?

 Zingaxazululwa kanjani lezi zinkinga?

 Usebenzisananezigcemeezingaki?,ziqambe?

 Uwuthandakangakananiumsebenziwakho?

 Ususebenzeisiikhathiesingakananikulomsebenzi?

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 CHAPTER SEVEN

HEALTH CARE WASTE MANAGEMENT IN COMMUNITY-BASED CARE

PERSPECTIVES OF COMMUNITY HEALTH WORKERS IN SCARCE

RESOURCE COMMUNITIES IN SOUTH AFRICA

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 HEALTH CARE WASTE MANAGEMENT IN COMMUNITY-BASED CARE:
PERSPECTIVES OF COMMUNITY HEALTH WORKERS IN SCARCE
RESOURCE COMMUNITIES IN SOUTH AFRICA

Lydia Hangulu1 Olagoke Akintola2,3

1. Health Promotion PhD Programme, University of KwaZulu-Natal.

2. Discipline of Psychology, Health Promotion Programme University of KwaZulu-
Natal.
3. School of Human and Social Development, Nipissing University, North Bay, Canada.

This manuscript was prepared for submission to the Canadian Journal of

Development Studies

I Lydia Hangulu [LH] was responsible for the conception and designing of this study
with the guidance from my supervisor (Dr Olagoke Akintola [OA]). Noloyiso
Dlilanga [ND] was a research assistant who assisted with facilitating focus group
discussions. I wrote the chapter under the guidance of my supervisor.

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 Abstract
Introduction: Health care waste (HCW) is a by-product of health care activities. In South Africa,
most HIV/AIDS patients who are also co-infected with tuberculosis (TB) receive care at home
through community-based care programmes. Community health workers (CHWs) provide nursing
care whose activities generate HCW. Improper management of HCW poses health risks to the
people and tampers with environmental aesthetics. There is also a need to be concerned with HCW
that is generated in community-based care because unlike hospitals/clinics, homes are not meant
to accommodate HCW. There is more literature on HCW management in hospitals/clinics but there
is none on community-based care (CBC) in South Africa. The study aimed at exploring health care
waste management (HCWM) in community-based care in Durban, South Africa from the
community health workers’ perspective.
Methods: Ethnographic methods (Focus group discussions, participant observations and informal
discussions) were conducted with 112 CHWs in 29 communities in the Durban metropolis and
were selected using snowball sampling. Focus group discussions were guided by a focus group
guide with open-ended questions. All observations were guided by an observation guide.
Results: Sharps and infectious waste was generated in homes of the patients and was mixed with
domestic waste in the house bins. Due to irregular waste collection services, inadequate water and
long distance to access the toilets, HCW was illegally dumped along roads or in bush, burnt openly
and buried. Liquid HCW such as vomit, urine and sputum were disposed of in the yards and were
accessible to animals and children.
Conclusion and recommendations: With the increased levels of flooding, HCW can find its way
into drinking water sources causing contamination. Increased temperatures can cause HCW to
ferment and become a breeding ground for disease-causing organisms thereby affecting the most
vulnerable populations, women and children. Even if South Africa has the largest antiretroviral
programme, it is undeniable that HIV/AIDS patients do receive care at home. Proper disposal of
HCW is a way of improving hygiene and sanitation in order to protect the patients from
opportunistic infections. There is need for policy-makers to address service delivery issues at
household level to improve HCW management in CBC. This could improve the health of the
patients, the general public and the environment.

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Key words: Health care waste, community-based care, caregivers, HIV/AIDS.

Introduction

Globally, the management of health care waste (HCW) is a major challenge (Harhay, Halpern,
Harhay, and Olliaro, 2009). HCW is the waste that is generated in health care facilities such as
hospitals, clinics, pharmaceutical manufacturing plants, research laboratories, nursing homes and
other settings like homes where there is care for a patient (Pruss, Giroult and Rushbrook, 1999;
Botelho, 2012). In low-and middle-income countries (LMICs), there is poor management of HCW
(Hossain et al., 2011; Wilson, Velis and Cheeseman, 2006). Studies in selected hospitals and
clinics in LMICs found that there are various challenges that are encountered while trying to
manage HCW. For example, in most African countries, there is insufficient knowledge on how to
handle HCW among health care workers and other staff working in health care settings (Mundia
and Mbewe, 2006). Moreover, there is lack of segregation of HCW from point of generation to the
point of disposal, most dumpsites are poorly managed and there are no interventions to prevent
scavengers from having access to dumpsites (Gabela, 2007). Studies also reveal that there is lack
of clear financial investment and clear policies to manage HCW (Phorano, Nthomang and
Ngwenya, 2005; Mbongwe et al., 2008). This together with inadequate technologies for managing
HCW make the use of incineration the most common method for management of HCW (Abah and
Ohimain, 2011).

Similarly in South Africa, as in many other African countries, HCW management is improperly
managed. For example, a desk top study by Leonard (2005) found that about 45% of HCW in
KwaZulu-Natal province is unaccounted for. There are instances where HCW is dumped in
communities that are inhabited by poor black people. Gabela and Knight (2010) conducted a study
on health care waste management (HCWM) in 30 health care clinics in a rural health district in
KwaZulu-Natal province and found that HCW was not segregated from point of generation in all
the facilities and four of the 30 facilities burnt and buried the HCW in shallow pits in the premises
of the clinics. Improper management of HCW has negative ramifications for a variety of people,
including exposing the general public, health care workers, waste handlers, caregivers, patients,
waste pickers and animals to injuries (Pruss et al., 1999). Ferreira and Teixeira (2010) reported
44 injuries from contaminated material among staff members in a

156
hospital in the Algarve region of Portugal. Regrettably, there is lack of comparable data in South
Africa.

Improper management of HCW promotes scavenging in landfills. In India, a study conducted by

the India Clinical Epidemiology Network in 2004 on HCWM revealed that in almost 10 of the
health care facilities nationwide, more than 30% of the 3-6 billion injections that were administered
every year were done with used syringes that were recycled by unskilled scavengers who sold them
on the black market (Harhay, et al., 2009). Additionally, health care workers, waste handlers and
the general public exposed to HCW can be at risk of infection with hepatitis A, B and C (Harhay
et al., 2009; Franka et al., 2009). Exposure to HCW can cause diseases like diarrhoea, leptospirosis,
typhoid, cholera, and HIV and Tuberculosis [TB] (Mato and Kassenga, 1997; Bdour et al., 2007)
all of which could cause death. Indeed, approximately
5.2 million people globally die every year due to diseases caused by improper management of
HCW (El-Salam, 2010). While there are challenges with managing HCW in health care facilities,
the waste that emanates from community-based care (CBC) settings is of greater concern because
unlike in hospitals, homes are not built to accommodate HCW (Miyazaki et al., 2007; Verma et
al., 2008).

Achieving equitable access to health care and equitable health outcomes is the goal of primary
health care (Akintola, Lavis, Hoskins, 2015). However, most health care systems worldwide are
faced with shortages of funds and medical personnel (Schneider, Hlophe and Rensburg, 2008);
burdens with communicable diseases and the HIV/AIDS pandemic (Maher, Ford, Unwin and
Fronti, 2012). CBC is a primary health care strategy to provide on-going care to the chronically ill
patients in their own homes within the community (Aantjes, Quinlan and Bunders, 2014). Most
CBC programmes in sub-Saharan Africa assist in dealing with the impacts of HIV/AIDS. They
aim at improving access to care, and initiating and managing patients on antiretroviral treatment
(ART) (Callaghan, Ford and Schneider, 2010). Task shifting in CBC involves the use of
community health workers (CHWs) who are nonprofessionals but are trained to provide home-
based care, social services, palliative care, psychological and social support to the patients and
family members (Akintola, 2008).

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In South Africa, CBC is a health policy priority. Thus, community-based organisations (CBOs)
are heavily relied upon to provide health and social services to poor and marginalised communities
(Akintola, Gwelo, Labonte and Appadu, 2015). Community-based organizations provide on-going
care to people with chronic illnesses such as HIV/AIDS, TB and cancer in their homes with the
help of CHWs living in these communities. These activities could potentially generate HCW
(Akintola, Gwelo, Labonte and Appadu, 2015; Young and Busgeeth, 2010; De Maesenneer and
Flinkenflogel, 2010; Akintola and Hangulu, 2014). However, this issue has rarely been explored
in the literature. Current reforms in primary health care (PHC) seek to scale- up CBC through the
re-engineering of PHC as a fundamental component of the national health insurance (NHI). The
reform which has been rolled out in pilot sites since 2012 entails the use of outreach teams led by
nurses providing care in marginalised communities across the country (Shasha and Schneider,
2010). The scaling up of health care services provision in CBC brings into sharp focus the issue of
HCWM in homes and communities. Given the potential for home- based care activities to generate
HCW there is the need to understand issues related to HCWM in homes. However, we found no
research exploring the perspectives of community health workers who provide the bulk of the care
activities. This study therefore aims to explore how HCW is managed in CBC from the perspective
of community health workers.

Methods
This was a qualitative study and it was appropriate because it focuses on the subjective perceptions
and understanding that result from the experiences of participants (Ulin, Robin, Tolley and
McNeil,2002) within the social context (Ospina and Wagner, 2004). The qualitative approach
allowed us to explore what is real for the participants in their own language (Terre Blanche,
Durrheim and Painter, 2006). Using the design, we were able to explore the community health
workers’ perspectives about HCWM in CBC in South Africa.

Study setting and context

We conducted the study in KwaZulu-Natal (KZN), the province with the highest HIV and TB
prevalence in the country (Statistics South Africa, 2014). Additionally, 80% of TB patients in KZN
are co-infected with HIV (Kavanagh, 2014). We drew participants from thirteen CBOs providing
health and social services in 29 resource poor communities located on the outskirts of Durban,
South Africa (see Table 1). These comprise three informal settlements, 21 peri-urban
and five rural communities. According to the Housing Development Agency (2013), informal
158
settlements are communities that are occupied by migrants from rural areas or foreign nationals
who are in search of employment and social services. Municipal services in these areas are often
free, very basic and are mostly unavailable. Peri-urban communities are neither rural nor urban;
they are densely populated and underdeveloped. Rural communities consist of scattered elderly
populations who rely on social grants. Municipal services in these areas are also basic and free.
All these communities are occupied by the poor blacks (Indigenous African people classified as
blacks under the apartheid era) (Roma et al., 2010). All the communities fell within the jurisdiction
of eThekwini metropolitan municipality.
Table 1: Demographics of the organisations
Name of Location of the Year Number of Number of
CBOs organisations organisation communities participants in
was founded served FGDs
A Informal 2006 3 8
settlement Rural
B area 1999 2 7
C Peri-urban 1998 2 6
D Peri-urban 2001 3 7
E Peri-urban 1992 2 7
F Peri-urban 2002 1 6
G Peri-urban 1999 2 5
H Peri-urban 2000 2 8
I Peri-urban 2000 1 8
J Rural area 1990 3 6
K Peri-urban 1996 2 6
L Peri-urban 1999 3 5
M Peri-urban 1997 3 6

All organisations provided education programmes on HIV/AIDS/TB, drug abuse, rape and
antiretroviral treatment (ART) awareness programmes. They offered life skill programmes such
as gardening and bead work. Basic counselling programmes were also offered to patients to help
them to accept their HIV positive status, develop coping mechanisms such as dealing with stigma,
adherence to ART and coping with bereavement. Social services offered include referrals to
relevant social support structures, help with accessing pension grants for the elderly citizens, child
grants and accessing national identity cards. These organisations provided home-based care and
day care services for orphans and vulnerable children. Activities carried out in home-based

159
care are basic nursing care offered to people living with HIV/AIDS (PLWHA), TB and most of
them have other lifestyle diseases such as diabetes and hypertension.

Participants
A list of community-based organisations was obtained from the AIDS Care Foundation and the
first two organisations were chosen and contacted. We used snowball sampling, a technique used
to locate participants through referrals (Ulin et al., 2012, p, 61), to identify other organisations; the
first two organisations provided referrals to the other organisations that they had partnered with.
All organisations were selected if they were willing to participate in the study and if they provided
home-based care to people living with HIV/AIDS/TB, because we believed that CHWs working
in such organisations will be in a better position to provide insights into HCWM. The gate-keepers
of the CBOs provided permission for the study to be conducted in their organisations. A total of
112 CHWs were purposively recruited to participate in the study; if they were willing to
participate, they had worked in these organisations and provided home-based care to people living
with HIV/AIDS/TB for a period of six months or more. This criterion was necessary because
participants with such work experience were thought to be in a better position to provide rich
insight about the study topic (Ulin et al., 2005). CHWs in the study were all female and their ages
ranged between 23 and 60. Their work experience ranged between one and 21 years and they
served a total of twenty-nine (29) communities (see Table 1).

Data collection method and procedure

Ethical approval for this study was obtained from the Humanities and Social Science Research
Ethics Committee of the University of KwaZulu-Natal, South Africa (see appendix A). All the
CBOs approved of the study and gave permission to conduct the study with the CHWs. We
employed three ethnographic research approaches to collect data: focus group discussions,
participant observations and informal discussions. The three data collection approaches were
appropriate for triangulation purposes which aim at eliminating the researchers’ biases, and to
improve the quality of data (Babbie and Mouton, 2001).

Firstly, we conducted focus group discussions (FGDs) with CHWs to capture a wide range of
responses (Kidd and Parshall, 2000) and to understand normative practices (Blanche et al., 2006)
about HCWM. All focus group discussions were guided by a focus group schedule which

160
contained open-ended questions (see appendix 3). Open ended questions were appropriate because
they provided participants with the opportunity to provide detailed responses and for the research
to probe (Ulin et al., 2012). The focus group guide covered three main themes: 1) various nursing
activities provided to the patients and the nature of the HCW that is generated in the process, 2)
management of HCW in CBC: how HCW is handled and managed in CBC, and
3) barriers and facilitators to the management of HCW and 4) strategies used to respond to
challenges of health care waste management. One FGD was conducted in each of the thirteen
organisations and between 5 and 8 CHWs participated in each focus group (see Table 2).

The focus group discussions were conducted in meeting rooms provided by the organisations.
Participation in FGDs was voluntary; the aims of the study were explained to participants,
informed consent was sought from participants prior to the commencement of FGDs and all CHWs
gave written (see appendix 2) and verbal informed consent. We also obtained permission to record
all FGDs. All FGD were conducted in IsiZulu, the main local language spoken in the communities.
FGDs were facilitated by a trained research assistant (ND) who was a native IsiZulu speaker and
lasted between 60 and 85 minutes. Data collection took place from July 2013 to August 2014.

161
 Table 2. Characteristics of community health workers
Name of the Number of participants Years of services Age range
organisations in FGDs in CBOs
A 8 2-6 23-39
B 7 1-2 23-39
C 6 3-9 34-59
D 7 2-15 27-54
E 7 1-6 29-48
F 6 2-10 34-54
G 5 2-19 38-45
H 8 1-10 32-44
I 8 1-2 27-52
J 6 1-8 33-37
K 6 6-21 30-50
L 5 1-8 37-60
M 6 2-3 31-41
Total: 13 112 1-21 23-60

Secondly, following all focus group discussions, observations were conducted on the HCWM
practices of CHWs within the homes of the patients. Participant observation was important because
it enhances data quality and interpretation (DeWalt and DeWalt, 2010). I (LH) accompanied the
CHWs on daily visits to the homes of the patients. Permission was also obtained from families to
conduct observation of the state of the homes and HCWM practices. At the household level, the
environment of all households was observed and documented. These included the availability, type
and state of toilets in the households, access to water facilities, waste storage facilities and
equipment such as house bins and garbage bags. Hygiene and HCWM practices of the CHWs
were also observed. At the community level, observations were made on the location of communal
toilets and distance to patients’ homes, accessibility of roads, community waste storage facilities
and the general cleanliness of the environment (streets, paths, cliffs, surrounding bushes and some
streams where necessary). Thirdly, during observations, informal discussions were conducted with
CHWs for clarity on HCWM practices. The observed

162
activities, events and responses provided from the informal discussions were written down in a
note book.

Data analysis
All the recorded data from focus group discussions was transcribed verbatim and translated from
IsiZulu into English by the research assistant who facilitated the focus group discussions. Both
authors met to discuss how to apply the six steps of thematic analysis proposed by Braun and
Clarke (2006). One of the authors (LH) conducted the analysis in active discussion with the second
author (OA). Both authors met regularly to review the coding. We followed the six steps proposed
by Braun and Clarke (2006): 1) to familiarise ourselves with the data, we read all the transcribed
scripts from the focus group discussions, field notes obtained during observations and informal
discussions, (2) we also read the data to identify and generate the codes, (3) we then identified
themes from all the generated codes, (4) all identified themes were reviewed and sub-themes were
generated, (5) all the reviewed themes and sub-themes were grouped together, and (6) all the
grouped themes are presented as shown in the results below.

Results
The findings present an overview of what goes on in the homes of the patients in the 29
communities with respect to HCWM. The findings are presented using three themes. The first
theme describes the nature of activities and how HCW is generated in CBC. The second describes
how HCW is handled and managed in homes of the patients. The third theme describes the barriers
to management of the HCW and the strategies used to deal with such barriers. All bold themes are
discussed together with sub-themes (in bold and italicised) and are supported by direct quotes from
the participants in italics.

Activities responsible for generating health care waste in community-based care

In starting out the focus group sessions, we sought to understand what activities contribute to
generating HCW in CBC. We therefore asked CHWs about the services that they provide to the
patients on a day-to-day basis and the waste that is generated in the process. Their responses
revealed that they provide nursing care activities to HIV/AIDS patients who are incontinent,
bedridden, have stroke or are diabetic. Some of the diabetic patients have wounds resulting from

163
amputations while other patients have opportunistic infections such as TB and diarrhoea. Most of
the patients also have other diseases such as asthma, arthritis and high blood pressure.

CHWs provide nursing care activities such as cleaning and dressing of wounds, changing of
diapers, bed baths, brushing of teeth, washing of linen and administering insulin injections. While
performing the nursing care activities, waste materials such as used gloves that are worn when
providing care to the patients, soiled diapers, swabs, used bandages and soiled linen are generated.
These materials are typically contaminated with faecal matter and bodily fluids such as urine,
blood, vomit, pus, sputum and phlegm. There is also waste water resulting from giving bed baths
to the patient and cleaning containers used to receive sputum, phlegm and vomit by patients with
nausea and TB. Additionally, CHWs described instances where incontinent patients and those that
are too weak to walk to the toilet use buckets for toileting purposes because they cannot afford to
buy diapers.

“Some patients cannot walk to the toilet. They pee (urinate) and do everything on
themselves, so at the end of the day you find that we have urine…even faeces in a
bucket because some patients do not have diapers so you put a bucket for them to
use.” (Focus group D)

Management of health care waste in community-based care

According to the World Health Organisation’s (WHO) guidelines, proper handling of HCW
involves protecting the health of the handlers and the environment. The handler is supposed to be
protected through wearing of personal protective equipment (PPE) and avoiding contamination of
HCW waste in the environment (Pruss et al., 1999). CHWs in the study indicated that they received
training that equips them with knowledge and skills on how to handle waste. They were taught
that HCW is hazardous and that they must wear gloves when handling it in order to protect
themselves from infections. In instances where they do not have gloves, they are expected to
improvise by wearing plastics as protective devises. CHWs pass on this knowledge to the family
members of the patients by training them. During FGDs, CHWs said that they apply the skills that
they learnt during training in practice. This position is consistent with what we observed during
our home visits. CHWs were seen wearing gloves or plastics when handling HCW. We also noted
that they seemed to be disgusted when handling HCW due to the fact that
it has a repulsive smell.
164
However, contrary to the training, some of the CHWs in FGDs indicated that, due to lack of gloves,
there are occasions when they do not wear plastics as protective devices because they believe that
plastics hamper their work. They said that plastics do not cover all the fingers as gloves do and
therefore does not protect them from being exposed to HCW. The cited instances when they end
up handling HCW with their bare hands while wearing plastic for protection. We confirmed this
assertion during observations. In particular, we observed some CHWs changing diapers of the
patients, picking up all the used diapers and the containers containing vomit, sputum and phlegm
with their bare hands. When asked why they did this during informal discussions, one of them said
that she she had no time to look for a plastic to wear because that she was pressed for time to attend
to other patients. She also said that she was going to wash her hands afterwards to prevent any
infections.

WHO recommends that HCW be segregated according to the risk it possesses and its storage must
be done in a way that does not pose risk to the people or the environment. Collection entails
carrying and transporting HCW to the disposal sites, while disposal requires that HCW is discarded
in a way that does not allow pollution of the environment (Pruss et al., 1999). Based on WHO’s
recommendations, section 5 of the Constitution of the Republic of South Africa gives the
responsibility of management services including refuse storage, refuse removal and refuse dumps
to the local government (Republic of South Africa, 1996). As such, the Municipal Systems Act
(Act No. 32 of 2000) gives the municipality power to provide municipal health services including
waste management services from homes in the community (Department of Labour, 2000).
Effecting these regulations, the municipalities in South Africa are in charge of removing all
domestic waste from homes. They provided all households with black plastic bags for storing all
domestic waste.

To ensure proper management of HCW, the South African National Standards on HCW
management in health care facilities requires that all infectious waste must be segregated according
to the risk it poses and must be stored in red plastic bags with a clear label that reads ‘infectious
waste’ and sealed with a non-polyvinyl chloride (PVC) tag. The standards also stipulate that
sharps must be stored in yellow puncture and leak proof containers labelled

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‘danger, contaminated sharps’. And all general/domestic waste is required to be stored in black
plastic bags without any hazard label (South African Bureau of Standards, 2011). Although CHWs
indicated that they received training regarding segregation of HCW in FGDs, observations
revealed that the training only equipped them with knowledge and skills to segregate HCW from
domestic waste. In homes, CHWs did not separate HCW. Households are not provided with yellow
containers for storing sharps, and as a result, all sharp waste was mixed with other HCW. In
addition, we observed that neither CHWs nor households are given red plastics to store infectious
waste as stipulated by the standards. As a consequence, all households and CHWs store all HCW
in black plastic bags meant for domestic waste. CHWs felt that the reason why they are not
provided with red plastics for storing HCW is a lack of supply of materials and home-based care
kits by the funders.

During FGDs, they indicated that prior to the year 2010, most home-based care programmes were
funded by the European Union and that CBOs had fairly regular supply of home-based care kits
from the department of health which contained all necessary supplies for providing nursing care.
The kits contained items such as bandages, swabs, sanitisers, gloves, masks, medication, linen
savers and aprons. Red plastic bags were included in the kits and were meant for storing the HCW
resulting from nursing care activities. According to the participants, they used to store all HCW in
the red plastics and thereafter, took the red plastics containing HCW to their organisations from
where the HCW was transported to local clinics and finally taken for disposal by the relevant
authorities. They however indicated that most CBOs experienced funding cuts since 2010 and
since then they have experienced shortage of these materials. At the time of the study, none of the
CBOs were receiving materials or HBC kits from the Department of Health. CHWs indicated that
they have had to rely on alternative sources of donations for these materials including from the
nearest clinics, individual donors and local business owners. All the black garbage bags containing
HCW in homes are tied ‘to prevent smell or spillage’ and also to prevent children from scavenging
for used gloves.

“…We put everything in a big plastic [black plastics] and tie it [them]so that
children will not access it [them] because they like to get gloves to use as
balloons…” (Focus Group D).
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The plastic bags that are tied to prevent spillage are then stored in the house bins together with
domestic waste. In informal settlements, most houses are clustered together and as a result, there
are no formal roads. The municipality provides communal waste storage facilities that are located
close to the main roads. All households are expected to store their waste in these facilities on a
daily basis. Communities in peri-urban and rural areas, on the other hand, have access to roads
therefore all households are expected to have bins for storing their waste and they are expected to
remove the waste to the kerbside for collection by the waste collectors on particular waste
collection days. Observations on environmental hygiene in homes showed that some households
in the informal settlements and peri-urban communities did not have house bins. In such homes,
black garbage bags containing HCW were stored in a hidden corner of the house without any
proper protection or supervision, and were therefore accessible to children who were seen
scavenging for toys.

Barriers to proper health care waste management

Barriers to the proper management of HCW in homes include: lack of co-operation from family
members, irregular waste collection services by waste collectors, inadequate water to practice
hygiene and sanitation and also long distances between the toilets and the homes of the patients.
Lack of assistance from family members
In hospital settings, incontinent patients and those that are too weak to walk to the toilet are usually
given bed pans to use. In CBC, the majority of patients are too poor to afford bed pans and diapers.
Some patients cannot afford to buy diapers and are too weak to stand, hence they use buckets for
toileting. TB and nausea patients use containers to vomit and spit, and this means that in the
absence of CHWs, family members are supposed to help lift the incontinent and weak patients for
them to use the buckets. Family members are also supposed to help empty and clean all buckets
used for defecation and containers used for spiting and vomiting. For patients who use diapers,
family members are supposed to help change diapers. Family members are also supposed to
remove all the HCW that is generated in homes to the curbs for collection. CHWs reported that
most family members did not provide care to incontinent and weak patients as such; patients end
up relieving themselves on their beds thereby developing bedsores. Further, some

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family members did not change the patients’ diapers and did not dispose of HCW appropriately.
This made the patients’ rooms and indeed some homes smell badly and repulsive.

“… They do not change the diapers, they do not dispose of the diapers that we leave
behind, instead we find them in the same room where the patient is when we come
back. So how can a person heal like that? It is just not fair! You find that the room
is smelling because of the nappies [soiled diapers]…” (Focus Group J).

With such a challenge, CHWs feel helpless and frustrated but they also continue to educate the
family members about HIV/AIDS and the importance of practicing hygiene to promote the
wellbeing of the patient.

“There is nothing we can do…but we teach the family members how to take care
of a patient because that is what we are trained to do and we cannot force them to
do it if they do not want to…” (Focus Group A).

Irregular waste collection by waste collectors

All households in the communities are provided with waste collection schedules and are expected
to remove all waste from homes onto the curbs on a particular day set for waste collection. With
the responses from FGDs and from observations, all HCW and domestic waste from house bins or
yards is put in one black plastic bag that is tied and then it is taken to the curbs to make it accessible
to the waste collectors who pick it up and transport it to the landfills for disposal. All waste from
homes is supposed to be collected at least once a week. Despite having waste collection schedules,
there were several instances when waste was left uncollected. CHWs and households felt that they
are ‘left in the dark,’ which means that no reasons or warnings were provided to them. Waste was
usually left on the curbs for long periods of time, and was blown away by strong winds and
scattered by dogs.

“We put the plastic bags on the road side every Wednesday so that [the]
municipality will pick it up but you find that they do not come so it is blown away

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 by [the] wind…also dogs come and tear it up and the waste will be all over
everywhere” (Focus Group H).
Because the waste collectors only collect waste that is packaged, the waste that is scattered by the
wind or animals is neither swept nor removed by the waste collectors. This makes it accessible to
children and waste scavengers that are at risk of being exposed to injuries and disease-causing
organisms in the waste. CHWs also complained that the uncollected waste created extra work for
them because they had to clean it up, so that their work is not undermined. This means that they
spent more time at a particular patient’s house while they had other patients to care for.
“It is too much work for us…even the waste collectors they leave it [the uncollected
waste] like that because they only collect the waste that is packaged; it is not their
duty to clean up… so we have to clean it…” (Focus Group K).
Observations showed that irregular collection of waste made community members resort to
unfriendly environmental practices. For example, in peri-urban townships, households resorted to
dumping the waste illegally along the road sides, forest or bush. In some rural communities, waste
is buried and is also burnt openly in the backyards causing the production of smoke due to
incomplete combustion of waste, especially diapers. In the informal settlements, CHWs during
FGDs revealed that households dumped waste illegally due to irregular waste collection services.
However, it was also observed that waste disposal facilities are far from homes. As a result, some
households dig shallow pits and dispose of the waste while others dump their waste on any
unoccupied spaces such as paths, cliffs, roads and streams.

Inadequate water for practicing hygiene and sanitation

Adequate water is needed for practicing hygiene such as washing clothes and linen. In informal
settlements, households do not have piped water and toilets are communal. Therefore, CHWs
confronted challenges in washing their patients’ clothes and linen. CHWs stood in long queues to
have access to water to wash linen for the patients. CHWs felt stigmatized because there was no
privacy for their patients. They said that everyone who uses the communal toilets knows whose
clothes are being washed by the CHWs. Sometimes CHWs were not given a chance by some
community members to wash because some of them feared contagion.
“…When we wash the clothes everyone now knows whose clothes you are
washing. You just hear them gossiping, some, pointing fingers at you...you will be

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 waiting in the queue, they won’t give you space, they feel you will infect them…”
(Focus Group B).
Water is also needed for cleaning containers used for spiting/vomiting and buckets used for
defecation by incontinent and weak patients. For sanitation purposes, water is also needed to flush
waste water used for bed baths, vomit, urine, sputum and faeces. It is also important for cleaning
the toilets and also for washing hands after providing care to the patient. From observations on
water sources and sanitation facilities in homes of the patients, some households did not have piped
water. As such, it was difficult to keep the patients clean, to flush the waste and to wash hands.
For example, in one rural home where there was no piped water, we observed that the patient was
not given a bath; a community health worker (CHW) was seen pouring urine at the back of the
house. We also observed that the CHWs neither washed the container nor their hands afterwards.
The CHW had other patients to attend to, as such little attention was paid to the patient and little
time was spent at that particular house. When asked why she did that, she complained about her
schedule:
“I cannot go and fetch water now, the next house where I can get water is far and
I have another patient who I am supposed to take to the clinic. So I will just come
back tomorrow and do everything properly…” (CHW, community, J).

Long distance between the house and the toilets

In most peri-urban communities, homes have flush toilets. In informal settlements, there are
flushable communal toilets but they are located far from homes. These facilities consist of urinals
and toilets with separate units for females and men that consist of toilets or urinals; they have hand
washing basins and showers and are connected to a local sewer where the effluent is channeled.
They also have storerooms and wash stands. The municipality provides all installation costs while
the users are expected to manage the facilities. The community members appoint care takers who
clean the toilets either on a voluntary basis or through a pay per use scheme. The care takers also
liaise with the municipality on the maintenance requirements and costs (Roma et al., 2010). The
challenge with communal toilets is that they are only open from 5am to 6pm daily. In the night,
households are expected to find their own alternatives.

Long distances between toilets and homes made CHWs reluctant to use communal toilets because
they feared being robbed of their belongings. They indicated that they had been victims
170
of crime in the past citing instances where their belongings and the patient’s antiretroviral drugs
(ARVs) were stolen from the patient’s home by the ‘Whoonga boys’ (the boys who are known to
use drugs made from ARVs in the communities) while escorting a patient who is unable to walk
to the toilet or while washing linen in the communal toilets. Because of this challenge, CHWs felt
compassionate for the patients and encouraged them to use diapers at night. But for those that
could not afford to buy diapers and did not have anyone to assist them to go to the toilet, they
encourage them to just relieve themselves on the bed and they visited such patients on a daily basis
including those that lived alone or those who do not have any assistance from family members.

In rural areas, most homes have pit latrines which are located outside the house. CHWs said that
it was impossible for weak patients to walk on their own, as they needed help from family members
or CHWs to access the pit latrines. Another challenge is that latrines were frequently vandalised
by boys in the community who stole all the roofs and doors and sold them for money to buy drugs.
Vandalism of pit latrines make then repulsive to the households and patients. Those who use the
pit latrines are deprived of their privacy and dignity. To deal with these challenges, CHWs used
bed sheets as doors just to allow the patients who were able to walk to use the toilets. I observed
that because of the long distance to reach the communal toilets or pit latrines, CHWs end up
pouring liquid HCW like urine, waste water, sputum and vomit in the open yards. Chickens were
also seen scavenging for food from such HCW.
“… Instead of going all the way to the toilet to flush the waste water or urine or
vomitus you just pour on the yard because you have other things to do…it will dry
up…” (Focus Group C).

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Discussion
Findings of this study reveal factors that influence the management of HCW at two different levels.
1) At the community level, we, discuss practices relating to HCWM in the homes of the patients
within the community. 2) At the municipality level, we discuss practices relating to HCWM
officers responsible for overseeing HCWM in the communities.
The community level
Previous studies that have been conducted in clinics and hospitals in low-and-middle-income
countries show that HCW is not usually separated (Leonard, 2005; Mundia and Mbewe, 2006;
Harhay, Halpern, Harhay and Olliaro, 2009). Our findings regarding segregation of HCW in homes
extends knowledge about waste management by revealing some inadequacy in the training for
CHWs. CHWs received training only on the segregation of HCW from domestic waste but not on
the segregation of HCW according to the risk posed. The insufficient training is reflected in the
knowledge and skills of family members who rely on CHWs for education on proper segregation
and overall management of HCW. The lack of segregation of waste such as sharp waste exposes
family members, CHWs, community members and waste handlers to physical injuries and
psychological issues like anxiety/stress disorders (Cairncross et al., 2003; (Dounias et al., 2005).
). There is a need for CBOs and the department of health to train CHWs on the correct segregation
techniques for HCW. Mechanisms to monitor HCW management practices by CHWs must be
introduced in CBC and there must be constant discussions with the trainers and CHWs to see and
understand the kinds of challenges that hamper proper HCWM practices.

In hospital settings, patients who are too weak to walk to the toilets, incontinent and bedridden are
given bedpans, diapers, portable urinals, catheters or urine collectors to use (Heller, 1999; Tomes
and Ernest, 2013; Cottenden et al., 2013). However, most households in our study were too poor
to afford any of the required materials for care of the patients. As a result, most of the patients used
buckets for toileting; patients with nausea used containers to vomit while those with TB used
containers for spiting. The use of containers and buckets can easily expose the CHWs and family
members to bacteria that cause diarrhoea, cholera, typhoid and leptospirosis (Mato and Kassenga,
1997). Family members and CHWs are also exposed to TB infections and may also cause death
from such infections (Joshi, Reingold, Menzies and Pai, 2006; Lonnroth et al., 2010; Akintola and
Hangulu, 2014). These findings highlight the need for the department of

172
health to develop means of assisting patients in CBC with materials. This could help in improving
the well-being of the patients.

Our findings also show that due to insufficient supply of gloves, some CHWs used their bare hands.
The Occupation Health and Safety Act of Act 85 of 1993 in South Africa, states that any health
care provider must not accept to handle any hazard without PPE. HCW is hazardous and providing
care without wearing PPE puts CHWs at risk of infection like HIV, hepatitis A, B and C and could
result in death of the CHWs. For instance, in the year 2000, about 21 million hepatitis B, 2 million
hepatitis C and 260 000 HIV infections were reported globally due to exposure of HCW (WHO,
2005). In Libya, HCW handlers had either hepatitis B virus or hepatitis C virus due to exposure of
HCW (Franka et al., 2009). The lack of supply for PPE has tended to lead to negative attitudes
among CHWs. Given that family members rely on CHWs for training and for modelling proper
health behaviour and practices, incorrect HCWM and infection prevention and control practices
by CHWs could send the wrong message to the family members of the patients who may imbibe
such wrong practices. In addition, lack of PPE compromises the quality of care given to the patients
and the risk of infection by CHWs (Akintola and Hangulu, 2014). There is a need for CBOs to
work together with the Department of Health to ensure that CHWs are provided with adequate
training on the importance of using PPE. Even so, training alone is not enough to ensure good
practices of HCWM. CHWs should also be provided with PPE and this could assist CHWs in
modelling appropriate health behaviours and practices for family members in the community. The
activities of CHWs should also be monitored to ensure sustainability of proper HCWM practices.

Our finding that some homes did not have access to piped water is an impediment to proper hygiene
practices such as keeping the patients clean, washing linen, flushing the HCW, cleaning the
buckets and containers and washing of hands. Hygiene practices such as washing hands with soap
and proper disposal of faecal matter and other bodily fluids like vomit and sputum prevents the
transmission of diseases such as diarrhoea (Gorter et al., 1998) and respiratory illnesses (St Sauver
et al., 1998). It has been documented that hygiene practices help in reducing mortality and
morbidity (Aiello and Larson, 2002; WHO, 2007). There is a need for government to revise its
water policies for the poor communities to ensure equity.

173
Previous studies in South Africa have reported shortages of home-based care kits and inadequate
supply of materials (Akintola and Hangulu, 2014; Mabude, Beskinska, Ramkissoon, Wood and
Folsom, 2008). Most CBC programmes in middle and low-income countries including South
Africa are funded by government and international donor agencies as well as private and individual
donors (Arieff et al., 2009; Akintola, Gwelo, Labonte and Appadu, 2015; Akintola, Lavis and
Hoskins, 2015; Seguino, 2009). However, funding has dwindled in recent years due to the credit
crunch created by the global financial crisis as well as change in donor policy agendas (Akintola
et al., 2015 a). This reduction in funding has had negative ramifications for most of the CBOs who
have experienced a drastic reduction in financial and material support.

Lack of appropriate storage facilities left households with little choice but to store HCW in their
yards. This made it accessible to children, waste scavengers and animals. Proper storage of HCW
is needed to protect the health of the people and it makes it easier for the waste collectors to
transport it correctly to designated disposal sites as stipulated by the South African National
Standards (SANS, 2004) on health care waste management (Republic of South Africa, 2004). In
the hospitals, the Department of Health is responsible for overseeing issues relating to HCW
management; it is not clear, however, which government agency is responsible for providing red
plastics and yellow containers for accommodating HCW in homes. Lack of supply of red plastics
and yellow boxes for sharps in CBC by the municipality could mean that the municipality and the
policy makers are not paying the necessary attention to HCWM in CBC. This is emblematic of a
larger problem of poor service delivery by the municipalities in South Africa. Research has shown
that service delivery in sub-Saharan Africa is failing due to lack of funds, misallocation of public
funds and corruption (Odoro, 2012; Wolf, 2007). Mdlongwa (2014) has attributed poor service
delivery in South Africa to lack of skilled personnel to assist municipalities with rendering quality
services to the people, lack of transparency in the provision of services for the people, and
insufficient funds at the municipal level, and this affects the quality of the services that are
rendered.

The fact that CBC aims at improving the quality of life and well-being of the patients highlights
the importance of HCWM which should be addressed by all relevant organs of the state such as
174
the Departments of Water and Sanitation, Department of Environmental Affairs and Department
of Health. Insights provided by this study can help inform the rollout of the primary health care
re-engineering model in South Africa. The finding shows that HCW is an issue that must be given
priority attention in the new national initiative. The Department of Health needs to liaise with the
relevant authorities to ensure that red plastics and yellow containers are supplied in homes where
there is patient care. There should be a link between the patients in homes and the nearest clinics
to ensure monitoring of such patients in CBC. This could help in monitoring the generation of
HCW in CBC, and could help facilitate its disposal. There is need to carry out further investigations
with the policy makers from the municipality and Department of Health to understand who is
responsible for supplying materials in CBC, what causes the shortages with the supply of materials,
and why red plastics bags and yellow containers are not supplied in homes.

At the household level, family members did not assist with the removal of HCW from the patients’
rooms for collection by waste collectors. Most studies about caregiving and family support indicate
that there is lack of support from family members (Akintola, 2008) and this has been linked to
stigma and discrimination (Akintola, 2006, 2008). In this study, lack of removal of HCW by
family members could be due to three different reasons: (a) stigma towards the patients, (b) fear
of contagion, and (c) lack of proper education about HCWM in homes. The non-removal of HCW
exposes patients and CHWs to a dirty environment and foul odour which has negative
ramifications for them. It could also demoralise and discourage CHWs from performing their
duties, thereby compromising the quality of care given to the patients (Uys, 2002; Akintola, 2006).
There is need for CBOs to work together with the Department of Health, Department of Sanitation
and Water and the Department of Environmental Affairs to develop intervention at the primary
health care level aimed at addressing the importance of hygiene and sanitation, and HCWM in
promoting the well-being of people in the community. This could improve the well-being of the
patients and could prevent cross-infections in homes and the community as a whole.

The municipality level

Inadequate waste management services are a common issue in LMICs (Ogu, 2000; Katusiimeh,
Moi and Burger, 2012). The major contributing factor is the increase in population which puts a

175
strain on governments that have inadequate resources and finances of providing waste
management and other services to households (Fay, Beck, Fay and Kessinger, 1999; Kassim and
Ali, 2006). In this study, irregular waste collection services were affecting HCWM in the
communities. In South Africa, literature suggests that irregular waste collection in the hospitals
and clinics is as a result of lack of reliable transport (Gabela and Knight, 2010; Mbongwe, Mmereki
and Magashul, 2008). In our present study, CHWs or households could not provide reasons for
this problem. This suggests the need for exploration of the perspectives of relevant stakeholders in
charge of waste management in the communities to gain a deeper insight into the issue.

Irregular collection of waste from the communities caused illegal dumping of the HCW on the
environment like streets, bushes, off cliffs and water sources. HCW was also buried in the yards
and also burnt openly. Disposal of HCW in the environment has both negative environmental and
health ramifications. HCW in the environment reduces environmental aesthetics (Phorano et al.,
2005). HCW in the streets can cause social contagion in that when HCW is seen in the streets,
people always assume that people living in that street are also dirty (Kassim and Ali, 2006).
Additionally, the foul odour from the HCW can cause the breeding of disease causing vectors such
as cockroaches, flies and rodents in the environment (Ramokate, 2008; Drackner, 2005). HCW
that is buried can find its way into water sources which can cause water pollution, adversely
affecting the health of the people (Blackman, 1993). Most of the HCW that is produced in CBC
is incombustible. Burning of HCW and other waste in open air can cause air pollution through the
production of dioxins and furans. Dioxins and furans are carcinogens that are produced due to
incomplete combustion (Ketlogetswe et al., 2004).

Lack of access to piped water in some of the study communities could cause households in the
communities to opt for open defecation (Thilde et al., 2010; Sahoo et al., 2015). In our study, lack
of piped water had a negative impact on hygiene practices. Adequate water supply is needed for
practicing good hygiene which helps to reduce opportunistic infections which are caused by
unhygienic practices (Mafuya and Shukla, 2005). Practicing good hygiene can also prolong the
lives of the patients (WHO, 2008). There is need for policy makers to address water issues in the
community.

176
In some communities, pit latrines and communal toilets were located far from the homes of the
patients. Tshililo and Davhana-Maselesele (2009) found that long distance between the toilets and
the homes of the patients made them soil themselves before reaching the toilets. However, our
study shows that patients who were too weak to walk to the toilets used buckets for toileting due
to fear of soiling themselves before reaching the toilets. Another finding is that CHWs were afraid
to travel long distances to access toilets with their patients because of fear that their belongings
and those of a patient might be stolen while away at the toilets. As a consequence they disposed
of liquid waste like urine, vomit and sputum in the open yard.

A study conducted in three HIV/AIDS affected settlements in Limpopo province of South Africa
revealed that the majority of the households lacked toilet facilities for disposing of human excreta
and other solid waste. As a result they resorted to using the bush while some used their neighbours’
toilets (Kgalushi, Smits and Eales, 2004). The pit latrines in some communities did not have doors
or roofs as such, patients who are weak but able to walk, felt uncomfortable using them. In a recent
study by Sahoo et al. (2015) on sanitation-related psychological stress among women in India,
women were afraid to use toilets without doors because they felt vulnerable to sexual violence. To
deal with this challenge of lack of doors, most CHWs used bed sheets as doors to allow patients to
use them. These are not effective or sustainable methods; there is need for the municipality to
provide toilets that are durable. There is need for the municipality, the Department of Health and
other relevant departments to address crime issues in the communities. Residents must be provided
with education about the need to keep their toilets clean.

Furthermore, most pit latrines and communal toilets were unclean, malodorous and repulsive to
patients and households. These findings are similar to the findings of Roma et al. (2010) and
Rheinlader et al. (2010). O’Reilly and Louis (2014), in a study on understanding successful
sanitation in rural India, found that households are motivated to use toilets if those toilets are
comfortable, convenient, and promote privacy and dignity of an individual. They also found that
women were reluctant to use toilets because of fear of contracting infections (Sahoo et al., 2015).
Findings of this study show that communal toilets in informal settlements only opened from 5am
to 6pm. Community members were expected to improvise in the night. Such conditions could
cause open defecation. Roma et al. (2010) argue that most water and sanitation programmes in

177
South Africa fail because service providers only focus on meeting the deadlines. Furthermore,
unskilled people are hired and as a result, there is inadequate allocation of finances (Eales, 2010).
O’Reilly and Louis (2014) also argue that sanitation and hygiene practices by individuals are not
based only on knowledge, but also on designs that are socially acceptable and culturally
appropriate. Our study calls for the South African government to provide water and sanitation
facilities that are socially acceptable and designs that are culturally appropriate. To ensure
sustainability of such facilities, the government must involve the people from the designing process
to its implementation process.

Conclusions
Our qualitative study provides insight into overall activities responsible for generation of HCW
and various factors influencing its management at the community and municipality levels. Our
findings together highlight the interaction between the practices of individual caregivers, and
community health workers at the level of the household and community and the lack of availability
of regular waste disposal infrastructure and services at the municipal level. These findings
highlight the need to address the issue of health care waste management at different levels. The
training of CHWs and households to enhance their knowledge and skills on HCW management as
a way of practicing hygiene and sanitation to improve their well-being and that of the patients is
an imperative. At the municipality level policy makers should work together with the Department
of Health and CBC managers to recognise CBC as contributors of HCW and must ensure the issue
of training, materials and facilities necessary for HCWM are addressed. In addition, service
delivery challenges which undermines health care waste management and indeed the management
of other kinds of waste at the municipality level needs to be addressed as part of broader
interventions at the national and provincial levels. With the rollout of a primary health care model,
there is need to develop policies that aim at HCW management in CBC and to monitor the
implementation of such policies at the municipal level.

Strengths and limitations of the study

The study has various methodological strengths. The qualitative approach was necessary for this
study because it helped to answer the what, when, where, why and how questions about HCWM
in CBC. The approach provided more insights into the study. The use of ethnographic methods:
focus groups, participant observations and informal discussions were appropriate because they
178
provided insights into the experiences of CHWs regarding HCWM. The study also made use of
CHWs who are more hands on with the HCWM practices in CBC. As such, their experiences
provide a clear picture of what goes on in the homes of the patients in CBC. The main limitations
were that, the experiences of the patients and the households were not explored and yet they could
have added more valued information to the study. In addition, the waste collectors were not
included in the study therefore, their contribution could have deepened our understanding of health
care waste management practices in community-based care

Areas for further research

There is need to conduct further research to understand how health care waste is managed in homes
of the patients from the patient’s and the household’s perspectives. More research should also be
conducted with waste collectors in order to understand how they collect, transport, treat and
dispose of the HCW from homes. Such kind of a research will provide detailed information on the
process of waste management from the point of generation to the point of disposal.

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185
Appendix 1: Introducing the study to the community health workers

Good morning/afternoon, my name is Mrs Lydia Hangulu. I am a student at the School of

Applied Human Sciences. I am doing my PhD in Health Promotion and Communication
(Student number: 210546147) at the University of KwaZulu-Natal, 4041, Durban, South
Africa. I am conducting a study on policy and practice of home care waste management
in community-based care organisations. I would like to speak to you only if you agree to
speak to me.

The discussion will take about 40 minutes to one hour. I will ask you about health care
waste management practices in the community, the kinds of challenges that you perceive
and the kinds of strategies that are used to deal with the challenges. I will need your
permission to use audiotape recorders to capture our discussion. All information that you
give will be kept confidential and only my supervisor guiding me on this research will
have access to it. Information will be used for research purposes alone and raw data will
be destroyed as soon as the study is completely over. Also, we will not use your actual
name or designation in reporting the findings of the study but will use disguised names to
make sure that no one links the information you have given us to you. You will not be
given any monetary payments for participating in the study but your organisation,
communities and the government will benefit from this study immensely. The results will
help us to understand the challenges encountered by your organisation in accessing
support for homebased care especially with regards to health care waste management.

Your participation in this study is voluntary and you have the right not to participate if you
do not want to. If you agree to take part in the study, I will ask you to sign a form as an
indication that you were not forced to participate in the study. Please note that you will
not be at any disadvantage if you choose not to participate in the study. You may also
refuse to answer particular questions if you don’t feel comfortable answering them. You
may also end the discussion at anytime if you feel uncomfortable with the interview. In
case you want to withdraw information given after the interview, you can call me on: cell:
073 335 6091 and email: lydiahangulu@yahoo.com and my supervisor Dr O. Akintola on
031-2607426 or Akintolao@ukzn.ac.za

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Appendix 1: Introducing the study to the community health workers (the Zulu version)

Sawubonaigamalamingingu Mrs. Lydia Hangulu ngifunda e Nyuvesiya Kwa- Zulu Natal , ngenza
I PhD yami kwezokuthuthukiswa Kwezempilo ‘’Health Promotion’’ (inombolo yomfundi :
210546147). Ngenza ucwaningo ngemigomo nemithetho mayelana nezokuqoqwa kwadoti
weziguli ezinakekelwa yizinhlangano.Ngingathanda ukuxoxa nawe uma ungangivumel.

Lengxoxo izothatha imizuzu engamashumi amane kuya kwi hora.Ngizokubuza ngemigomo

nemithetho emayelana nokuhlelwa nokulahlwa kuka doti weziguli, ngizobuza nangolwazi eninalo
ngodoti wazempilo neziguli.Ngizonibuza nangezigqinambi enibhekana nazo mayelana nokuqoqa
nokulahlwa kwalodoti, nokuthi nizixazulula kanjani lezo zinkinga.

Ngizodinga imvume yakho yokuku rekhoda nokugcina ingxoxo yethu. Yonke imininingwane
ozonginika yona izoba imfihlo , izogcinwa yimi ne superviser yami, akekho ozokwazi ukuyithola.
Lemininingwane engizoyithola kuwe izosethsenziselwa ucwaningo kuphela futhi, imininingwane
izosuswa eminyakeni emihlanu.Ngeke sisebenzise igama lakho langempela ngesikhathi sibhala
imiphumela yalolu cwaningo.

Angeke unikezwe mali kulolu cwaningo, noma izipho, umphakathi nomongameli bazozuza
kakhulu ngalolu cwaningo. Imiphumelo izosisiza ngokwazisisa ngokwazi izinkinga
enihlangabezana nazo, nokuthi imiphakathi nezinhlangano zizozuza ekwazini kabanzi ngosizo
abangaluthola kwi home-based care/ enhlanganweni yenu.

Kukuweukuthiuyalenzalolucwaningo, unaloilungelolokungaphenduli uma ungathandi.

Uma uvumaukubaingxenye yalolu cwaningo
kuzomeleungwaliseamaphephaukuzekucaceukuthiasizangesikuphoqeukuthiwenzelolucw
aningo. Ngicelakucaceukuthiakumeleuphenduleimibuzoongafuniukuyiphendula, futhi
ungayekaukuqhubekauphendule uma ungathandi noma ungazwisisi, uma
ufunangingawusebenzisiumniningwanengithintekulydiahangulu@yahoo.com my
supervisor Dr O. Akintola on 031-2607426 Akintolao@ukzn.ac.za

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Appendix 2: Consent Form

I have read the information about this study and understand the explanations of it given to
me verbally. I have had my questions concerning the study answered and understand what
will be required of me if I take part in this study.

Signature Date

Zulu version

IncwadiYemvume

Mina, Sengfundile mayelana nokuqukethweinhlolovo noma

ngiyaqondaizincazelozenhlolovonjengobangazisiwe futhi
ngachazelwangazongomlomo.Isiphenduliweimibuzo yami ngalenhlolovo,
ngakhongiyagondaukuthiiyiniebhekekekimina uma ngibayngxemyeyalenhlolovu

Signature Usuku:

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 Appendix 3: Focus group guide for community health workers Checklist for
Caregivers

A. Organizational demographics questions

1. What is your gender?

Female Male
2. What is the name of your organization?

3. What is your post in this organization?

Caregiver Manager
4. How long have you been working in this organization?

5. How many wards/communities does your organization serve?

Name all the areas:

6. What is the type of your organization?

NPO CBO FBO

7. How is your organisation funded?

General questions

• What kind of patients do you care for?

• How many do you see in a day?
• What kind of help do the family members offer you?
• How do community members react to you when they see you work with the sick
clients?
• How do you feel about your job?
• What challenges do you face while doing your work in the community?
• What could be the cause of these challenges in your own opinion?
• How do you deal with each of these challenges?
• How is the situation of water in these communities that you work in?
• Does water flow everyday? if not why?
• How do you do your work when there is no water?
• How do you feel about that?

189
 • What do you think could be done to help the water situation in this community?
• How will that improve your work?
• What kind of toilets are there in these communities that you work in?
• How do these toilets work or operate?
• Do they function properly?
• If not, how could they be improved?
• What materials do you use when caring for the sick? name all of them?
• Where do you get these materials?
• What challenges do you face with regards to materials?
• How do you do your work in situation when you dont have the materials?
• What do you think could be improved regarding materials?
• What kind of training do you receive regarding caring for the sick?
• What exactly were you taught?
• When do you receive the training?
• How does this training help you with your work?
• How do you feel about the training? is it enough? if not how? How could it be
improved?
 What kind of waste do you generate while performing your duties?
 How do you handle this waste that is generated?
 Where do you dispose it?
 Where do you store it?
 When is it collected? how many times does the track come to collect it?
 What happens when it is not collected?
What kind of rules/guidelines do you follow when handling
waste?  How did you come to know of these guidelines?
 How do these guidelines assist you in your daily duties?
 How could these guidelines be improved?
 What kind of training have you received with regard to handling waste?
 How long is the training?
 What are the things that you are taught during this training?
 How do you feel about the training that you have received with regard to handling waste?
 How has the training helped you in your daily work and life?
 What do you think is the importance of handling of this waste?
 What could be done to improve handling of this waste?
 May you please tell us the challenges that you face when handling the waste that you
generate while performing your daily duties?
 How do these challenges affect your work?

190
 What do you think are the reasons for having such challenges regarding handling of
waste?
 How do you feel about these challenges?
 How do you deal with these challenges?
 How would you want to improve HCWM in your organisation?

191
 Appendix 1: Focus group guide for community health workers the (Zulu version)
Checklist for Caregivers

Organizational demographics questions

1. ubulili Owesifazane Owesilisa

2.Ibizwa ngani inhlangano yakho/igama?

3. Yini igama lesikhundla sakho?

Onakekela iziguli Umphathi
4. Usunesikhathi esingakanani ukulenhlangano?

5.Inhlangano yenu isebenzisana nama wards amangaki?

6.Iwuliphu uhlobo inhlangano yenu?

NPO CBO FBO

7.Niyitholaphi imali yokuqhuba inhlangano yenu?

general questions

• Ninakekela iziguli ezinjani?

• Nibona ezingaki ngosuku?
• Uluphi usizo eniluthola emindenini yeziguli?
• Umphakathi wona uziphatha kanjani uma ubona nisebenzisana
neziguli,uyaye uthini?
• Uzizwa kanjani ngomsebenzi wakho?
• Iziphi izingqinamba ohlangabezana nazo ngesikhathi usebenza
emphakathini?
• Ngokubona kwakho yini ebanga lezi zingqinambi?
• Uzixazulula kanjani ngalezi zingqinambi?
• injani indaba yamanzi kulemimphakathi enisebenza kuyo?
• Akhona yini amanzi, uma cha, yindaba engekho?
• Niwenza kanjani umsebenzi uma engekho amanzi?
• Uzizwa kanjani ngalokho?
• Ucabanga ukuthi indaba yamanzi ingaxazululwa kanjani?
• Ingakuziza kanjani emsebenzini lokho?
• kulemiphakathi kusetshenziswa ama thoyilethe anjani?
• Asebenza kanjani lama thoyilethe?
• Kungabe asebenza kahle?
• Uma cha, kungenziwani ukuthi ukuze abe ngcono?
• Nisebenzisa ziphi izinto ukuze ninakekele iziguli?

192
 • Nizitholaphi izinto zokulapha, nokunakekela?
• Nivelelwa iziphi izinkinga mayelana nezinto zokunakekela izinguli?
• Uwena kanjani umsebenzi uma ningeazo izinto zokusebenza?
• Yini engenziwa kangcono kulezo zinto zokusebenza?
• Niyaqeqeshwa yini mande nikwazi ukusiza iziguli?
• Nafundiswani kahle kahle? Niqeqeshwa nini?
• Lokukuqeqeshwa kukusiza ngani?
• Uzizwa kanjani ngokuqeqeshwa, futhi ngabe kwanele yini, uma cha,
yindaba usho njalo?
• Kungalungiswa kanjani lokho? Kuvela luphi uhlobo ladoti uma nisiza
iziguli?
• Niluhlela kanjani lowodoti?
• Niwulahlaphi lodoti?
• Niwugcinaphi?
 Uma seniwuqoqile , imoto iza nini ukuzowulanda futhi kangaki?
 Kwenzekani uma ingafikanga ukuzowulanda?
 Imiphi imigomo nemithetho eniwulandelayo mayelana nokuqoqwa kwadoti?
 Lemigomo nemithetho ikusiza kanjani emsebenzini wakho?
 Lemithetho ingalungiswa kanjani yenziwe ibe ngcono?
 Nike naqeqeshwa mayelana nokuqoqwa kwadoti, nokuwuhlela?
 Loko kuqeqeshwa kathatha isikhathi esingakanani?
 Nafundiswani ngenkathi niqeqeshwa?
 Uzizwa kanjani ngalokho kuqeqeshwa enakuthola mayelana nokuhlelwa kwadoti?
 Lokho kuqeqeshwa kwakusiza kanjani empilweni yakho?
 yini oyibona ibalulekile gokuqoqwa kwalo doti?
 Yini engenziwa ukuze lokuqoqwa kwadoti kwenziwe ngobucwepheshe?
 Ngicela usho izinkinga ohlangabezana nazo ngenkathi nihlela udodi
eniwuthola ngesikhathi nisiza iziguli?
 Lezi zingqinamba ziwuhlasela kanjani umsebenzi wenu?
 Uma ucabanga lezi zingqinamba ziqhamukelaph I, futhi zibangwa yini?
 Uzizwa kanjani ngalezi zingqinamba?
 Ubhekana kanjani nalezi zingqinamba?
Ungenzani ukuthuthukisa kulenhlangano?

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 CHAPTER EIGHT

Integrative Conclusion

Introduction
This chapter presents an integrative conclusion drawn from all the chapters in the thesis. Using
Bronfenbrenner’s theory of human development as a framework, this chapter presents mini
abstracts for each chapter (starting with chapter 2; theoretical framework) and then integrates all
the findings and practical implications. I conclude with a discussion of the overall contribution of
the study, limitations and recommendations.

Chapter two: Theoretical framework

The ecological systems theory (EST) is a theory of human development developed by Urie
Bronfenbrenner in the 1970s. The EST proposes that, when a person or group is connected and
engaged in a supportive environment, the functioning also improves. The EST has four levels of
influence on a group or an individual: 1) the micro-system level for the individual, 2) meso- system
a level for the social agents, 3) the exo-system level for the organisations, 4) the macro- system
level which describes the nation in which individuals lives.

The four levels of the EST that have been applied to this study as follows. At the macro-level, I
discuss the international policy environment. International health care waste management
(HCWM) policies were reviewed at this level to understand laws, provisions, regulations,
standards and requirements relating to HCWM in health care facilities and in community-based
care. At the exo-level is the South Africa’s national policy environment. South African national
policies about HCWM were reviewed to understand the laws, provisions, regulations, standards
and requirements relating to health care waste management from health care facilities and in
community-based care. The meso-level is the municipality and community level where policy
makers (ward councillors) and stakeholders (CBC managers, area cleansing officers, education
officer) are found. Policy makers and stakeholders oversee service delivery issues in the
community including waste collection and refuse bag distribution programmes. At this meso-
level, I discuss the perceptions of HCWM in community-based care among policy makers and the
stakeholders. The micro level describes the HCWM practices of community health workers

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and household members. All levels are summarized in Figure 1 below. The main assumption
guiding this study is that, there is consistency among all levels when it comes to policy and practice
of health care waste management (HCWM). This means that, if there are international and national
policies that govern HCWM in South Africa, policy makers and stakeholders are more likely to
implement them hence the practices of HCWM are improved at the community level by the
community health workers.

The Macro level: International policies

on HCWM

The Exo level: National HCWM

policies in South Africa

The Meso level: (Municipality/Community)

policy makers’ and stakeholders’ perspectives on

HCWM in CBC

The Micro level: (Household)

HCWM practices of CHWs in CBC
&hose CBC

Figure 1 Ecological systems theory as applied to this study sourced from (Bronfenbrenner, 1974)

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Chapter 3: The scoping review
To achieve the first objective, a scoping review was conducted. The scoping review was more
applicable to the international and national policy level. Terminologies such as biomedical waste,
clinical waste, HCW, health care risk waste, hospital waste, infectious waste and medical waste
were found to be the most common terms used to describe health care waste in high income and
LMICs. Using the WHO manual on health care waste management from health care facilities as a
guide, the scoping review sought to understand how the different terminologies used to describe
HCW align with the definition, categories and classifications provided by the WHO manual.

One hundred and twelve (112) articles met the criteria and were analysed using thematic analysis.
Findings showed that, notwithstanding the different terminologies used both in high- income and
LMICs, their definitions, categories and classification of HCW align with those provided by the
WHO manual. Therefore, the terminology provided by the WHO manual could be adopted. This
could help with policy formation, interpretation and implementation and could improve health care
waste management practices in homes and other health care facilities. A broader scoping review
that uses more terms and more data bases should be conducted whose findings can be used as a
bases for developing common terms for use in all countries and settings.

Chapter 4: Review of international and South African policies governing health care waste
management.
International and South African national policies that govern HCWM were reviewed to achieve
the second objective: understanding the international and the South African policies governing
health care waste. Policy documents were accessed online and were reviewed. The main findings
are that, at the international level, the World Health Organisation manual on ‘health care waste
management from health care facilities is a global guide for all health care facilities including
home care settings. The main finding about HCWM provided by the WHO manual is that, it
assumes that HCW from homes is in small quantities hence recommends that it must be removed
from homes by the municipal waste authorities and must be treated before disposal (Pruss et al.,
1999:55). Other options provided by the manual are 1) Health care providers are responsible for
ensuring that patients who are sent to receive care from home are provided with containers for

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storing needles and syringes. 2) The health care provider must make arrangements for the HCW
to be removed from homes by a contractor or arrangements can be made with the nearest clinics
or hospitals where the patients or the health workers can take the waste for disposal (Pruss et al.,
1999:55). Considering the fact that community-based care organisations in LMICs play an
important role in the HIV/TB care (Akintola and Hangulu, 2014), their ability to generate health
care waste cannot be ignored. There is need for the WHO to revise its guidelines n about HCW
that is generated in CBC.

In South Africa, provincial HCWM policies are fragmented. The main guidelines relating to health
care waste management in South Africa are those provided by the African National standards
(SANS, 2004) and the national health care waste management draft policy. Both policies are
replicas of what is provided by the WHO manual. The national policy on HCW is still a draft. The
main strength of the draft policy is that, it recognizes CBC as generators of HCW however, just
like the WHO manual; it assumes that HCW from CBC is in small quantities. It is a replica of
WHO Manual on health care waste. Its limitation is that, given the fact that South Africa has the
highest HIV/AIDS/TB prevalences in the world; it does not adequately recognize community-
based care as contributors of health care waste that needs greater attention.

This chapter provides new insights highlighting the need for policy makers to pay attention to
health care waste management in homes. Considering health care waste management as a policy
issue in community-based care could promote hygiene practices and could help improve the
wellbeing of the patients and of the community members. This could also help in the fight against
the spread of HIV and TB. There is need for the government to pass the draft policy into law. There
is need for the policy makers to come up with uniform standards for regulating health care waste
in the country. The SANS (2004) should be revised by policy makers to consider health care waste
that comes from homes in the context of HIV/AID/TB and other lifestyle diseases. More research
should be carried out to understand the quantity of health care waste that is produced in homes
where there is care of the patient. This will help in the development of HCWM policies that
accommodates HCW from CBC. There is need for the further research to be conducted to
understand health care waste management policy formulation processes and the

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contexts in which they are formed. This could assist with the appropriate recommendation of
policies aimed at health care waste management in community-based care.

Chapter 5: Print media analysis

This chapter achieved the third objective of exploring how the media frames the problem of
healthcare waste in South Africa. The aim was to understand media frames of HCWM in South
Africa. Using the South African media database, a total of 189 news stories were retrieved from
20 newspapers and were analysed using thematically. The media frames revealed health care waste
management problems as caused mainly by government even if the main perpetrators are waste
contractors. There is blame on the government for delaying in developing a national HCWM policy
and for having inadequate HCW disposal and treatment facilities in the country. As a result, options
for addressing the issue of illegal dumping were directed at the government. Options proposed
include, developing of policies and providing HCW treatment and disposal facilities in the country.
Failure of the print media to propose options that includes waste contractors who are the main
perpetrators of illegal dumping and stockpiling could lead to half solutions that mask the real
problem. Half solutions could only focus on palliatives instead of focusing on all levels of society
such as the government policy makers and implementers; government agencies; waste contractors;
health facilities; individual health care workers; health care professionals; waste workers and
cleaners in the health facilities that contribute to this problem. The most intriguing thing about the
media frames is that, there was no mention of health care waste from homes. This raises questions
as to whether HCW from homes is even considered as a policy issue in South Africa.

Chapter 6: Interviews with policy makers and stakeholders

This chapter addresses the fourth objective. This is the municipality and community level. The aim
was to explore the perspectives of the policy makers and the stakeholders about HCW management
in community-based care. Semi-structured interviews were conducted with 30 policy makers and
stakeholders working in 29 communities offering CBC. At the municipality level, it was found
that the Durban Solid waste (DSW) unit of the eThekwini Municipality is responsible for
overseeing all waste management programmes in communities. At the micro- level (household)
the main findings are that nursing care activities are responsible for generating

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HCW in CBC. HCW is mixed and removed together with domestic waste from homes. There is
illegal dumping of HCW in CBC mainly due to irregular collection of HCW by the waste collectors
and insufficient supply of garbage bags for storing waste. At the municipality level, factors
affecting HCW management practices include corrupt tender processes and insufficient funding
for waste management programmes.

To deal with the barriers of proper HCWM, all the policy makers and the stakeholders collaborate
and work together to provide education campaigns to community members about proper waste
management. Issues related to inadequate resources are reported to their superiors. The WHO
manual (Pruss et al., 1999) and the SANS (2004) prohibit mixing of HCW and illegal dumping.
Based on the findings in this study, it can be concluded that HCW is not managed in a manner
which it is supposed to be managed. The findings are an addition to the body of literature on health
care waste management in homes in community-based care. There is need to conduct studies to
understand how HCW is collected, treated and disposed of by the waste collectors. The
government should address the issues of corruption, inadequate garbage bags, in order to improve
health care waste management services and practices.

Chapter 7: Practices and perspectives of community health workers on HCWM

This study was conducted to achieve the fifth objective. This is the micro-level and described the
HCWM practices of CHW in the homes of the patients. The aim of the study was to explore the
perspectives of CHWs on HCWM in CBC. Using ethnographic methods: focus group discussions,
participant observations and informal discussions were conducted with 112 CHWs. The study
found that CHWs provided nursing care performing activities which are responsible for generating
HCW. The HCW generated include, used gloves, used diapers, used needles and syringes, urine,
faeces in buckets, vomit, and waste water. All HCW was mixed with domestic waste and was
removed by the DSW unit of the eThekwini municipality. The main barriers to proper management
of HCW found are irregular waste collection services, inadequate garbage bags for households,
inadequate water supply in some homes and long distance to access the toilets in the informal
settlements. As a result, solid HCW was illegally dumped along roads or in bush, burnt openly and
buried. Liquid HCW such as vomit, urine and sputum were disposed of in the yards and were
accessible to animals and children. The findings point to the need for the

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managers of community-based care organisations and policy makers to work together to see to it
that health care waste from homes is managed properly. There is need for the municipality to
distribute garbage bags in homes that are meant for storing health care waste. Secondly, there is
need to further investigate how HCW is transported and treated and how it is disposed of. The
government should see to it that adequate services such as waste and sanitation facilities are
provided to the people. This could improve health care waste management.

Convergence of all the findings

Based on the assumption of the ecological systems theory which states ‘when systems work
together, their function also improves,’ there is a link among the findings of all the studies that
have been conducted for this thesis. The convergences of the findings are in two categories: the
policy and the practice aspects of health care waste management on community-based care. Media
analysis is at the intersection of these studies.

1. The policy aspect of health care waste management in community-based care

The scoping review of terminologies used to describe, define, categorise and classify health care
waste revealed that the WHO manual uses the term ‘health care waste’ while the most common
terms used in high and LMICs are biomedical waste, clinical waste, HCW, health care risk waste,
hospital waste, infectious waste and medical waste. It is not clear why these various terms are used
meanwhile their definition, categorization and classification are consistent with the one provided
by the WHO manual. A study from Botswana found that, the term ‘clinical waste’ is known to
mean all waste that is generated from health care facilities. Because of this definition, most health
care workers and the general public ended up not segregating HCW into non- hazardous and
hazardous waste. Instead health workers disposed of all categories of waste together as hazardous
waste in red bags. The consequence of this practice was the unnecessary use and wasting of red
bags, and the overloading of resources needed for transportation and storage of health care waste
(Mbongwe, Mmereki and Magashula, 2008).

Although there are no similar studies in South Africa, the use of different terminologies to describe
HCW can cause confusion when it comes to developing waste management policies by policy
makers and can affect the practices of HCWM by ordinary people who are generators and handlers
of HCW. There is need for further studies to be conducted to understand the extent to
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which terms used to describe HCW are understood in the context of policy formulation and how
they among practitioners: health facility managers/directors, health professionals, cleaners, waste
handlers and collectors in the communities and waste companies working with health facilities.

Internationally and in South Africa, there are no policies that specifically address HCWM in CBC.
So far, internationally, the WHO global manual on the safe management of health care waste
management provides HCWM guidelines. By assuming that HCW from home is in “small
quantities”, the manual fails to adequately recognize the role that CBC plays in the context of
HIV/AIDS/TB and other communicable diseases like diabetes that requires home care. The way
that WHO manual describes HCW from homes, has influenced South Africa to inadequately define
HCW from CBC. Instead what the South African draft policy contains is a replication of the
WHO’s recommendation on how HCW from homes must be managed without a putting the
context of the country-HIV, AIDS and TB prevalence and the recent initiative to scale-up primary
and community care into consideration. Empirical studies on HCWM in LMICs show that
inadequate policies that govern HCW in most health care facilities serve as barriers to proper
management of HCW (Soliman & Ahmad, 2007; Sawalem, Selic, & Herbell, 2009, Gabela and
Knight, 2010). In South Africa, a lack of a national policy is known to have been the cause of
fragmentation and lack of uniformity in the implementation of provincial HCWM policies
(Erasmus, Poluta and Weeks, 2012; Van Schalkwyk, 2013).

Additionally, from the media analysis chapter, one of the dominant media frames of the causes of
the problem of HCWM in South Africa is a lack of national policy and fragmentation in policies.
These media frames align with the findings from empirical studies. This shows that the media has
reported the issue of lack of policy correctly. However, the media framing of health care waste
management problems as caused mainly by government, results into failure of the print media to
propose options that includes waste contractors who are the main perpetrators of illegal dumping
and stockpiling. One sided options directed at the government could lead to half solutions that do
not address the real problem and may ignore important levels of society (mainly the government
policy makers and implementers; government agencies; waste contractors; health facilities;
individual health care workers; health care professionals; waste workers and cleaners in the health
facilities) that contribute to the problem. Furthermore, the problem of lack of
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policies for HCWM focuses on the health care facilities mainly ‘hospitals and clinics’ unlike CBC.
The finding of a lack of CBC policy on HCWM is a new finding both internationally and in South
Africa as this is the first study that has been conducted to explore HCWM in CBC. These findings
could be used for policy makers to re-think policy about how HCW from CBC managed and to
develop relevant policies aimed at improving HCWM in CBC. In the context of HIV and AIDS
and TB, policies on proper management of HCW is an imperative because of its potential role in
promoting hygiene practices and in turn improve the wellbeing of the patients. Together, these
studies provide empirical evidence that can inform a review of existing draft national policy on
health care waste management.

2. The practices of health care waste management in community-based care

The two studies: the policy makers’ and stakeholders’ perspective and also the community-health
worker’s perspectives address the practice aspects of health care waste management in
community-based care and are complimented by media frames in the media analysis chapter. The
common themes found regarding practices of HCWM are lack of segregation, illegal dumping and
insufficient supply of garbage bags.

Lack of segregation of HCW

The HCW from homes is mixed with domestic waste instead of segregating it into hazardous and
non-hazardous categories as recommended by the WHO manual and the SANS 2004 (Pruss et al.,
1999; Republic of South Africa, 2005). The lack of segregation of HCW from domestic waste is a
new finding in the context of CBC. Studies from health care facilities indicate that lack of
segregation of HCW is caused by insufficient knowledge by HCW handlers (Mbongwe, Mmereki
and Magashul, 2008; Magdy and El-Salam, 2010; Gabela and Knight, 2010). Although the policy
on the management of HCW in CBC is not adequate as discussed earlier, what was clear from this
study is that stakeholders and policy-makers at the community level lacked a common
understanding of how to deal with health care waste in CBC. There responses indicated confusion
and a lack of implementation of the existing draft national policy. These findings call for the
relevant agencies such as the Department of Health and the Department of Environmental Affairs
and Tourism to put in place appropriate mechanisms for monitoring the implementation

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of existing policies while working on developing more appropriate and up to date policies that
addresses the current needs in CBC.

Illegal dumping
This study found that illegal dumping is a problem that is mainly facilitated by insufficient supply
of HCW bags by the municipality and irregular collection of HCW by contractors. Illegal dumping
of HCW is prohibited (Pruss et al., 1999) and makes the HCW accessible to animals, waste
scavengers and children (Bendjoudi, Taleb, Abdelmalek, Addou, 2008). The findings of
insufficient supply of HCW bags in CBC are an addition of knowledge on HCWM in CBC. They
indicate how big the issue is and these insights need the attention of policy makers. Most literature
about HCWM in health care facilities indicate that there is irregular collection of HCW
(Bendjoudi, Taleb, Abdelmalek, Addou, 2008; Mbongwe et al., 2008) without mentioning who is
responsible for collecting the HCW. The findings about who is responsible for collecting HCW
from homes are new in the context of CBC in South Africa and they are important as they provide
insights where more insights about collection of HCW can be found, and also specifies where the
intervention should be targeted. More importantly, this study reveals that corrupted tender
processes facilitates the problem of irregular collection because contractors are chosen based on
their political connections unlike their ability to provide HCWM services. There is need for further
studies to be conducted to gain more insights of the extent of corrupt tender processes regarding
HCWM. Adequate information will help to provide recommendations for addressing the problem.

Furthermore, the problems of lack of segregation of HCW and illegal dumping were framed as
caused by the government who delay developing HCWM policies and also for having corrupt
tender process resulting in contracting of incompetent waste contractors. Empirical studies about
HCWM in health care facilities in African countries (Gabela and Knight, 2010; Mundia and
Mbewe, 2006; Bendjoudi, Taleb, Abdelmalek and Addou, 2008; Sawalem, Selic and Herbell,
2009; Mangaa, Fortonb, Moforc and Woodardd, 2011), do not indicate the perpetrators of illegal
dumping. Further studies should be conducted to determine the accuracy of the media frame. Large
scale studies should be conducted to have more insights about the issue of illegal dumping in the
health care sector in South Africa.

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Practical interventions
Applying the ecological systems theory to this study, I found that the existence of international
and national policies influence policy makers and stakeholders to implement such policies of
HCWM at the national level, this in turn influence practices at the municipal by waste collectors:
the DSW unit, waste contractors and the community-health workers at the community and
household levels. The findings have shown that a lack of adequate policy at the international level
has negatively influenced the formulation of the South African HCWM policies in CBC hence the
practices have also been affected negatively. Thus, at the macro-level (international policy level)
WHO should revise its manual and re-define HCW from CBC. WHO should take into account the
role of CBC and the context in which it was introduced. Alternatively, being the governing body
in issues related to health and HCWM, WHO should develop a policy specifically for CBC.

At the exo-level (the South African national policy level), there is already a draft policy on HCWM
but it does not adequately provide for HCW from CBC. The definition of HCW that is in the draft
policy should be revised to in cooperate HCW from CBC. At the meso-level (policy makers and
stakeholders), CBC managers should collaborate with ward councilors and environmental activists
to advocate for a policy regarding proper management of HCW in CBC. This should help to get
the attention of the public and the policy makers. Policy makers should begin to think of a way of
revising the home-based care policy and in-cooperating management aspects of HCW from CBC
into the policy. To address the issue of lack of garbage bags for storing HCW in homes, the
stakeholders and the CBC managers should negotiate and advocate for red garbage bags and leak
proof containers for storing HCW to be provided in homes. At the micro-level (homes where
community health workers work), since CHWs are a link with the health care facilities, they should
continue to educate people on the importance of segregation of HCW. The CHWs should also join
forces with environmental activists, nurses, CBC managers and ward councillors to protest against
lack of attention for HCW and inadequate resources for CBC. This could catch the attention of the
media, possible donors and the policy makers. The attention could facilitate the formulation of
HCWM policies in CBC and also address the issue of inadequate materials.

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Overall academic contribution of the study
The overall thesis has the following strengths: firstly, to my knowledge, this is the first study that
has been conducted in South Africa regarding HCWM in CBC. The findings of this study have
shown a link between policies and practices of HCWM from the international level to the
community health workers’ level in South Africa. The study shows that CBC establishments are
contributors of HCW which is improperly managed. The HCW that is produced is more than just
sharps and needs more attention. HCWM is an issue that affects the health of the public and the
environment. The findings about improper management of HCW from CBC are an addition to the
body of literature on HCWM in CBC, environmental health and public health. These findings can
be used as a guide to develop various inquiries about HCWM and policies in CBC.

Secondly, the strength of this dissertation lies in the use of various methodologies in exploring and
understanding policy and practices of HCWM in CBC in South Africa. The use of scoping review,
analysis of policy documents, media analysis, interviews of policy makers and stakeholders, focus
group discussions, informal interviews and participant observations have provided in-depth
understanding of HCWM from various perspectives by answering the what, where, when, why
and how of health care waste management. These questions are vital in understanding health
problems in society as they determine how a particular health issue can be addressed. Using the
levels provided by the ecological systems theory has helped to identify HCWM policies and
practices. This is helps policy makers and stakeholders identify the nature of the issues relating to
health care waste management and the level at which to address deign interventions aimed at
addressing particular problems at those specific levels.

Overall limitations and recommendations

Some of the limitations of the study are: these findings cannot be generalised to all communities,
thus, there is a need to conduct a similar study from different settings to further understand the
issue of HCWM in CBC. I did not investigate the quantities of HCW that is generated in CBC.
There is need for further research to conduct a study to determine the amount of HCW generated.
This will help understand the magnitude of the problem of improper HCWM in CBC. Although I
observed the practices of family members providing care to the ill, I did not explore their

205
perspectives directly yet they could have provided more insight to the study. There is need for this
issue to be explored further. The opinions of the people in charge of HCWM from the Department
of Health and those of the contractors were not explored, yet they could have added more insight
to the study. Such studies should be conducted as they could be useful for informing policies on
HCWM in CBC. This study did not examine how HCW is handled, transported, treated and
disposed of. Such studies will add more insight about what happens to the HCW from CBC,
beginning from the point of generation to the point of disposal.

206
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