When we are beset with physiological problems, one thing more often than others come up.  We have to go to a hospital.  We have to consult a doctor there and undergo the tests that they have to do.  In short, the hospital for us is an institution of healing, a center for wellness.  We view hospitals more or less within this framework. 

Who among us would even dare think of the hospital as a source of very dangerous wastes capable of spreading an epidemic?  Well, the over-all operations of a health institution inevitably produce wastes.  These wastes, like ordinary wastes, have to be disposed.  This is the focal point of our study:  How do hospitals dispose of their wastes? 

This study aims to assess the current hospital waste disposal system in Davao City. This is intended to assist both the city and individual medical institutions to improve waste management. With our very limited resources we hope to awaken people’s awareness on the risks involved as well as to remind our authorities to come up with a well-designed waste policy that is both affordable and feasible. Hospitals have a duty to care for our environment and for public health in relation to the waste they produce.  Hospital waste includes all the wastes generated by health care establishments, research facilities and laboratories. Between 75% and 90% of the waste produced by hospitals is general waste comparable to domestic waste. The remaining 10-25% of waste produced is hazardous waste (Table 1). 

TABLE 1:      Categories of Health-Care Waste 
 
 

II. Statement of the Problem  

 
The Philippines, including Davao City, has no survey on hospital waste production. In the absence of this survey, the following estimates for the average waste distribution is useful for comparison: 

-80% general health waste, which may be dealt with by the normal domestic and urban waste management system; 
     -15% pathological and infectious waste; 
-1% sharps waste 
-3% chemical or pharmaceutical waste 
-less than 1% special waste 

As a take-off point, this data will serve as a basis for waste management evaluation within an individual health-care establishment.  In general, waste generation is lower in middle and low-income countries than in high-income countries. The amount of radioactive wastes produced is small as compared to a country with nuclear industry. 

All individuals exposed to hazardous hospital wastes are potentially at risk. The main groups at risks are the following: 

- medical doctors, nurses, paramedics, hospital maintenance  personnel; 
- patients in hospitals or receiving home care 
- visitors to health care establishments 
- workers in support services in hospitals 
- workers in waste disposal facilities including scavengers 
 An individual may get these potential hazards through the following: 
- through a puncture , abrasion, or cut in the skin; 
- through the mucous membranes; 
- inhalation; 
- ingestion. 
 
Hospital Directors and overseers are beset with various emergencies and other health related cases that other less crucial matters tend to be overlooked.  There are even times when a disregard of these crucial matters border on negligence and carelessness.  As in most cases, the negligence or carelessness of hospitals can lead to devastating ramifications. 

In the absence of any thorough scrutiny, Filipino hospitals in general and the hospitals here in Davao in particular would tend to be negligent or careless in their waste disposal.  True enough, there are as yet no reported epidemic resulting from improper waste disposal by hospitals.  However, it would be foolhardy to wait for adverse effects first and be vigilant later.  An ounce of prevention is always wiser than a pound of cure. 

III. Background of the Study 

For an accurate backgrounder, we have decided to quote excerpts from a paper done by Atty. Ramon Edison Batacan on the issue of hospital waste management entitled:  “HOSPITALS AS WASTE GENERATORS” 
 
 

Indeed, our group’s concern regarding the disposal of hospital wastes, triggered by the awareness bestowed upon us by the lectures in Environmental Law, has led us to focus on hospital waste disposal for our project.  We are citizens of Davao City who love Davao City.  We know that we are the ones who will be affected adversely should any crisis erupt from improper hospital waste disposal. 
  

IV. Objectives  

We aim to provide a critical analysis of the present conscientiousness of hospitals when it comes to waste disposal.  We shall, at the end of this endeavor, be able to answer the following questions: 

a. Is there a proper waste management program for every hospital in Davao City? 
b. Are there guidelines set by the Department of Health for proper hospital waste management? 
c. If so, are there hospitals that violate the above guidelines? 
d. If so, are there sanctions imposed for violators? 
e. Are there existing ordinances in Davao City specifically tailored for the waste disposal methods of hospitals and other health facilities? 
f. Finally, are Davao’s hospitals at par with hospitals nationwide or even internationally when it comes to waste management? 
 
 

V. Methodology 

We shall mainly rely on interview and ocular inspection of the hospitals we have selected to represent the entire health-care facilities of Davao City.  The data we will be able to gather shall be compared to the standards and criteria set by both the World Health Organization and the Department of Health. 

 A comparative study will then be done among the subject hospitals and consequently, an evaluation of their over-all waste management.  

VI. Scope and Limitation:  

VII. Body: 

1. National Level (please see attached copies) 

A. Department of Health Circular No. 152-C 

B.  Manual on Hospital Waste Management 
 
 
2. Local Level 

A. CENRO 

The City Environment and Natural Resources Office is the one in-charge in the collection of the general waste disposed off by the hospitals and clinics around the city. 

Wastes for the purpose of collection was divided into household waste, commercial waste, industrial waste. Waste coming from hospitals even though called “general waste”, falls under the category of an industrial waste. Hospital waste comprises only of two percent of the total industrial waste collected everyday. 

According to the CENRO, hospital and clinic monitoring should be done quarterly.  However, by their own admission, they said that this is not the case at all.  They were even proud that they were able to visit the hospitals and clinics twice last year (2000) not because it is there duty but because some of their employees who were on the graduate studies made a study on the matter. 

They also reported of cases wherein what hospitals considered as general waste sometimes contain needles and other sharp object.  In one case in fact, one of the garbage collector was stung by a needle in the leg while transferring the “general waste” from the transfer station to the truck. 

It is also from them that we found out that the water treatment plant located in the Davao Medical Center has no particular personnel to manage and maintain the facilities.  Good for now that it is new, but when the time comes that it would require some repairs or even a routine maintenance to extend the life of the treatment facility, there will be no money nor personnel for such activity. 

 
3. International Level 

International Agreements 

International agreement has been reached on a number of underlying principles that govern either public health or safe management of hazardous waste.  These principles should be taken into consideration when legislation and regulations governing health –care waste are formulated: 

· The Basel Convention on the Control of Transboundary Movements of Hazardous Wastes and Their Disposal (1989), signed by more than 100 countries, concerns transboundary movements of hazardous waste; it also applicable to health-care waste.  Countries that signed the Convention accepted the principle that the only legitimate transboundary shipments of hazardous waste are exports from countries that lack the facilities or expertise to dispose safely of certain wastes to other countries that have both facilities and expertise.  Exported waste should be labeled according to the UN recommended standard. The health-care waste producer is responsible for safe packaging and adequate labeling of waste to be transported off-site and for authorization of its destination.  Packaging and labeling should comply with national regulations governing the transport of hazardous wastes, and with international agreements if wastes are shipped abroad for treatment.  In case there are no such national regulations, responsible authorities may refer to Recommendations on the transport of dangerous goods, published by the United Nations. 

· The “polluter  pays” principle implies that all producers of waste are legally and financially responsible for the safe and environmentally sound disposal of the waste they produce.  This principle also attempts to assign liability to the party that causes damage. 

· The “precautionary” principle is a key principle governing health and safety protection.  When the magnitude of a particular risk is uncertain, it should be assumed that this risk is significant, and measures to protect health and safety should be designed accordingly. 

· The “duty of care “principle stipulates that any person handling or managing hazardous substances or related equipment is ethically responsible for using the utmost care in that task. 

· The “proximity” principle recommends that treatment and disposal of hazardous waste take place at the closest possible location to its source in order to minimize the risk involved in its transport.  According to a  similar principle, any community should recycle or dispose of the waste it produces, inside its own territorial limits. 
 

B.  HOSPITALS 

Davao Doctors Hospital 
(Interviewed March 1, 2001) 

HOSPITAL ACCREDIATION BY THE INTERNATIONAL STANDARDS ORGANIZATION 

The group visited Davao Doctors Hospital a month and a half prior the completion of this paper. We have prepared a questionnaire in connection with our project, but unfortunately, the said questionnaire was too long that the interviewees had no time to answer each and every item provided therein. So we limited our actual research with ocular inspections and to oral information given by the hospital staff. 

 The group was accommodated by the administratrix of Davao Doctors Hospital by the person of Mrs. Elizabeth Hilario Anzures. She is responsible for the administration of the entire hospital. In the course of the interview, we recently found out that Davao Doctors Hospital is already accredited by the International Standards Organization. The hospital has proven that it has an effective waste disposal management and such is being observed by the institution. The International Standards Organization conducts an inspection on the accredited institutions every six months in order to find out that the waste hospital management procedures are still complied with. It was also stated by Mrs. Elizabeth Hilario Anzures that Davao Doctors Hospital is only one out of three hospitals which the International Standards Organization has accredited. This is the reason why this hospital continuously looks for ways to derive effective waste disposal management . 

Administratrix Anzures, after answering some of our questions, then referred us to Mrs. Venus Sungahid the Head of Housekeeping of Davao Doctors Hospital. Administratrix Anzures assured us that Mrs. Sungahid had much more to share with regards to the hospital waste management than she has. 

Mrs. Sungahid showed us a waste disposal procedure which they have formulated for almost a year. This waste disposal procedure has been their pathway to get the accreditation from the International Standards Organization. Unfortunately, it is against hospital rules and regulations to provide copies to non-staff members, and for that we were not able to procure a hard copy. However, she was accommodating enough that she allowed us to scan the waste disposal procedures so that we may have enough idea on how they dispose wastes. 

HOSPITAL WASTE COLLECTORS AND SHIFTING SCHEDULE 
Hospital janitors play a great role in the hospital waste disposal. Hospital janitors, as part of the hospital wage management, are not actually directly hired by the hospital, but a janitorial agency provides the hospital with janitors. From time to time, the housekeeping department conducts seminars to monitor and evaluate the efficiency of these janitors and to instill in them new waste disposal procedures. There are about thirty-six (36) janitors in the hospital; thirty (30) are assigned in the hospital premises while the remaining six (6) are assigned to the medical tower. The janitors’ job in the waste disposal is in a shifting schedule from 6 a.m. to 3 p.m. and 3 p.m. to 11 p.m. respectively. As to the protective devices, the janitors are provided with gloves and mask to minimize contamination and different diseases that might affect their health. However, these protective devices do not totally prevent contamination that can be brought about by the garbage disposal nor assure safety to the janitors, they just minimize them. 

ROOMS, WARDS, AND THEIR RESPECTIVE WASTE SEGREGATION DRY AND WET WASTE SEGREGATION 
Davao Doctors Hospital has eight (8) wards all in all, delivery rooms, and operating rooms. Each of these wards has a similar waste segregation process. There are two kinds of Hospital waste segregation; namely, the infected/wet waste segregation and the dry waste segregation. The infected/wet wastes are placed in yellow garbage bags; dry wastes are stored inside a black garbage bag. These bags are then collected by the janitor by the use of a garbage cart with two large containers. One of the containers is for the infectious wastes while the other is for the dry wastes. The janitor collects these wastes from time to time and deposits them to the garbage area of the hospital wearing their protective devices; except that in the operating and delivery room, the janitors are required to wear special outfits in the waste disposal since all the garbage in these rooms are infectious or wet garbage. 
 
The 8 wards have 2 large containers each for the garbage, two large containers for each operating room and another two for each delivery room. In private rooms, each has two small garbage containers. One is placed in the comfort room which all the wet and infectious wastes are placed. And just beside the door is another container where the dry wastes are placed. These colored bags are then respectively placed by the collectors or janitors in the designated large containers on the garbage cart. The wastes are then thrown at the transfer station where the city garbage trucks collect them every morning to be finally brought to the city dumping area. Meanwhile some of the wet or infectious wastes are stored in a different area, and the hospital disposes them through different methods depending on the kinds of wastes. 

Some of the yellow container that contain infectious/wet wastes remains at the disposal of the hospital. These wastes, before being disposed, are soaked with chlorine mixture after which they are being forwarded to the transfer station, for city garbage trucks collection. 

SHARPS 
However sharps, such as needles and blades are segregated and placed in a puncture free plastic. They are being gathered in one area. After reaching a specified volume for disposal, these sharps are then brought to Ma-a Public Cemetery for burial. However, the sharps are burned first before being buried in order to eliminate possible contamination and infection. 

RADIOACTIVE WASTES 
With regards to radioactive containers, the hospital returns these containers to the suppliers, and it is the suppliers themselves who will take care of the disposal. 

Radioactive linens used by patients are allowed to decay by themselves. The hospital staff keeps these radioactive linens in a specialized room in order to minimize radiation. After a span of time, these linens are being placed in one place and left aside to decay. 

BLOOD DISPOSAL 
 Excess blood coming from patients and donations by other people are preserved for possible future use. Blood has two weeks before it expires, thus the hospital sees to it that the blood are being properly preserved. The excess usable blood are again donated to Davao Medical Center (DMC). However, unusable or contaminated blood is being drained down the sewer. 

EXPIRED DRUGS 
In the disposal of pharmaceutical expired drugs, the liquid or the syrup is being drained down the sewer; while tablets, capsules and other solid medicines are dissolved  first in hot water before being drained, or they are directly returned to the supplier for disposal. 

OPERATING ROOM WASTES 
Blood, placenta or other body parts that needs to be disposed are placed in the yellow bag and are part of the infectious/wet wastes. However, the hospital is personally responsible for its disposal. 
 
Before the enactment of the clean air act, the hospital used incinerators, but after the prohibition of its use, Davao Doctors Hospital is forced to recourse to their previous waste disposal of body parts or other infectious wastes. These body parts, before being transported to Ma-a Public Cemetery are being soaked with chlorine or formalin. They are then brought to the cemetery for burial. When these body parts reach the burial site, the hospital has no responsibility whatsoever in the supervision of its burial. The undertakers themselves make the plan or the area wherein these body parts and other sharps are to be buried. 

GARBAGE COLLECTION AND DISPOSAL 

I.   Purpose – to control and minimize infection at all time 
II.  Scope – covers the daily preparation, classification collection, identification and final disposal of hospital generated wastes 
III. Persons involved – housekeeping, janitorial agency, and janitors 
IV. Procedure 

Wastes generated from hospital rooms 
1. Each room has two (2) bags – instructions are posted on doors 
a.) wet wastes – comfort room 
b.) dry wastes – room 
2. Janitor collects everyday with the use of two big utility carts 
3. Left over food, spoiled diapers, sanitary napkins, used tissue, and dressing are segregated especially and collected as infectious wastes 
4. utility carts are then brought to the transfer station 
5. used disposable needles with syringe are placed in sharp proof container – final disposal will be in Ma-a Public Cemetery by burning and burying thereafter 
6. garbage from Intensive Care Unit (ICU), Coronary Care Unit (CCU), Pulmonary, Hemodialysis, Lab Units are collected as infectious wastes 
7. placenta and body parts are placed in  plastic bags with formalin – brought to Ma-a Public Cemetery for burial. The disposal of body parts is done every one to three months 
8. chlorine is placed in yellow plastic bags according to the Department of Health Standards 

GENERAL DISPOSAL OF EXPIRED MEDICINES 

1. tablets and capsules – dissolved in hot water and flushed down the drain 
2. liquid – emptied and flushed down the drain 
3. empty vials – pulverized and buried in the hospital lot or brought to public cemetery for burial together with the sharps 

SPECIFIC DISPOSAL OF EXPIRED MEDICINES 
IDENTIFICATION AND SEGREGATION OF EXPIRED MEDICINES 

· Inventory encoder generates a list of stock form items that expired during the month and the next six months to be printed out in four (4) copies every first Tuesday of the month 
· Inventory encoder shall forward one (1) copy of the list of the stock room items that expired during the month and the next six months to each of the following: 

(1) one copy – purchasing clerk 
(1) one copy  - pharmacy 
(1) one copy – stockroom 
(1) one copy – inventory 

· The pharmacy head and the stockroom head shall segregate the expired medicine from their respective shelves and classify them into returnable expired medicine and unreturnable expired medicine 

NON-RETURNABLE AND IRREPLACEABLE EXPIRED MEDICINE 
· If the replacement is not possible after one month of the expired date, the pharmacy head and the purchasing clerk shall endorse to the head of the committee on disposable of the non-returnable and irreplaceable unexpired medicines, and shall accomplish a report on non-returnable and irreplaceable expired medicines from a quadruplicate which indicates the following: 

1. Brand name of drug 
2. Quantity/unit 
3. Expiration date 
4. Unit cost 
5. Total cost 
6. Remarks 

· The pharmacy head shall endorse the non-returnable unexpired medicines report to the following for information:` 

1. Account/comptroller 
2. Administrator 
3. Housekeeping Head 
4. File 

· The Housekeeping Head shall dispose the expired medicines properly 

LABORATORY WASTE 
 
* LABORATORY SAMPLE DISPOSAL 

BLOOD 
· All used blood samples and body fluid specimen contained in test tubes and vials are placed in a container and treated with presept. After treatment, the blood samples shall be drained using a stainless strainer so as not to clog the designated sink. The remaining clotted blood shall be placed and sealed in a yellow plastic bag and place in the garbage bin. 

· The test tubes and vials are soaked in presept solution for one hour then cleaned with soap and water before thoroughly rinsed with tap water. 

· The test tubes and vials are place in an oven to dry and set aside for re use 

· Expired blood is properly disposed in a septic tank provided for blood. 

· The septic tank for blood is first lined with sawdust four (4) inches thick where blood is punctured and drained from the bags and an addition of sawdust applied enough to cover the punctured blood 

· Expired blood is disposed accordingly 

 URINE 

· Used urine samples are discarded in a designated sink. 
· Urine containers are soaked in presept solution for one (1) hour and cleaned with soap and water before thoroughly rinsed with tap water 

· Urine containers are placed in an oven to dry and set aside for reuse 
 

STOOL 

· The stool, including its container and glass slides are placed in a yellow coded plastic bag as described in Department of Health Hospital Waste Management Manual, which is sealed and brought by the janitor to the garbage bin. 
 

USED REAGENTS 

· Used reagents are discarded in a designated sink and flushed thoroughly with tap water. 

· Their containers are placed in a yellow coded plastic bag properly sealed and disposed by the janitor in the garbage bin. 

  In general, Davao Doctors Hospital follows their own procedures according to the International Standards Organization requirements and the Department of Health Hospital Waste Management Disposal. 

 Most of the wastes from this hospital are disposed by the government at the city dump site; whereas, some of the wastes are personally disposed of by the hospital at the Ma-a Public Cemetery. 

 It was shared to us by Mrs. Venus Sungahid, Head of Housekeeping, that the waste segregation process (color coding) is a lot of help in the waste disposal of the hospital; however, this process are sometimes not complied with specially with patients in the private rooms. She further added that there is a need for a stricter compliance with the waste disposal procedure as to avoid accidents and contamination. It is also a must that a more developed and effective procedure be formulated in order to have a systematic waste disposal management procedure. 

Davao Medical Center 
(Interviewed on March 5 and 12, 2001) 
With an 800 bed-capacity, Davao Medical Center is undoubtedly the biggest hospital in Davao City.  Tasked with keeping this gargantuan institution is Mr. Rodrigo Pepugal, the over-all dormitory manager and housekeeping supervisor. 

Waste management in the Davao Medical Center begins at the ward.  Its personnel and nurses are routinely trained, waste disposal included.  The training on waste disposal is most especially centered on janitors who are at the forefront of the waste management of the hospital.  However, it is conceded that a big portion of waste segregation is dependent on the cooperation of patients, their watchers, and visitors. For this purpose, they conduct weekly seminars for patients and watchers on, among other things, proper waste disposal inside the wards and private rooms. 

Despite this, however, there still is a big limitation on the management of their waste.  Receptacles for infectious wastes and general wastes are provided in every room of the hospital but the patients, watchers and visitors simply refuse to segregate. 
After collection of the wastes from the individual receptacles inside the wards and private rooms, they are then segregated and disposed according to their classification.  The radioactive wastes from the chemotherapy facilities in the hospital are taken by the suppliers themselves, thereby reducing the waste disposal problems of the housekeeping personnel. The infectious wastes such as needles and wastes coming from Rabies and A.I.D.S. patients go straight to the hospital’s incinerator (please refer to picture A).  The general wastes are dumped into the City Environment and Natural Resources Office transfer station (please refer to picture B).  Mr. Pepugal said that CENRO collects the waste from them at least once a day.  DMC also makes use of chemical disinfectants as well as microwave disinfectants for their infectious wastes (please refer to picture C). 

Other wastes come from the operating rooms, the delivery rooms, and the morgue.  These are generally made up of human organs.  For these, the Davao Medical Center has constructed a dump pit (12 feet X 12 feet X 12 feet) (please refer to picture D).  Its vast area ensures that they are able to dig a new pit when the old one is full (at least once a year). 
Davao Medical Center produces more or less 800 kilos of solid wastes a day.  Most of these come from the operating room and the Obstetrics and Gynecology department. 

Mr. Pepugal said that there are a lot of areas for improvement.  Among these is the segregation of waste from source.  There has to be a continuous promotion and upkeep of waste management consciousness among patients and watchers, as well as visitors.  This, coupled with ample signages, would greatly improve the problem with waste segregation. 
Finally, the Davao Medical Center is the only hospital in Davao City with a waste water treatment facility.  However, Mr. Pepugal said that the increasing costs in the upkeep and maintenance of the facility is slowly endangering its continuous operation.  As a matter of fact, we found very alarming signs that the Davao Medical Center is preparing to abandon the operation of the treatment facility. (please refer to picture E) 
 
 
 

San Pedro Hospital 
(Interviewed on March 9, 2001) 

At the San Pedro Hospital, we were able to interview Ms. Lourdes Raymundo, R.N. and Mr. Norberto Betita.  Ms. Raymundo is the head nurse responsible for infectious wastes while Mr. Betita is the Head of the Janitorial Services.  Their waste management is anchored on the color coding of wastes.  Like the Davao Medical Center, their waste management is largely dependent on the patients’ responsibility in disposing of their wastes properly.  Their color coding: 

a. Black-  dry/non-infectious (general) 
b. Yellow-  infectious wastes 
c. Green-  wet waste 
d. Red (puncture proof containers)-  sharp wastes (needles, scalpels) 

The black and yellow containers are found at the nurses’ station, as well as the red container. (please refer to picture F)  Inside the wards and private rooms, we found only green containers. (please refer to picture G)  We also found yellow containers inside the utility room. (please refer to picture H)  Finally, organs and tissues are buried in cemeteries as well as disposed through their septic tanks. 

Apart from the above information, we were not able to gather anything more during the interview.  The interviewees appeared to be in a hurry.  After the interview, we asked permission to inspect the premises of the hospital.  Upon an ocular inspection, we saw various instances of blatant disregard of the hazards and potential problems posed by the improper disposal of hospital wastes, most especially their sharps. (please refer to picture I). 
 
 
 

Brokenshire 
(Interviewed on March 7, 2001) 

 At the Brokenshire Hospital, we were able to talk to Dr. Jack Estuart, the Medical Director of the hospital.  According to him, their waste management disposal system is patterned from the Department of Health Manual. 

 Basically, they only have two kinds of wastes: mainly the general, and the biological.  These are collected by their house-keeping department and the general waste are directly collected by the City Environment and Natural Resources 
Office.  The biological wastes are placed in the septic tank located within the vicinity of the hospital. 

 General wastes according to them are those wastes that do not pose any health hazards such as leftovers, food wrappers, or those we can consider as household waste.  Biological wastes on the other hand are those wastes that have potential health hazard if improperly disposed of, such as, placenta, tissues, and other infectious wastes.  These they place in the septic tank without the necessary treatment to disinfect.  Except for sharp objects and glassware which they buried in the area within the hospital property sans the treatment to disinfect. 

 Collection of the garbage from the wards are done by the in-house janitors who has no particular training in proper health disposal except the basics in waste disposal given by the nurse in-charge of the housekeeping.  They depend on the color scheme on collecting the garbage but there is no way for them to know if the wastes were properly segregated by the patients or nurses.  The wards use black for their general waste, while the emergency rooms also use black for their dry waste. 
 One frustration we had in Brokenshire Hospital is that they did not give as a chance to have an ocular inspection of their septic tank and the collecting station for the general garbage.  Although they did not refuse directly, they gave us lame excuses so that we can not inspect these facilities. 
 
5.  Fabie General Hospital and Medical Mission Group of Hospital 
The Fabie General Hospital  - Multispecialty and Diagnostic Center is a 25-bed secondary hospital. It is primarily a maternity hospital where most of the admissions are normal deliveries and caesarian sections. There is no waste management team. There is no waste segregation with all the garbage classified as general waste including the placenta. Collection is done by the janitor or student-midwife and placed in a receptacle located near the emergency room entrance. 

The Medical Mission Group of Hospital Davao City (MMGH) is an 80-bed hospital. The waste management team is composed of the chief executive officer, infectious control nurse, chief medical technologist and the head of housekeeping department. Waste collection is done by the hired janitorial services. Waste segregation is by general waste to include wet and dry garbage and by infectious waste. Sharps and syringes are not recycled and are collected separately. Due to the lack of space there is no transfer station. The general wastes are placed in garbage containers located near the emergency room entrance. The CENRO collects the garbage daily usually early morning. The sharps, body parts, unused blood samples and blood sets are disposed by burying them at the vacant lot owned by MMGH located along J.P.Laurel Avenue. Previously, these wastes are disposed by incineration. It was stopped upon the order of DENR. 
 
 
 VIII. Conclusion 

Everything that we have encountered leaves much to be desired.  The Manual on Hospital Waste Management seems very idealistic when compared with the existing conditions among the hospitals here in Davao City.  As expected, the superficiality of compliance is very evident.  There is no real or serious dedication to the guidelines set by the Department of Health, much more the guidelines of the World Health Organization. 

First:  in the area of planning.  The World Health Organization, in Safe Management of wastes from health-care activities : “The formulation of objectives and planning for their achievement are important for improving health-care waste management at the national, regional, and local level.  Planning requires the definition of a strategy that will facilitate careful implementation of the necessary measures and the appropriate allocation of resources according to the identified priorities.  This is important for the motivation of authorities, health-care workers, and the public, and for defining further actions that may be needed.”  Without doubt, not one of the five hospitals we have interviewed passed this primary requirement.  In the interviews that we conducted, we have not heard nor seen a waste management plan or program.  At best, the hospitals merely segregate and separate the wastes into general and infectious without assigning personnel who are specially trained in handling them. 
Second:  in the area of implementation.  Most of the hospitals are chiefly dependent on the patients and their watchers for the most important part of waste management:  SEGREGATION.  Due to this major dependence, the hospitals have not gone beyond mere superficiality in their effective waste management.  The patients and the watchers are well beyond the control of hospital administrators and are therefore not to be relied upon in this area.  As enunciated by the WHO, “The key to minimization and effective management of health-care waste is segregation (separation) and identification of waste.  Appropriate handling, treatment, and disposal of waste by type reduces costs and does much to protect public health.”  Therefore, if at the first stage the hospitals have failed, they are bound to fail the other tests of proper waste management. 
Third:  in the area of supervision.  Not one among the five hospitals have a waste management monitoring team.  Even if, for argument’s sake, they have properly planned and properly implemented their waste disposal procedures, these could not be implemented in the long run without proper supervision.  As a matter of fact, none of the hospital administrators showed that they are strictly supervising the effectiveness of their waste disposal procedures.  This fact further strengthens the group’s opinion that proper waste disposal for these hospitals is a mere superficiality. 

Finally, the six questions we presented at the objective statement of this study shall be answered in the light of our observations, to wit: 

a. Is there a proper waste management program for every hospital in Davao City? 

Regrettably, we answer this question in the negative, no exceptions.  The Davao Medical Center’s waste disposal is based mainly on the segregation of wastes by the patients and their watchers.  It is without any established method of segregating its wastes.  The Davao Doctors’ Hospital claimed to have their own waste management program.  However, they refused to provide a copy of their program.  The San Pedro Hospital has no clear-cut plan on how they dispose their wastes, be it general or infectious waste.  The Brokenshire Hospital merely assigns their personnel to handle the hospital wastes.  Sadly, these personnel are not trained to handle the various wastes produced by hospitals.  The Fabie General Hospital and the Medical Mission Group of Hospitals do not practice waste segregation.  Therefore, the group concluded that these two hospitals do not exercise any form of waste management, not even superficially. 

b. Are there guidelines set by the Department of Health for proper hospital waste management? 

Yes, there are guidelines set, namely the MANUAL ON HOSPITAL WASTE MANAGEMENT.  However, these are mere guidelines that do not impose any penal clause for non-observance or violation.  They remain as guidelines which the hospitals in Davao City in particular and the Philippines in general do not feel obligated to follow.  In fact, a glance of Department Circular No. 152-C issued by the then Secretary of Health Dr. Juan Flavier states that “the guidelines…are [only] for information and guidance” and not for strict compliance, as they should be. 

c. If so, are there hospitals that violate the above guidelines? 

Had the guidelines been mandatory and not directory, all the hospitals we have studied are violators.  The Color Coding of wastes is very superficial and there is no real waste segregation among the hospitals.  Even though the wastes are disposed in different colored containers, the contents of these color-coded containers are all the same. 

d. If so, are there sanctions imposed for violators? 

Again, we have to answer in the negative.  There are no existing statutes providing for sanctions against violators because the Department of Health only issued Department Circular 152-C as a “contribution to World Clean-up Day” and not as a real order directed to hospitals around the country. 

e. Are there existing ordinances in Davao City specifically tailored for the waste disposal methods of hospitals and other health facilities? 

After extensive research, we found no existing ordinance enacted by the Davao City Council specifically tailored for the waste disposal methods of hospitals and other health facilities. 
 

IX. Recommendation 

Theory and practice are indeed two different things.  The first paragraph of the Foreword of the Manual on Hospital Waste Management provides: 

“Proper Management of hospital waste is a priority concern of the Department of Health, as it strives to ensure a health-promoting environment in a rapidly urbanizing society.” 

These are flowery words that evince admiration, if and only if they are put into practice.  Our study of the foremost hospitals in the city has left us disillusioned.  However, we still believe that something can be done.  Therefore, we humbly offer the following recommendations for future guidance of those who will care to listen. 

TRAINING 

A.  The public must be trained and educated on all the hazards linked to health care wastes through: 
· Poster exhibitions on hospital wastes issues including the risks involved in scavenging 
· Explanation by the staff of hospitals to incoming patients and visitors on waste management policies 
· Information poster exhibition at strategic points within the hospitals 

A. The hospital personnel including medical consultants, resident physicians, and hospital administrators and staff, must likewise be educated and trained themselves on proper hospital waste management. 

THE ROLE OF THE CITY GOVERNMENT 

 The city government should provide resources that will ensure proper disposal of hospital wastes.  These resources must be made accessible to hospitals and other health-care facilities.  We suggest the following options: 

· On-site treatment facility in each hospital or health-care facility 
· A regional or cooperative waste treatment facility supplemented by individual facilities of nearby hospitals 

The city should pass an ordinance specifically for hospital waste management with the following provisions: 

· A clear definition of hazardous hospital wastes and their specific categories in accordance with the standards set by the World Health Organization 
· A precise indication of legal obligations of hospitals and health-care facilities regarding safe handling and disposal of their wastes 
· Specification of an inspection system to ensure a strict enforcement of the ordinance 
· Penal clauses for violations 

THE ROLE OF THE HOSPITALS 
 
 The hospitals should establish a clear-cut plan suited for their individual waste management needs.  Furthermore, they should provide ample supervision to ensure that whatever programs of waste management they enact are properly implemented. 
 Corollary to these is the obligation of the hospitals to provide their workers with the proper clothing and equipment to handle the wastes generated by them.  They must also provide immunization, post-exposure prophylaxis and medical surveillance. 
 
THE ROLE OF THE DEPARTMENT OF HEALTH 

 The Department of Health should organize a well-funded, extensive, and in-depth study on the adverse effects so far of the wastes generated by hospitals and other health-care facilities.  Such a study will provide a standard with which hospitals around the country will base their waste management.  It should also include existing data on the major hospitals in the Philippines and how they have maintained proper waste management.