A Policy Framework for the Improvement of Health Care Waste ...

A Policy Framework for the Improvement of Health Care Waste Management in Indonesia

Sri Irianti B Sc (Environmental Health) BPH M Phil (Environmental Engineering)

Griffith School of Engineering Science, Environment, Engineering and Technology Griffith University

A thesis submitted in fulfilment of the requirements for the degree of Doctor of Philosophy July 2012


ABSTRACT Indonesia is a developing country in the South East Asian region (SEAR), with a total population of 237,641,326, in 2010, living in 33 provinces. In line with economic development and decentralisation of the health system, the number of health care establishments steadily increases to keep up with population growth and public needs. Institutions delivering health services, including hospitals and health centres (HCs), inevitably generate a tremendous amount of wastes, a fraction of which are infectious and hazardous. The majority of health care institutions do not manage their medical wastes, properly, to minimise their risks. Consequently, their wastes are unsafe for patients, health care workers, waste handlers and the general population. These can spread health care-acquired infections (HAI). The Government of Indonesia (GoI) enacted a number of laws and regulations to govern the implementation of sound environmental management, municipal solid waste management (MSWM), and hazardous waste management. However, there is no clear policy framework to ensure safe health care waste management (HCWM), in accordance with such laws and regulations. A cross-sectional study was carried out in 2010 to develop a suitable policy framework for sustainable HCWM. It employed concurrent mixed methods, including quantitative and qualitative inquiries, consisting of mailed survey questionnaires and in-depth interviews, waste audits and onsite observations. The mailed survey, using a structured questionnaire, reached 237 sample public hospitals across 27 provinces. In-depth interviews with relevant policy makers were conducted in eight hospitals, five HCs from five provinces, and four institutions at the central level, including the Ministries of Health (MoH), and Environment (MoE), as key stakeholders. The waste in eight large hospitals across five provinces was audited. A large hospital in Queensland, Australia, was studied for observable best practice of HCWM, as a lesson learned and a comparable case study. Regulations and policies governing HCWM of the Queensland Government, the implementation of the Waste Management Hierarchy (WMH), 3R‘s (reduce, reuse, and recycle), cleaner production (CP), privatisation of waste treatment and disposal, infection control program (ICP) and

Sri Irianti

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occupational health and safety, were examined. The researcher, importantly, observed the operative leadership in the overall HCWM in the hospital. IBM Statistical Programs for Social Science (SPSS) versions 19 and 20 were used to analyse quantitative data of 194 variables, to obtain descriptive and inferential statistics, whereas, qualitative data were analysed manually, using content analysis. The inferential statistics applied multivariate logistic and linear regression analyses. The research findings were presented as descriptive and inferential statistics, and triangulation results, to identify and explain a number of important variables for developing a policy framework. The descriptive statistics presented more than 100 variables of the current HCWM status, including hospital characteristics, waste generation per occupied bed per day, stages of the WMH, compliance with relevant regulations, 3R practices, resources and training, the availability of other programs within hospitals, such as, ICP, and health promoting hospitals (HPH). The medical waste generation ranges from 0.01 to 1.60 kg/bed/day with an average of 0.4395kg/bed/day. The inferential statistics analysis reveals that the determinants of general waste generation were: the number of inpatients (p