HEALTHCARE WASTES MANAGEMENT IN THE PHILIPPINES: Policies, Rules and Regulations and Status of Implementation 1 GERI GERONIMO R.

SAEZ2 BASELINE DATA With a population of approximately more than eighty (80) million and with the rapid industrialization, incidences of diseases are increasing. These are the health implications of environmental pollution brought about by the changing climate, lifestyles and modern technologies and modified consumer products. Thus, establishment of healthcare facilities and institutions are at present an imperative to cope up with the demand on healthcare services. Based on the 2003 survey and inspection conducted by the Environmental Management Bureau (EMB)-Regional Offices (ROs) of the Department of Environment and Natural Resources (DENR) and consolidated by the EMB Central Office (CO), there are about one thousand seven hundred nineteen (1,719) hospitals and medical centers nationwide and majority of which are located in the National Capital Region (NCR). Of these, only two hundred twenty seven (227) are registered with DENR-EMB as hazardous waste generator (HWG) in compliance with Republic Act (RA) 6969: Toxic Substances and Hazardous and Nuclear Waste Control Act of 1990 as shown in Table 1 below. Table 1. Regional Distribution of Unregistered Hospitals as Hazardous Wastes Generators (As of 2003) Region Registered Unregistered Total Number of Hospitals Hospitals Hospitals No. % No. % Total % of National Total Region 1 2 1.65 119 98.34 121 7.03 Region 2 2 2.43 80 97.56 82 4.77 Region 3 3 1.58 187 98.42 190 11.05 Region 4A 8 3.58 215 96.41 223 12.97 Region 4B 2 3.92 49 96.07 51 2.96 Region 5 12 9.91 109 90.08 121 7.03 Region 6 13 18.05 59 81.94 72 4.19 Region 7 7 6.60 99 93.39 106 6.16 Region 8 1 1.31 75 98.68 76 4.42 Region 9 1 1.54 64 98.46 65 3.78 Region 10 18 18.94 77 81.05 95 5.52 Region 11 35 31.53 76 68.46 111 6.45 Region 12 9 9.47 86 90.52 95 5.52 Region 13 8 13.33 52 86.66 60 3.49 NCR 98 53.55 85 46.44 183 10.64 CAR 8 16.00 42 84.00 50 2.90 ARMM 0 0 18 100.00 18 1.05 National Total 227 13.20 1,492 86.79 1,719 100.00
Source of data: EMB GPOA: 2005-2010.

Country Report presented during the 1 Thematic Working Group on Solid and Hazardous Waste on 28-29 February 2008 in Singapore 2 Chief, Hazardous Waste Management Section, Environmental Quality Division, Environmental Management Bureau, Department of Environment and Natural Resources, PHILIPPINES

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However, the most recent consolidated compliance data (2007) revealed that there are already one thousand nine hundred fifty two (1,952) healthcare facilities (medical centers, hospitals and clinics) registered as HWGs nationwide which is about 21.21% of the total registered hazardous waste generators that include among others major industries and environmental laboratories. Table 2 shows the three (3) year consolidated registration data on HWGs. It is noticeable that as of December 2007, it exceeded the total number of healthcare facilities ad hospitals conducted in 2003 that indicates additional facilities either newly constructed or come to compliance with environmental regulation. Table 2. Number of Registered Hazardous and Healthcare Wastes Generators in the Philippines (2005-2007) Year Industrial Healthcare Percentage (%) Total Generators Grand Total (as of..)
Source: EMB Regional Offices

2005 1,250 606 32.65 1,856 5,657

2006 1,081 514 32.23 1,595 7,252

2007 1,720 232 13.49 1,952 9,204

Total 4,050 1,352 25.02 5,403

According to the website of the Philippines Department of Health (DOH) [www.doh.gov.ph], the following healthcare facilities and services are being regulated by its Bureau of Health Facilities and Services (BHFS) in coordination with Centers for Health Developments (CHDs): ambulatory surgical clinic, blood bank, clinical laboratory, dental laboratory, dialysis clinic, drug abuse treatment and rehabilitation center, drug testing laboratory, health maintenance organization, HIV testing laboratory, hospitals, kidney transplant facility, laboratory for drinking water analysis, medical facility for overseas workers and seafarers, newborn screening center and psychiatric facility. At present, there are about seventy (70) DOH hospitals, medical centers and reference laboratories nationwide and most of which, twenty one (21), are located in the NCR (Metro Manila). Among the hospitals and medical centers located in Metro Manila are: the Philippine Childrens Medical Center (PCMC), the National Kidney Institute (NKI), the Lung Center of the Philippines (LCP), the Philippine Heart Center (PHC), the San Lazaro Hospital (SACCL)-HIV Reference Center, the Philippine Orthopedic Center (POC), the National Center for Mental Health (NCMH), and the Research Institute for Tropical Medicine (RITM). With regard to the categories, classification, scale and level of services offered by hospitals and healthcare facilities, the DOH classified them as government or private, general or special and according to service capability. Government hospitals or healthcare facilities are operated and maintained partially or wholly by the national, provincial, city or municipal, or other political unit, or by any department, division, board or agency thereof while the private is established and operated with funds through donation, principal, investment, or other means, by any individual, corporation, association, or organization. General hospitals or medical centers provide services for all types of deformity, disease, illness or injury while special hospitals and other healthcare facilities are primarily engaged in the provision of specific clinical care and management. A primary, secondary and tertiary care hospital or medical center or infirmary may provide special clinical services. With regard to the service capability of hospitals, medical centers and other healthcare facilities, the following are DOH classification and criteria in relation to the categories, scale and level of services offered: a. Primary Care Non- departmentalized that provides clinical care and management on the prevalent diseases in the locality;

Clinical services include general medicine, pediatrics, obstetrics and gynecology, surgery and anesthesia; Provides appropriate administrative and ancillary services (clinical laboratory, radiology, pharmacy); and Provides nursing care for patients who require intermediate, moderate and partia category of supervised care for 24 hours or longer.

b. Secondary Care Departmentalized hospital that provides clinical care and management on the prevalent diseases in the locality, as well as particular forms of treatment, surgical procedure and intensive care; Clinical services provided in Primary Care, as well as specialty clinical care; Provides appropriate administrative and ancillary services (clinical laboratory, radiology, pharmacy) and Nursing care provided in the Primary Care, as well as total and intensive skilled care. c. Tertiary Care Teaching and training hospital that provides clinical care and management on the prevalent diseases in the locality, as well as specialized and sub-specialized forms of treatment, surgical procedure and intensive care; Clinical services provided in the Secondary Care, as well as sub-specialty care; Provides appropriate administrative and ancillary services (clinical laboratory, radiology, pharmacy); and Nursing care provided in the Secondary Care, as well as continuous and highly specialized critical care. d. Infirmary A health facility that provides emergency treatment and care to the sick and injured, as well as clinical care and management to mothers and newborn babies. e. Birthing Home A health facility that provides medical service on pre-natal and post-natal care, normal spontaneous delivery, and care of newborn babies. f. Acute-Chronic Psychiatric Care Facility A health facility that provides medical service, nursing care, pharmacological treatment and psychosocial intervention for mentally ill patients.

g. Custodial Care Psychiatric Facility A health facility that provides long-term care, including basic human services such as food and shelter, to chronic mentally ill patients. On the healthcare waste generation rates, characteristics, composition, collection, storage and transportation system, Table 3 shows the profile of the three (3) year estimated or reported and consolidated data on generated, treated, disposed and stored healthcare wastes in the Philippines. These data are reported by the registered HWGs to the EMB-ROs in compliance with RA 6969 implementing rules and regulations. For the year 2007, the consolidated data reported are for the first three (3) quarters. The composition and characteristics of healthcare wastes are in conformance with the classification of hazardous wastes under Table 1-1: Classification of Hazardous Waste of the Department Administrative Order (DAO) 2004-36, the Procedural Manual on Title III of DAO 1992-29 Hazardous Waste Management. Healthcare wastes are classified under DAO 2004-36 as Miscellaneous Wastes Pathogenic or infectious wastes and Pharmaceuticals and drugs

with assigned Waste Numbers M501 and M503, respectively. M501 includes pathological wastes i.e., tissues, organs, fetuses, bloods and body fluids, infectious wastes and sharps while M503 includes expired pharmaceuticals and drugs stocked at producers and retailers facilities. Table 3. Approximate Annual Hazardous and Healthcare Wastes Generated, Treated, Disposed and Stored in the Philippines (tons/year) [2005-2007] Year Hazardous Wastes Generated Miscellaneous (Healthcare) Waste Healthcare Wastes Treated Healthcare Wastes Disposed Healthcare Wastes Stored Hazardous Wastes Treated Hazardous Wastes Disposed Hazardous Wastes Stored
Source: EMB Regional Offices

2005 1,670,180.02 798,033.67 797,495.69 797,565.88 475.21 1,095,339.20 956,749.40 660,494.79

2006 11,786,052.68 912,724.45 906,908.99 886,571.94 26,425.24 1,473,129.92 1,051,021.53 2,093,431.31

2007 569,015.92 1,945.01 1,866.95 1,119.86 2,879.24 241,073.50 618,802.95 84,304.42

Although other hazardous wastes are classified under miscellaneous waste such as M502 (Friable Asbestos Waste), M504 (Pesticides), and M505 (POPs-persistent organic pollutants), most and majority of the quantities quarterly reported belongs to M501 and M503. Collection and transportation of these wastes are regulated and requires the necessary registration of hazardous waste transporters from the EMB-CO and secure the required permit to transport processed and issued by the EMB-RO including the submission of the manifest of each transport. The required and acceptable type of conveyance for the transport of healthcare waste is either a refrigerated van or closed van. Permit to transport is only issued to a registered transporter with a service agreement with a registered TSD with approved treatment, storage and disposal method. As of February 2008, there are sixty-one (61) registered hazardous waste transporters capable of transporting healthcare waste as contained in the Hazardous Wastes Tracking System (HWTS) and most of these are operating or servicing the NCR and Region 4A (CALABARZON). The HWTS, database established and being operationalized at the EMBCO, is updated regularly to further capacitate it in extracting data and information specific to the waste class of interest, quantities generated, and the treatment and disposal method employed. The HWTS also hosts the data and information on the registered hazardous wastes transporters and TSD facilities in the Philippines. Since the Effectivity of the Philippine Clean Air Act of 1999 (RA 8749) through its implementing rules and regulations (DAO 2000-81), only non-burn technologies are allowed to be used in the destruction, treatment and disposal of biomedical (healthcare) and hazardous wastes. Section 20 of RA8749 provides the regulatory Ban on Incineration of municipal, biomedical and hazardous wastes. The allowed non-burn technologies in the destruction of healthcare wastes must comply with the criteria and emission standards on non-burn technologies provided in Rule 28 of DAO 2000-81. Non-burn technologies include thermal treatment i.e., pyrolysis, autoclave, hydroclave, microwave and sterilization. The HWTS registered, as of February 2008, about twenty-four (24) TSD facilities that employs or uses non-burn technologies as well as encapsulation and solidification in the treatment of healthcare wastes and expired pharmaceuticals and drugs. Final disposal of the treated healthcare wastes and residues are in authorized landfill with specific cell for it.

INSTITUTIONAL ANALYSIS The EMB, central and regional offices, is the responsible and primary regulatory agency mandated by law in the Philippines in relation to healthcare waste management i.e., collection, transport, treatment, storage and disposal. The EMB is tasked to enforce the requirements and procedures including the permitting system on healthcare management. Registration of healthcare facilities as hazardous waste generators are done at the EMBROs where the facility is located as well as the processing and approval of permits to transport of such waste. At the EMB CO, it is tasked to evaluate and approved applications for registration as hazardous waste transporter with specific capability (handling) and the required type of conveyance as well as the registration of TSD facility with specific appropriate technology for the treatment and disposal of healthcare wastes. Licensing and issuance of permit to operate healthcare facilities such as hospitals, medical centers, clinics, etc., is the responsibility and mandate of the Bureau of Health Facilities and Services (BHFS) of the Department of Health (DOH). Its vision is to set regulatory policies and standards, as mandated of the licensing, accreditation and monitoring of health facilities and services to ensure quality of health care. The following are its functions: a) sets standards for regulation of health facilities and services; b) disseminates regulatory policies and standards for information and compliance; c) issues permits to construct, license to operate, clearance to operate HMOs and certificate of accreditation; d) ensures sustainability of health facilities compliance with regulatory standards; e) provides consultation and advisory services to stakeholders regarding health facilities regulation; and f) develop and conducts research relative to regulation of health facilities and services. The BHFS has three (3) main divisions, namely: Standards Development Division, Licensing and Accreditation Division, and Quality Assurance and Monitoring Division. The Bureau of Health Devices and Technology (BHDT)-DOH, on the other hand, develops plans, policies, national objectives, programs, projects and strategies for regulating health technologies, medical and health devices and facilities and other health-related devices that may pose hazards to human health. Policies and Legislations RA 6969: Toxic Substances and Hazardous and Nuclear Waste Control Act of 1990, is at present, the only legislation in the Philippines that regulates healthcare waste. Its implementing rules and regulations, most recent is DAO 2004-36, classifies healthcare waste under Miscellaneous Waste with waste number M501 that includes pathological wastes (tissues, organs fetuses, bloods and body fluids), infectious wastes and sharps. It also classifies expired pharmaceutical and drugs as hazardous waste with waste number M503. In an effort to strengthen and streamline policies, rules and regulations on healthcare waste management, the Joint Administrative Order (JAO) No. 02, series of 2005, Policies and Guidelines on effective and proper handling, collection, transport, treatment, storage and disposal of health care wastes is issued by the DENR and DOH in 24 August 2005. The JAO is issued pursuant to the following laws, rules and regulations: a. b. c. d. Clean Air Act of 1999 (RA 8749) Toxic Substances and Hazardous and Nuclear Waste Control Act of 1990 (RA 6969) Ecological Solid Waste Management Act of 2000 (RA 9003) Refuse Disposal of the Sanitation Code of the Philippines [Chapter XVIII, Implementing Rules and Regulations, Presidential Decree 856] e. Clean Water Act of 2004 (RA 9275)

f. Environmental Impact Statement (EIS) System (PD 1586) g. Hospital Licensure Act (RA 4226) Among the objectives of the JAO 2005-02 is a) to provide guidelines to generators, transporters and owners or operators of treatment, storage, disposal (TSD) facilities of healthcare waste on the proper handling, collection, transport, treatment and storage thereof; b) to clarify the jurisdiction, authority and responsibilities of the DENR and DOH with regard to healthcare waste management; and c) to harmonize efforts of the DENR and DOH on proper healthcare waste management. Under the JAO 2005-02, health care wastes include all wastes generated as a result of the following: 1. 2. 3. 4. Diagnosis, treatment, management and immunization of humans or animals; Research pertaining to the above activities; Producing or testing of biological products; and Waste originating from minor or scattered sources (i.e. dental clinics, alternative medicine clinics, etc.)

The categories of healthcare wastes are: general waste, infectious wastes, pathological waste, sharps, pharmaceutical wastes, genotoxic wastes, chemical waste, waste with high content of heavy metals, pressurized containers, and radioactive waste. With regard to the responsibilities of implementing and cooperating agencies, the JAO shall be implemented by the DENR through EMB and its Regional Offices, the National Solid Waste Management Commission (NSWMC) and by the DOH through Center for Health Development (CHD), BHFS, BHDT, the National Center for Disease Prevention and Control (NCPDC), the National Center for Health Facility Development (NCHFD), and the National Reference Laboratory (NRL)-East Avenue Medical Center in Quezon City. The following are some of the main responsibilities enumerated in the JAO, to wit: DENR-EMB shall: 1. Be the primary agency responsible for implementing pertinent rules and regulations on the management of healthcare waste in the Philippines, particularly concerning the issuance of necessary permits and clearances for the transport, treatment, storage and disposal of such wastes as governed by RA 6969, RA 8749, RA 9275, RA 9003 and PD 1586. 2. Formulate policies, standards and guidelines on the transport, treatment, storage and disposal of healthcare wastes. 3. Require TSD facility operators and on-site treaters to present to the DENR copies of the results of microbiological tests on the healthcare waste treated using autoclave, microwave, hydroclave and other disinfection facilities prior to the renewal of their Permits under RA 6969. DOH shall: 1. Regulate all hospitals and other health facilities through licensure and accreditation under the Hospital Licensure Act (RA 4226). 2. Require all healthcare waste TSD facility operators and healthcare waste generators with on-site waste treatment facilities to use DOH-BHDT registered equipment or devices for the treatment of healthcare wastes. 3. Issue Department Circulars to ensure that all environmental requirements are complied with.

4. Notify DENR on actions taken on cases of non-compliance or notice of violation issued to healthcare facilities, institutions and business establishments. DOH-Centers for Health Development shall: 1. Advocate healthcare waste management (HCWM) practices to the Local Chief Executives, key leaders and stakeholders. 2. Provide technical assistance on HCWM through training, advisory on the preparation of HCWM plans as a requirement for licensing or renewal thereof, dissemination of policies, guidelines and information, ensure compliance by healthcare waste generators with all pertinent laws, rules and regulations. Further, the JAO sets the specific criteria, standards, and guidelines on: a. Handling, Collection, Storage and Transport b. Treatment (thermal, chemical, irradiation, biological process, encapsulation and inertization) c. Final Wastes Disposal Systems and Facilities (Controlled Dump Facility, Sanitary Landfill facility, Safe Burial on Healthcare Facility Premises, Sharps and Syringes Disposal through Concrete Vault) d. Wastewater Treatment Facility. INTERNATIONAL AND REGIONAL INITIATIVES Currently, there are no interventions of multilateral organizations, international collaborative programs and local and regional research institutes on healthcare management in the Philippines. Since the Philippines is a contracting party to the Basel Convention on the Transboundary Movements of Hazardous Wastes and their Disposal and the domestic legislation in place, RA 6969, there is no documented illegal disposal of healthcare waste except for an incident in 1999. However, international Non-Governmental Organizations (NGOs) like Greenpeace, Healthcare without Harm (HCWH), and Global Alliance on AntiIncinerators (GAIA) are very vigilant and active in monitoring healthcare wastes treatment and disposal including the use of treatment technology and disposal methods. They are also very active and supportive on some legislative and policy formulation of the government. AREAS FOR ACTION In the Philippines, laws, rules and regulations are in place with respect to healthcare management. However, the following are still necessary to further strengthen enforcement of policies, rules and regulations on healthcare management: Capacity building for the TSD facility operators on new or best available technology (BAT) for environmentally sound management of healthcare wastes Implementation of capacity building needs and awareness program among healthcare facilities on the importance of pollution prevention through waste minimization Harmonization of different agencies policies, rules and regulations pertaining to healthcare waste management through enactment of a law with specific provisions on healthcare wastes Exchange of information and establishment of a regional database on healthcare waste management technologies and strategies

RECOMMENDATIONS Regional exchange of information and experiences on healthcare waste management through the conduct of focus group discussions (FGDs), seminars, workshops, meetings, etc. Conduct of regional trainings on healthcare waste management with special attention on best available treatment technologies, packaging and handling procedures, best and safe disposal methods. Involvement of International Funding Institutions for the financial aspects of healthcare management.

REFERENCES 1. www.emb.gov.ph 2. www.doh.gov.ph 3. DENR Administrative Order 36, Series of 2004: Revising DAO 29, series of 1992, to further strengthen the implementation of RA 6969 (Toxic Substances and Hazardous and Nuclear Waste Control Act of 1990) and Prescribing the Use of the Procedural Manual. 4. DENR-DOH Joint Administrative Order No. 02, Series of 2005: Policies and Guidelines on effective and proper handling, collection, transport, treatment, storage and disposal of health care wastes 5. EMB Hazardous Waste Tracking System (HWTS)- database on hazardous waste management