The key to minimization and effective management of HCW is segregation and identification of waste. Segregation means the separation of the HCW into different categories. Wastes are separated to reduce risks associated with HCW and minimizing costs of waste treatment and disposal by reducing the volume of infectious waste generated. Segregation is most effective when done at the site of waste generation. The correct segregation of waste at the point of generation depends on a clear protocol for the identification of different categories of waste and disposal methods.

To encourage the segregation at source, reusable waste containers or baskets with liners of the correct size and thickness should be placed as close as possible to the point of generation (Table 1). They should be color-coded and have specific symbols marked on them, for example, yellow or red for infectious waste [1].

Separating hazardous from non-hazardous waste one can dramatically reduce the volume of waste that requires specialized treatment. Other elements of healthcare waste management include waste classification, waste minimization, containerization, colour coding, labeling, signage, handling, transport, storage, treatment and final disposal. To maintain such a system requires continuous training, planning, budgeting, monitoring, evaluation, documentation and record-keeping.

Direct observation revealed that waste was collected in different types of waste bins. There was no form of color coding to indicate the type of waste to be deposited in a particular waste bin. There was no provision of weighing scales for

Source: [10].

measuring the weight of wastes generated at any of the wards or locations that waste were collected. As a result it is impossible to determine precisely the quantity of waste generated in the health facility. Sharp waste segregation was done in the wards. No other form of waste segregation occurs at any level and no strategy is in place for waste minimization. Temporal storage of waste occurs in the receiving receptacles or waste bins which are emptied daily or more frequently depending on the filling rate. Waste is collected daily by ward attendants and cleaners for dumping directly from storage receptacles or bins (Figure 1).

According to the results that was conducted during the survey most of the facilities at all levels had containers for three categories of HCW that is, highly infectious, infectious and non-infectious. A good observation was among the regional hospital (100%), followed by district facilities (94%) and finally health centres (92%) (Figure 2).

It was further observed that even though HCW sorting at the point of generation was fairly practiced, safe management is still challenged by the lack of consistent color coding for separate waste types and disposal mechanisms separately. Therefore there is a potential for diseases infection at the wards and units and also at the storage points when sorted by waste handlers, as well as at disposal points by scavengers. A study conducted on two hospitals in Tanzania showed that at least 25% of the medical waste in the two hospitals was not sorted at the source [11].

The findings from Figure 3 show that there were variations between the number of facilities and availability of standard waste bins. The standard waste bins according to the assessment guide were those which are color-coded.

The situation was not good in Simiyu and Shinyanga Regions where availability of standard waste bins was below 50% of the facilities (40.4%) and (40.3%) respectively. The situation was worse in Pwani Region as only 22.4% of the facilities had standard waste bins. Most of the waste bins observed were coded into red colour (for highly infectious waste), yellow color (for less infectious waste), and black colour (for non infectious waste), as well as safety box (sharps). However, there were a few cases where blue bins were used for black bins. In Kilosa District Hospital, there were even green waste bins for black or green colour coded bins. There were also cases of improvised waste bins in some hospitals like Mtwara DC in Mtwara and Kalambo DC in Rukwa region.

Alongside standard waste bins, assessing the availability of bin liners also was of a great importance due to the role they play in healthcare waste management. Figure 2, capture distribution of bin liners in the surveyed facilities. The availability of bin liners is not different to the distribution of waste bins in the healthcare facilities assessed.

This can be evidenced from the regions like Kigoma, Geita, Tanga and Arusha. However, Pwani, Ruvuma and Lindi regions were the most vulnerable to shortage of bin liners (30.7%, 23.3%, and 12.7% respectively) compared to the rest of the regions. The shortage of bin liners risks healthcare management practices as waste handlers had to use waste bins to carry the generated healthcare wastes.

The assessment on adherence to national standards and guidelines on waste segregation was extended to onsite verification, where assessment team conducted

visual inspection of compliance practices on site. In the overall 64.3% of facilities were in compliance with national protocols was; of the remaining facilities 5.3% did not comply with the protocols at all and the remaining complied partly only. Table 2, present assessors’ judgment on adherence to segregation protocols in visited facilities.

Observations of non-adherence to waste segregation protocols are in line with other similar studies [12] [13]. A well-functioning waste segregation protocol provides no chance for sorting through waste before disposal after it has been placed in a bin. A study done to healthcare workers from five hospitals in Southern Ethiopia found that only 53.8% of healthcare workers practiced healthcare waste segregation [12]. It was also noted that, the self-reported practice of healthcare waste segregation is correlated with the presence of onsite waste segregation receptacles. Similar practice was observed in a study done to five hospitals in Ghana, where colour coding practice was also inconsistent across the health facilities [13].

In addition, a survey conducted on medical waste management systems in the low-level health facilities (LLHFs) in Dar es Salaam [9]. The results showed that the segregation of waste in some of the surveyed LLHFs follows the national guidelines and are performed properly, even though sharp wastes are mixed with general waste during incineration and in some facilities, segregation is not perfectly performed despite the availability of specific containers for waste collection.

The results showed that the segregation of waste in some of the surveyed LLHFs follows the national guidelines and are performed properly, even though sharp wastes are mixed with general waste during incineration and in some facilities, segregation is not perfectly performed despite the availability of specific containers for waste collection.

After the transportation of healthcare wastes to the disposal site, the wastes should be disposed properly to avoid the risk of environmental pollution and public health problem. Each class of HCW requires specific treatment. Infectious

HCW can be treated to reach the level of infectiousness that is considered acceptable. Infectious waste can be treated on-site or off-site.

The most preferable solutions for safely disposal of all forms of hazardous, pharmaceutical, and medical waste is having functioning and effective incinerator for preventing the transmission of blood borne pathogens from exposure to needle stick injuries. Figure 4 shows the percentage distribution of the surveyed health facilities using incinerator for waste treatment methods in Region, District hospital and Health centers.

In this Study it was revealed that some HCFs use disposal methods that are not recommended by the national guidelines. Some HCFs use improper methods to dispose of HCW such as burning the waste in an unprotected environment. They did not have a specific designed ash pit, and they dispose off either in placenta pit, latrine opening, or open dumping [14]

Findings of the study (Figure 4) have shown that some of the surveyed facilities have incinerators for medical waste treatment and disposal. The highest numbers of incinerators were found in Region Referral level (75%) and the lowest was in District hospital level (40.7%) while in Health centres (45%). This was assumed to be due to availability of resources either from Ministry or donors who inject funds to Regional levels and not district or healthcare facilities. This also was observed a large number of the health facility used open pit burning for HCW (39%), which is not advisable. due to the fact that this is an expensive technology therefore, it is not easy for the Government to supply incinerators to all facilities at district and lower level facilities [4]. Though the study shows availability of incinerators at all levels the survey intends to determine if the incinerator in respective HCF is functioning or not. The surveyed health facilities have an incinerator either high tech or De Montfort Mark II for healthcare waste treatment and disposal (Figure 5).

The findings of the study show that majority of the surveyed HCFs in the three levels of health facilities which indicated to have an incinerator most of the incinerators are not functioning within the respective health facilities. At region level only 41.7% are functioning, while at district level only 29.6% and health centre 38.27% have incinerators which are functioning.

However, the capacity of these incinerators is very low compared to volume of healthcare waste generated per day. In the study another study conducted earlier (Honest et al., 2020), indicated that majority of incinerators used in Tanzania have low waste holding capacity with an average of 125 kg/hour, while the rate of healthcare waste generated in all hospitals goes up to 3,250 kg/day. Therefore, to minimize the healthcare waste generated in the surveyed facilities the management opt for other alternatives including burning structures and opening air burning (Figure 6(a) & Figure 6(b)).

For the pathological waste most of the facilities used the placenta pits (Figure 7(a)

& Figure 7(b)).

Treatment of medical wastes aims at minimizing exposure of workers to hazards and infections from the point of generation to disposal [6] [14] [15]. This observation calls for the need of allocating funds for waste management from either from the Ministry of Health or donor agency on the importance of treating infectious wastes in order to safeguard environmental and public health. It also calls for enforcement of waste management regulations, which require that infectious wastes are treated before disposal.

Most of the incinerators have worn out chimneys or were made without chimneys, and most of the incinerators lack covers for the waste feeding door and in the ashes removing door. It is just in few facilities in which the disposal sites with incinerators are fenced and located far from the human settlement areas. Most of the incinerators have no ash pits for ashes collection, thus 46.7% of the surveyed facilities. In practice it is contrast to the standard specified by guidelines incinerators usually are located within 10 to 30 m of clinics/hospitals for reasons of convenience, management, etc., and they often are located adjacent to or within populated areas. Only 19.4% have ash pit and only 28.6% are accessible to users (Figure 8).

Figure 9 shows that, majority of incinerators 82.1%, 87.1% and 83.9% (Regional, district and Health center respectively) have non-functioning incinerators which give an indication of unsafe treatment and disposal practices for healthcare waste management. Unsafe HCW treatment and disposal practices are the root cause cross contamination and infection which pose a high risk to health of the community and healthcare workers.

Figure 10 indicated that very few 3.2%, 4.2% and 10.7% (health center, district and regional respectively have means of transporting municipal waste generated in the respective HCFs to dumpsite.

These unsafe practices are unacceptable and do not comply with the National Policies and Standards for Managing HCW. It is the duty of the HCFs to ensure waste generated during healthcare services are treated and disposed of in a safe method. This unsound practice usually happens when the hospital incinerator is not functioning and, in most cases, the available option could be open burning or take it to dumpsite. Majority of the dump site are uncontrolled and thus invite for scavengers who sort valuable items for safe or recycling. This pose a high risk through cuts, needle stick injuries, spills and site/surface contamination. Figure 11 indicated that few (5.1%) Transport HCW to Offsite Treatment and Disposal. The approach and Method are currently widely advocated as the best approach as it minimizes cost of HCW handling and disposal. However currently the method is not currently available in many hospitals thus few have access to offsite/centralized healthcare waste treatment and disposal.

Another study elsewhere indicated that the main disposal methods comprises of open pit burning (50%) and burying (30%) of the waste [16]. Furthermore, in that study it was revealed that a large proportion (71%) of the hospital use dust bins for transporting the waste from generation point to disposal site without plastic bags and most hospitals had low incineration capacity, with few of them having fire brick incinerators (Table 3 and Table 4).

All hospitals that were involved in this study had placenta pit. However studies indicate that anaerobic digestion process of pathological waste like human placentas can be used as an alternative source of energy (biogas generation) while digesting the solid pathological waste activated with food staffs (food remains) [17].

Figure 12 indicated majority of the HCFs assessed has shortage of PPEs supply for use by waste handlers.

The inadequate supply of PPEs put Healthcare workers at risks due to nature of work. The shortage of PPEs supplies is more critical at regional and district level attributed by high consumption of PPEs compared to Lower level facilities.

The percentage of PPE available per different categories is shown in Figure 13. With respect to the use of personal protective equipment (PPE), all the respondents reported use of gloves, Apron, Caps, google, Masks were the most common protective gear used. The provision of the PPEs was observed at 76% followed by appron (91.7%) and aprons (90.2%). However, all respondents reported that there was shortage of PPE in their facilities, implying that the workers are exposed to occupational hazards or risks due to inadequate protection during handling hazardous wastes.

The study indicated that the majority of the facilities (64.3%) were in compliance with national protocols, while 35.7% were either non-compliant or partially compliant. The highest number of incinerators is found in Region Referral level (75%), followed by the district level hospitals (40.7%) and Health centers (45%). In the absence of adequate waste incineration facilities, a larger number of the lower-level health facilities are practicing open pit burning of health care wastes (39%), which contributes to unnecessary exposure of health care workers, patients, and visitors to potentially hazardous or toxic chemicals leading to chronic public health and environmental impacts.

The study concluded that there was low compliance with standard HCW management. It was recommended that possession of HCW management guidelines, staff training on HCW disposal and provision of requisite equipment for proper treatment of HCW would promote environmental safety in HCW disposal. MoHCDGEC in Collaboration with partners should support and provide capacity building in all HCFs across the country on HCWM and WASH services. There is therefore the need for creation of more awareness and devotion of more resources to the management of HCW among healthcare facilities in Tanzania. Due to high volume of HCW that is daily generated, healthcare facilities must have workable and sustainable means of managing their large spectrum of wastes in a way that ensures utmost environmental and human safety. Finally, ensuring adequate supply of power and water is critical for HCW management in Tanzania. Specifically, incinerators cannot be functionally utilized if electricity supply is erratic. Similarly, several processes that are associated with waste disposal would require regular supply of water.