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HEALTHCARE WASTE IN ETHIOPIA
A STUDY OF WASTE GENERATION, COMPOSITION AND
MANAGEMENT IN THE AMHARA NATIONAL REGIONAL
STATE, ETHIOPIA
ESUBALEW TESFAHUN

Dissertation for the Degree of Doctor of Philosophy (PhD)
Addis Ababa University, Ethiopia
July, 2015
ADDIS ABABA UNIVERSITY
SCHOOL OF GRADUATE STUDIES
HEALTHCARE WASTE IN ETHIOPIA
A STUDY OF WASTE GENERATION, COMPOSITION AND
MANAGEMENT IN THE AMHARA NATIONAL REGIONAL
STATE, ETHIOPIA

A Dissertation submitted to the School of Graduate Studies of Addis
Ababa University in partial fulfilment of the requirements for the
Degree of Doctor of Philosophy (PhD) in Public Health

Esubalew Tesfahun (MPH)
Advisors: Abera Kumie (PhD)
Abebe Beyene (PhD)

SCHOOL OF PUBLIC HEALTH, COLLEGE OF HEALTH SCIENCES
ADDIS ABABA UNIVERSITY
July, 2015
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DISSERTATION APPROVAL
ADDIS ABABA UNIVERSITY
SCHOOL OF GRADUATE STUDIES

Dissertation title: Healthcare Waste in Ethiopia
A study of Waste Generation, Composition and Management
in the Amhara National Regional State, Ethiopia

By: Esubalew Tesfahun

SCHOOL OF PUBLIC HEALTH, ADDIS ABAB UNIVERCITY
APPROVED BY THE EXAMINING BOARD

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Chairperson, Examining Board Date
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Advisor (Primary) Date
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Advisor (Secondary) Date
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External Examiner Date
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Internal Examiner Date
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Internal Examiner Date

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ORIGINAL PAPERS
This dissertation is based on the following four papers, which will be referred to in the
text by their Roman numerals.
I. Esubalew Tesfahun, Abera Kumie & Abebe Beyene. Critical assessment of
healthcare waste management practice in Ethiopia. (Under review-
International Journal of Occupational & Environmental Health).
II. Esubalew Tesfahun, Abera Kumie, Worku Legesse, Helmut Kloos and Abebe
Beyene. Assessment of composition and generation rate of healthcare
wastes in selected public and private hospitals of Ethiopia. Waste
Management & Research 2014, Vol. 32 (3) 215–220.
III. Esubalew Tesfahun, Abera Kumie, and Abebe Beyene. Selection of best fit
models for the prediction of hospital healthcare waste generation rate.
(Under review-Waste Management & Research)
IV. Esubalew Tesfahun, Abera Kumie and Abebe Beyene. Healthcare waste
management practices: systematic review. (Under review- International
Journal of Environment and waste management)

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ACRONYMS
ANRSHB Amhara National Regional State Health Bureau
BMW Biomedical Waste
BOO Built, Owen, and Operate
BOT Built, Operate, and Transfer.
EG Emission Guideline
EPA Environmental Protection Agency
EST Environmentally Sound Technology
GEF Global Environmental Facility
HBV Hepatitis B Virus
HCC Health Care Centres
HCFs Health Care Facilities
HCV Hepatitis C Virus
HCRW Health Care Risk Waste
HCW Health Care Waste
HCWH Health Care Without Harm
HCWM Health Care Waste Management
HWM Hospital Waste Management
MoE Ministry of Environment
MoH Ministry of Health
MSW Municipal Solid Waste
MW Medical Waste
NGO Non-Governmental Organization
NSPS New Source Performance Standard
PAHs Polyhalogenated Aromatic Hydrocarbons
PCB Poly Chlorinated Biphenyls
PCDD Poly Chlorinated Dibenzo-p-Dioxins
PCDF Poly Chlorinated Dibenzo Furans
PI Principal Investigator
POP Persistent Organic Pollutant
PVC Poly Vinyl Chloride
RCN Royal College of Nursing
RSA Republic of South Africa
SARS Severe Acute Respiratory Syndrome
SNNPR Southern Nations Nationalities and Peoples Region
SPSS Statistical Package for Social Science
UNICEF United Nations Children’s Emergency Fund
US-EPA United State Environmental Protection Agency.
WHO World Health Organization
WIS Waste Information System
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GLOSSARY OF DEFINITIONS AND CONCEPTS
(Based on World Health Organization definitions)
Chemical waste: Consists of discarded solid, liquid, and gaseous chemicals, for example
from diagnostic and experimental work and from cleaning, housekeeping, and
disinfecting procedures. Chemical waste from healthcare may be hazardous or
nonhazardous; in the context of protecting health.
General waste: Is all solid waste not including infectious, chemical, or radioactive
waste. This waste stream can include items such as packaging materials and office
supplies. Generally, this stream can be disposed of in a communal landfill or other such
arrangement. Segregation of materials which are able to be reused or recycled will greatly
reduce the impact burden of this waste stream.
Genotoxic waste: Is consisting of, or containing substances with genotoxic properties,
including cytotoxic and antineoplasic drugs; genotoxic chemicals. It can be found in
vomit, urine, or faeces from patients treated with cytostatic drugs, chemicals, and
radioactive material.
Hazardous waste (another subset of healthcare waste): This has multiple sources in a
Facility and includes both chemically hazardous materials, infectious and radioactive
materials.
Healthcare waste: Is defined as the total waste stream from a healthcare establishment,
research facilities, laboratories, and emergency relief donations. Healthcare waste
includes several different waste streams, some of which require more stringent care and
disposal.
Heavy metals: Consisting of both materials and equipment with heavy metals and
derivatives, including: batteries, thermometers, manometers.
Infectious waste: Discarded materials from healthcare activities on humans or animals
which have the potential of transmitting infectious agents to humans. These include
discarded materials or equipment from the diagnosis, treatment and prevention of disease,
assessment of health status or identification purposes, that have been in contact with
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blood and its derivatives, tissues, tissue fluids or excreta, or wastes from infection
isolation wards.
Pathological waste: Consists of tissues, organs, body parts, human fetuses and animal
carcasses, blood, and body fluids. Within this category, recognizable human or animal
body parts are also called anatomical waste. This category should be considered as a
subcategory of infectious waste, even though it may also include healthy body parts.
Pharmaceutical waste: Consisting of/or containing pharmaceuticals, including: expired,
no longer needed; containers and/or packaging, items contaminated by or containing
pharmaceuticals (bottles, boxes).
Radioactive materials: Includes: unused liquids from radiotherapy or laboratory
research; contaminated glassware, packages or absorbent paper; urine and excreta from
patients treated or tested with unsealed radio nuclides; sealed sources.
Sharps: These are items that could cause cuts or puncture wounds, including needles,
hypodermic needles, scalpel and other blades, knives, infusion sets, saws, broken glass,
and nails. Whether or not they are infected, such items are usually considered as highly
hazardous healthcare waste.
Source: Pruss et al. 2013

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TABLE OF CONTENT
Contents
ORIGINAL PAPERS ................................................................................................................. iv
ACRONYMS ............................................................................................................................. v
GLOSSARY OF OPERATIONAL DEFINITIONS AND CONCEPTS ...................................... vi
TABLE OF CONTENT ............................................................................................................viii
LIST OF TABLES ...................................................................................................................... x
LIST OF FIGURES ................................................................................................................... xi
ABSTRACT ............................................................................................................................. xii
1.INTRODUCTION ................................................................................................................... 1
1.1.Statement of the problem ................................................................................................... 1
1.2. Rational of the study ......................................................................................................... 4
1.3.Literature review ............................................................................................................... 6
1.3.1. Background information ............................................................................................ 6
1.3.2. Hospital healthcare waste generation rate ................................................................... 7
1.3.3. Predictive models of hospital healthcare waste generation rate ................................. 11
1.3.4. Hospital healthcare waste management .................................................................... 13
1.4. Conceptual framework ................................................................................................... 18
2.RESEARCH QUESTIONS AND OBJECTIVES ................................................................... 20
2.1. Research questions-----------------------------------------------------------------------------------20
2.1.1. General research question-----------------------------------------------------------------------20
2.1.2. Specific research questions----------------------------------------------------------------------20
2.2. Objectives ...................................................................................................................... 20
2.2.1. General objective---------------------------------------------------------------------------------20
2.2.2. Specific objectives-------------------------------------------------------------------------------20
3. METHODS AND MATERIALS .......................................................................................... 21
3.1. Study area and setting ..................................................................................................... 21
3.2. Study design ................................................................................................................... 22
3.3. Source and study population ........................................................................................... 22
3.4. Sample size and sampling techniques ............................................................................. 22
3.5. Data collection tools and procedures .............................................................................. 24
3.6. Data management and statistical analysis ....................................................................... 26
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3.7. Data quality assurance mechanisms ................................................................................ 27
3.8. Ethical issues ................................................................................................................. 28
3.9. A tabular summary of the methods applied in the dissertation, 2014. ............................... 29
4. RESULTS ............................................................................................................................. 31
4.1. The practice of hospital healthcare waste management (paper I) ..................................... 31
4.2.Assessment of composition and generation rate of hospital healthcare wastes in selected
public and private hospitals (paper II) .................................................................................... 35
4.3. Selection of the best fit Models for the Prediction of Hospital Healthcare Waste Generation
Rate (Paper III) ................................................................................................................... 42
4.4.Evaluation of the impact of segregation practice on the generation rate of hazardous
healthcare waste .................................................................................................................... 46
4.5. Healthcare waste management practices: systematic review (Paper IV) ........................... 47
5.DISCUSSIONS...................................................................................................................... 50
5.1. The practice of hospital healthcare waste management systems....................................... 50
5.2. Composition and generation rate of hospital healthcare wastes ........................................ 52
5.3. Selection of best fit Models for the Prediction of Hospital Healthcare Waste Generation
Rate ...................................................................................................................................... 54
5.4. The effect of segregation practice on the generation rate of hazardous healthcare waste .. 55
6. VALIDITY AND GENERALIZABILITY ............................................................................ 56
7. STRENGTHS AND LIMITATIONS .................................................................................... 59
8. CONCLUSIONS .................................................................................................................. 60
9. RECOMMENDATIONS ...................................................................................................... 61
ACKNOWLEDGMENTS ......................................................................................................... 64
REFERENCES ......................................................................................................................... 65
Annex 1: Original papers ...................................................................................................... 74
Annex 2. Data Collection tools ............................................................................................ 128
2.1.Tools for observational checklist for assessing healthcare waste management practice ... 128
2.2.Tools for in depth interview questionnaire for assessing healthcare waste management
practice ............................................................................................................................... 131
Annex-3: Participant’s Consent Information Sheet .............................................................. 138
Annex 4: Declaration .......................................................................................................... 142

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LIST OF TABLES
List of tables
Table 1: Hospital waste generation rate in different Regions of the world, 1999. ............... 8
Table 2: Assumptions and given used for sample size calculation, 2014.. ......................... 23
Table 3: Summary of methods based on the objectives of the study ................................. 29
Table 4: Composition and generation rate of healthcare wastes based on the number of
total patients (kg/patient/day) in the nine study hospitals, Average with standard
deviation (SD) and percentage of hazardous waste, Amhara National Regional State,
Ethiopia, 2014......................................................................................................................... 37
Table 5: Composition and generation rate of healthcare wastes based on the number of inpatients
(kg/bed/day) in nine hospitals, Average with standard deviation (SD) and percentage of
hazardous waste, Amhara National Regional State, Ethiopia, 2014.. .......................................... 39
Table 6: Statistical characteristics of the model for referral public hospitals, Amhara
National Regional State, Ethiopia, 2014 (Equation 6). ............................................................. 44
Table 7: Statistical characteristics of the model for district public hospitals, Amhara
National Regional State, Ethiopia, 2014 (Equation 7). ............................................................. 45
Table 8: Statistical characteristics of the model for private general hospitals, Amhara
National Regional State, Ethiopia, 2014 (Equation 8). ............................................................. 46
Table 9: Composition and generation rate based on the number of inpatient (kg/bed/day)
of healthcare waste in Debre Birhan referral hospital before and after the implementation
of segregation practice, average with standard deviation (SD) and percentage of
hazardous waste, Amhara National Regional State, Ethiopia, 2014................................... 47
Table 10: Summary of the main findings, Amhara National Regional State, Ethiopia,
2014. ............................................................................................................................. 49

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