The study was conducted in five county hospitals in Kenya numbered from 1 - 5. These hospitals were selected purposively and were distributed across the regions from Coast, Eastern and Rift Valley.

This included Hospital 1 (3.3833˚S, 38.5667˚E), Hospital 2 (2˚16'30.00"S, 37˚49'12.00"E), Hospital 3 (1.0833˚S, 35.8667˚E), Hospital 4 (0.3500˚N, 37.5833˚E), and Hospital 5 (1.0167˚N, 35.0000˚E).

A cross sectional study design was adopted and qualitative and quantitative data was collected.

The integrated HCW management tool was used together with observational checklist, interviews, visual verification and review of documents.

The study introduces an integrated indicator set that was developed to facilitate assessment of HCW management systems in the hospitals sampled. The HCW management indicators and criteria used in this study are in agreement with the guidelines provided by [25] . The starting point for the application of the indicators is to obtain local and current reliable data from the hospitals which should be collected by an impartial expert in the field of HCWM. Therefore, fieldwork and cooperation with local hospital administration are important for administering questions in the indicator set contained in the assessment tool. The experts working in the areas being appraised should be targeted to answer questions on each criterion under each of the indicators contained in the assessment tool. Four methodologies should be adopted for completing the indicators:

• assessment of hospital policies, plans and standard operating procedures of HCWM;

• interviews with hospital directors, nurses, local medical engineers, and waste operators;

• Observation and visual verification during field inspection of HCWM generation, storage and collection, transportation, treatment and disposal areas;

• review of local documentation of HCWM (policies, standard operating procedures, minutes, audit protocols, commodities stock records in stores, IPC training records).

The assessment tool is structured as a function of the five indicators developed and applied to assess knowledge and practice of hospital technical managers (Infection, prevention and control coordinators, medical superintendents, hospital administrators and public health officers in charge of HCW management) and administrators. Other data collection methods that included observation, interviews, visual verification and review of documents (policies, standard operating procedures, minutes of meetings, service provision audit protocols, commodities stock records in stores, IPC training records) were used. Conducting interviews to health workers is a method used in other case studies [70] ; in this study, the indicators would provide an integrated approach for its appraisal, which can be replicable in other contexts. The structure of the indicators introduced by [71] for the assessment of municipal solid waste (MSW) management systems in developing countries was used and adapted for the specific analysis of HCW. Such an approach is similar to what others have introduced before, [21] , although it was implemented for a literature review, whereas in this research it is implemented for a real study. Other indicators that focus on five key areas of analysis which included: budget support, developing policies and legislation, technology and knowledge administration, treatment and final disposal issues, and quality of the collection and transportation system exists [18] . In this type of study aiming to calculate the level of performance of the selected county hospitals in HCW management, a methodology where several indicators are used for scoring and ranking outcomes was modified and adopted [71] [72] [73] [74] . In this study, the indicators used for scoring and ranking hospitals HCWM systems included; policies and procedures, management and oversight of HCW management systems, logistics and budget support, training of healthcare workers, waste handlers, incinerator operators, and occupational safety and health, and treatment, disposal and infrastructure.

Each indicator set is divided into seventeen to thirty-two criteria. The assessment tool containing the five indicators was used to rank the hospitals overall performance in HCW management. Each correct answer in the appraisal tool earned a score of one and the total per performance indicators calculated as a percentage which was interpreted as per the predetermined ranking scale and scoring criteria. An aggregate score in each of the five appraisal indicators between 0% - 49% had a ranking score of one (1) and was interpreted as poor, scores between 50% - 74% had a ranking score of two (2) and interpreted as fair while those assessment indicators that had scores of 75% and above had a ranking score of three (3) and were interpreted as good (Table 1). The indicators used in this study to assess the county hospitals’ HCW management systems can be applied in baseline data collection, monitoring progress, and evaluation of HCW management interventions, and for comparing different same level hospitals within countries and in particular those in low and middle income countries. The indicators are presented as percentages, from 0% to 100%, by a radar scheme. The rank scores were then used for presentation in a radar where the further a score was from the centre of the radar, the better the performance level [71] [72] [73] .

The criteria considered for assessing the HCWM system in hospitals were divided into five indicators:

A) HCWM policies and standard operating procedures,

B) Management and oversight,

C) Logistics and budget support,

D) Training and occupational health and safety

E) Treatment, disposal and incinerator housing.

Each indicator provides information regarding the topic considered, using qualitative and quantitative data about the management activities applied in the hospitals.

For each hospital, the information about its size should be presented, in order to compare the data with other hospitals: number of beds; percentage of beds occupied per year; number of patients per year; number of workers; and HCW produced per year. The indicators were chosen in order to provide a complete view of the HCWM system of the hospitals. The first step towards appraising health waste management system is the assessment of availability and utilization of HCWM policies and standard operating procedures by hospital management and HCWM actors. Second, existence and functionality of management and oversight structures is assessed. Effective functionality of this indicator is critical to ensure coordination of availability of HCW storage commodities at generation points, protection of waste handlers during collection and transportation and safety of the incinerator operators at the treatment and disposal sites. Third, provision of adequate and appropriate logistics for efficient and effective HCW management is critical. This is made possible through prioritizing financing of HCWM through the hospital budgets. Such dedicated budgets voted to support HCWM should be used to procure commodities (bins and bin liners, trolleys, PPEs etc.) to enhance segregation of HCW, development of information. Education and communication (IEC) materials and commodity procurement plans, commodity quantification tool, and a waste collection schedule. Fourth, the prevention system and the awareness of local operators is assessed in order to quantify the capacity of the operators in reducing the risk of cuts and contamination. Lastly, the fifth indicator is to assess treatment, treatment equipment disposal options offered at the facility to reduce pollution of the environment that consequently affects human health. The housing of the equipment is also assessed in order to quantify the capacity of the operators in reducing the risk of contamination. This indicator assesses operation and maintenance of the equipment through functionality of the equipment, whether the equipment has a temperature regulation device, waste treatment SOPs, availability and use of equipment operator’s manual and a maintenance schedule. A waste treatment equipment that is effectively operated and maintained will reduce emissions that pollute the air and consequently affect human health. The detailed assessment tool used is provided in Tables 2-6.

Indicator A: HCWM policies and standard operating procedures

This indicator provides criteria for assessing availability and utilization of policies and standard operating procedures. Table 2 reports the description of the twenty criteria used. The first (A1, A4, A8) criteria is to assess availability of policies, national guidelines and domesticated hospital HCWM plan, while criteria A2 and A5 are to assess access of the policies and national guidelines of HCWM by the healthcare workers at the hospital. Criteria A3 and A6 assesses level of understanding of the policies and the national guidelines of HCWM by the HCW. Criteria A7 assesses whether the hospital has a HCWM plan in line with the national one while A11 assesses HCWs access to the plan and knowledge of its contents. Criteria A9 assesses whether the hospital has set out training requirements and safety procedures that protect healthcare workers, waste handlers, incinerator operators, patients and the community from injury and contamination that emanates from the process of HCWM. Criterion A10 assesses whether the hospital plan contains a self-auditing procedure. Criterion A12 to A20 assesses availability of standard operating procedures (SOPs) for handling, treating and disposal of infectious waste, handling and transportation, liquid waste disposal, laboratory chemical decontamination, disposal of blood and blood products, disposal of laboratory vacutainers, placenta handling and disposal, incinerator operation and record keeping, and incinerator maintenance and repair respectively.

Indicator B: Management and Oversight

This indicator provides criteria for assessing management and oversight structures put in place within the hospitals to facilitate HCWM. Table 3 reports the description of the seventeen criteria used. Criteria B1 and B2 assesses presence of an Infection Prevention and Control (IPC) committee, and whether this committee had held a meeting within the last three months respectively. Criterion B3 establishes whether HCWM issues were discussed and appeared in the IPC committee minutes while B4 assesses whether the IPC committee had an audit checklist and B5 assesses HCWM inclusion into the audit checklist. Criteria B6, B7 and B8 assesses whether IPC committee had conducted HCWM audit in the last 6 months, had addressed gaps identified in HCWM audit, and whether audit feedback was given to the hospital management respectively. Criterion B9 assesses whether the IPC committee was multi-disciplinary in its composition while B10 assesses whether an officer had been appointed as in-charge of HCWM in the hospital. Criterion B11 assesses whether the position of a HCWM in-charge had been identified in the hospital policy and B12 assesses whether a job description for this officer appeared in the hospital HCWM policy. Criterion B13 assesses the functionality of HCWM officer through establishing existence of a report of hospital audit carried out in the last three months as evidence. Criterion B14 assesses whether departmental supervisors had HCWM conducted inspections while B15 looked for an inspection reports conducted in the last two months as evidence. Criterion B16 assessed whether section supervisors had IPC inspection checklists while B17 assessed whether the supervisors checked their employees HCWM training or Occupational Health requirements.

Indicator C: Logistics and budget support

This indicator provides criteria for logistics and budget support structures put in place within the hospitals to facilitate HCWM. Table 4 reports the description of the twenty-one criteria used. Criteria C1 to C9 assesses issues pertaining to waste segregation, color coding and labelling, availability and use of color coded bins and bin liners, whether waste segregation was done according to guidelines, sharps containers were available in waste generation areas, sharps containers were positioned within arm’s length, whether coded bins were matched with bin liners, segregation posters appropriately placed and waste segregation posters appropriately placed at departmental wards respectively. Criteria C10 to C15 assesses HCWM collection, availability of a waste collection schedule at collection points, use of a waste collection schedule from waste generation points, availability and use of trolleys, functionality of waste collection trolleys, provision of a dedicated trolley for general waste and for infectious waste. Criteria C16 to C21 assessed presence of hospital commodity procurement plans, whether the procurement plans were up to date, whether procurement plan addressed all HCWM commodities, whether hospital experienced stock out of HCWM commodities within the previous 6 months, whether there was a dedicated budget and that the hospital had a HCWM quantification tool respectively.

Indicator D: Training and occupational health and safety

This indicator provides criteria for assessing training and occupational health and safety procedures put in place within the hospitals to facilitate HCWM. Table 5 reports the description of the thirty-two criteria used. The indicator is appraised to ensure that healthcare workers, waste handlers and incinerator operators are provided with and wear personal protective equipment when at work. The expert appraising should also check on whether training has been conducted to new hires and practicing healthcare workers and those involved in storage, collection, transportation, treatment and disposal of HCW. Knowledge of existence and use of a twenty-four-hour post-exposure prophylaxis (PPE) protocols should be established. Vaccination of healthcare workers, waste handlers and incinerator operators against hepatitis B virus that can be transmitted through needle stick injuries should be assessed. Criteria D1 to D4 deals with assessment of provision and use of appropriate personal protective equipment to waste handlers and incinerator operators. Criteria D5 to D12 assesses training of waste handlers, incinerator operators, and HCW. They also assess induction training of new employees and documentation of training. D13, D14 and D15 assess training of incinerator operators on basic maintenance, incinerator operation and need to maintain a sharps injury surveillance register. Criterion D16 assesses availability of documented procedures in case of injury and D17 assesses availability and use of a needle stick injuries and other incidents documented in a log book register. Criterion D18 assesses whether documented post exposure prophylaxis (PEP) protocols are available while D19 assesses whether employees are knowledgeable of PEP procedures. Criterion D20 assesses availability of PEP to staff for 24 hours per day while D21 to D32 assess availability and use of different types of PPEs.

Indicator E. Treatment, Disposal and Incinerator Housing

This indicator provides criteria for assessing HCWM treatment, disposal and incinerator housing put in place within the hospitals. Table 6 reports the description of the nineteen criteria used. Criterion E1 looks for evidence of recording of waste generated from various departments within the hospital and E2 assesses the mechanical status of the incinerator. Criteria E3 to E5 establishes provision of temperature regulation device, functionality of calibrated temperature device and incinerator preventive maintenance log book respectively. Criteria E6 to E16 assesses use of guidelines during incinerator operation, SOPs, availability of operator’s manual, monitoring of incinerator usage, use of data collected to improve service, availability of a maintenance schedule, availability of incinerator spare parts locally, availability of a service maintenance contract, availability of a backup option for waste treatment in case of equipment failure and the status of environmental safeguards respectively. Criteria E17 to E19 assesses provision of water and sanitation facilities within the waste treatment plant.

The indicators were applied in five hospitals in Kenya as an example for presenting the potentiality of the methodology in a low-middle income country. A study that included five hospitals was carried out in five hospitals in Kenya, in order to assess qualitatively the generation, storage, collection, transportation, treatment and disposal of HCW. The five hospitals studied were considered the most representative of the HCWM system in rural Kenya, due to their size, extent of clinical area and waste generation. Information gathered through filling of the appraisal/indicator tool about the HCWM in these hospitals is provided in the results section. Data about the HCW yearly generation was not available. This represents a limitation of the study and of the HCWM system, underlined within the Results and Discussion sections.

The quantities of waste and the features of the hospitals chosen for implementing the indicators are reported in Table 7. Hospital 1 generates about 23.38 - 39.48, hospital 2, 21.37 - 36.09, Hospital 3, 36.30 - 61.28, Hospital 4, 38.74 - 65.415 and hospital 5, 48.54 - 81.96 tonnes of HCW per year. The significant variation in HCW generation can be a function of various factors: period of the year, day of the week, number of in and out patients, seasons in a year, units in healthcare, MCH/FP, surgery, emergency unit, obs/gyn ward, maternity ward, paediatrics ward, pharmacy, laboratory, VCT unit, TB follow up unit, dental unit, mortuary among others. It underlines the difficulty of HCWM and planning in this structure, a hidden issue if only average data is provided.

Hospital 2, with about 21.37 - 36.09 tonnes of HCW generated per year and 97 beds available, and 15 other departments can be considered smaller and generated the least amounts per year than all the other hospitals. Hospital 5 with an annual generation rate of 48.54 - 81.96 tonnes had 250 beds and cots, and 26 other departments. The HCW generation rates were not reported by all the hospitals and therefore adopted from the results published from a study done in Kenyan hospitals that documented HCW generation rates of between 0.61 kg/bed/ day to 1.03 kg/bed/day [75] . There was no data on total number of healthcare workers, waste handlers and incinerator operators from the five hospitals and therefore not reported in either Table 7 or Table 8.

A brief description of the five hospitals, according to the site visits and interviews, is provided below, following the structure of the indicator set.

Hospital 1

1) HCW management policies and standard operating procedures (SOPs)

The HCW generation rates of between 0.61 kg/bed/day to 1.03 kg/bed/day as documented in a study done in Kenyan hospitals were used to calculate the total HCW generated·day⁻¹ (kg) [75] .

HCW policies and SOPs were qualitatively evaluated using the criteria set (Table 2) and scored 33.3% which had a ranking score of 1 which was interpreted as poor (Table 1). This was due to the hospital not having the national HCWM plan and therefore healthcare workers not being knowledgeable on the national aspirations of HCWM. Although the hospital had the national guidelines for safe handling of HCW, the guidelines had not been disseminated to the healthcare workers and were therefore not aware of their role in ensuring safety in the process of HCWM. The national HCWM plan and the guidelines had not been domesticated leaving healthcare workers without guidelines on occupational safety, training requirements and audit procedures. Hospital 1 had not developed SOPs on safe handling, treatment and disposal of infectious waste, disposal of liquid waste, chemical decontamination of laboratory waste, disposal of blood and blood products, laboratory vacutainers, placenta handling and disposal, incineration operation and maintenance, record keeping and repair which are critical in reducing health risks from HCW.

2) Management and oversight structures for HCWM

HCW management and oversight structures were evaluated using the criteria set (Table 3) and scored 41.2% which had a ranking score of 1 and was interpreted as poor (Table 1). Hospital 1 had put an infection prevention and control (IPC) committee in place and had met and discussed HCWM in the past three months. This hospital had developed an IPC audit checklist which also included HCWM. It was noted that the IPC committee had informed the hospital management and addressed gaps identified during the audits. However, the IPC committee had serious gaps in that it had not addressed gaps identified within the last six months, IPC committee was not multidisciplinary, HCWM in charge had not been identified in the hospital policy and therefore not appointed. There was no job description for that position and therefore no evidence of that the in charge had carried out any inspections in the last three months. The supervisors of various departments and sections had not developed an IPC inspection checklist and there was no evidence of inspections within the past two months. The supervisors had not checked whether employees had been trained and met the occupational health and safety requirements.

3) Logistics and budget support

Hospital 1 scored 77.8% on making of provision for HCWM logistics and budget support when evaluated using the criteria set (Table 4), a ranking of 3 and was interpreted as good (Table 1) and was second to hospital 4 on this indicator. Although there were no segregation posters placed near the color coded bins, this hospital scored 80% which was good (score of 3) when the criterion for assessing healthcare workers waste segregation and color coding practices were assessed. Hospital 1 did poorly with 0%, a ranking score of 1 (Table 1) when availability, functionality and use of HCW transportation equipment from storage to treatment sites was evaluated. There was no HCW collection schedule and dedicated trolleys for transporting infectious waste to treatment sites. Hospital 1 score 87.7% when the criteria set was assessed. The hospital had a dedicated budget, an up to date procurement plan which addressed HCWM commodities and had not experienced HCWM commodities stock outs for the last 6 months

4) Training and occupational health and safety

Hospital 1 scored 46.7% when evaluated on criteria set (Table 5) for this indicator, ranking score of 1 and was interpreted as poor (Table 1). Incinerator operators used appropriate PPE, there was evidence of IPC and HCWM training to healthcare workers and waste handlers. Incinerator operators had not been trained on safe management and final disposal of HCW. An assessment on sharps surveillance and availability of post exposure prophylaxis to ensure occupational safety and health showed that there was a sharps injury surveillance register with a lack of a document procedure to be followed in case of an injury. All the needle stick injuries and other accidents were documented in a logbook register, there lacked a post exposure prophylaxis protocols. PEP to all members of staff was availed for 24 hours and employees were aware of PEP procedures to be followed. None of the PPEs for waste handlers was provided leaving them exposed to all the health risks associated with handling of HCW. Use of PPEs by the incinerator operators was assessed and it was found heavy duty gloves, boots, overalls and face masks were provided and being used leaving out googles and respirators which are important in ensuring occupational safety and health. Only one out of five enlisted for PEP did not receive.

5) Treatment, disposal and infrastructure

Hospital 1 scored 20% which was a ranking of 1 and interpreted as poor when evaluated qualitatively using the criteria set (Table 6) for assessing treatment, disposal and availability of sanitation facilities in the infrastructure provided for the incinerator (Table 1). The incinerator was in use, the incinerator infrastructure had a concreate floor which was easily cleansable, the operator had SOPs for waste treatment plant and equipment had a maintenance contract. There was lack of evidence of recording of waste generated from various departments, calibrated temperature regulation device, running water at the site, preventive maintenance logbook for the incinerator, available SOPs not used, operators’ manual, operation logs, equipment spare parts, maintenance schedule and the waste treatment equipment posed harm to human health and the environment since it lacked air pollution control devises.

Hospital 2

1) HCW management policies and standard operating procedures

The HCWM policies and standard operating procedures can be qualitatively evaluated at 33.3% which has a ranking score of 1 using the criteria set (Table 2), and which was interpreted as poor (Table 1). This was due to the hospital not having the national HCWM plan and therefore healthcare workers not being knowledgeable on the national aspirations of HCWM. The hospital did not have the national guidelines for safe handling of HCW, the guidelines had not been disseminated to the healthcare workers and were therefore not aware of their role in ensuring safety in the process of handling HCW. The national HCWM plan and the guidelines had not been domesticated leaving healthcare workers without guidelines on occupational safety, training requirements and audit procedures. Hospital 2 had not developed SOPs on safe handling, treatment and disposal of infectious waste, disposal of liquid waste, chemical decontamination of laboratory waste, disposal of blood and blood products, laboratory vacutainers, placenta handling and disposal, incineration operation and maintenance, record keeping and repair.

2) Management and oversight structures

Although hospital 2 had appointed an in charge of HCWM, all criteria set (Table 3) for effective management of HCW were lacking leaving the hospital with a score of 5.9%, a ranking score of 1 which was interpreted as poor. This hospital lacked IPC committee and therefore no HCW management and oversight structures put in place to forestall the effects of pollution to human health and the environment.

3) Logistics and budget support

Provision of HCWM logistics and budget support is critical. Hospital 2 was evaluated using the criteria set (Table 4) and scored 44.4%, a ranking of 1 which was interpreted as poor (Table 1). There was HCW segregation practiced in hospital 2 together with use of the recommended color codes for the bins and bin liners. Sharp boxes were availed and placed in all sharps generation areas and coded bins were matched with bin liners. However, waste segregation was not done according to guidelines, no HCW segregation charts displayed and there were no waste collection schedules displayed at the generation areas. There were no dedicated trolleys provided for waste transportation to treatment sites. This hospital didn’t have an up to date commodity procurement plan in place and a HCWM qualification tool, and only depended on what was supplied from the national commodity supply agency. This hospital had suffered HCWM commodity stock outs and had no dedicated budget.

4) Training and occupational health and safety

This hospital 2 was evaluated using the criteria set (Table 5) and scored 40%, a ranking score of 1 which was interpreted as poor (Table 1). Although the incinerator operators used PPEs that were in good condition, they were not the recommended ones for them. There was evidence that healthcare workers and waste handlers (WH) were trained on IPC and WH wore recommended PPEs that were in good condition. An assessment on sharps surveillance and availability of post exposure prophylaxis to ensure occupational safety and health showed that there was a sharps injury surveillance register with a lack of a documented procedure to be followed in case of an injury. This could be the reason this hospital recorded a higher number (Table 8) of who had occupational exposures. All the needle stick injuries and other accidents were documented in a logbook register, there lacked a post exposure prophylaxis protocols. PEP to all members of staff was availed for 24 hours and employees were aware of PEP procedures to be followed. PPEs provided to waste handlers included boots and overalls leaving them without heavy duty gloves, face masks and respirators and therefore exposed to all the health risks associated with handling of HCW. Use of PPEs by the incinerator operators was assessed and it was found that heavy duty boots, overalls and face masks were provided and being used leaving out googles and respirators which are important in ensuring occupational safety and health.

5) Treatment, disposal and infrastructure

Hospital 2 scored 5% when the criteria set (Table 6) were assessed qualitatively for treatment, disposal and availability of sanitation facilities in the infrastructure provided for the incinerator operators, a ranking score of 1 which was interpreted as poor (Table 1).

The incinerator was in use without any of the requirement set out in the criteria for assessment and the waste treatment equipment posed harm to human health and the environment since it lacked air pollution control devises.

Hospital 3

1) Policies and standard operating procedures

Hospital 3 was evaluated using the criteria set (Table 2) and scored 55.5% in this indicator, a ranking of 2 and interpreted as fair (Table 1). This hospital had the national HCWM plan and the guidelines which were also accessible to healthcare workers who could discuss their contents. In spite of having these documents, this hospital had not domesticated any of them. SOPs for handling, treating and disposal of infectious waste, disposal of laboratory vacutainers, handling and disposal of placenta, incineration and record keeping, and incinerator maintenance and repair had not been developed.

2) Management and oversight structures

In the indicator of development of management and oversight structures, hospital 3 was evaluated using the criteria set (Table 3) and scored 70.6%, a ranking of 2 which was interpreted as fair (Table 1). In all the criteria assessed, the IPC checklist developed was deficient of HCWM issues, HCWM in charge had not been identified and job description not availed, the department in charges did not have inspection checklists and could not produce evidence of any inspections conducted within their areas of work.

3) Logistics and budget support

Hospital 3 was evaluated using the criteria set (Table 4) and scored 66.7%, a ranking of 2 and which was interpreted as fair (Table 1). In the logistics and budget support indicator, healthcare workers waste segregation and color coding practices, trolley availability, functionality and use, and availability of HCWM commodity procurement plans and budget allocation were assessed. This study found that HCW was not segregated according to guidelines, sharps containers were not positioned at the recommended arm’s length locations, bins and bin liners were not matched, and there was no segregation chart displayed at waste generation points. The hospital had no dedicated trolleys for general waste and for infectious waste. The hospital had not developed a HCW quantification tool, the procurement plan did not address all HCWM commodities and therefore had experienced stock outs in the last six months.

4) Training and occupational health and safety

Hospital 3 was evaluated using the criteria set (Table 5) and scored 40%, a ranking of 1 which was interpreted as poor (Table 1). In this indicator where training of healthcare workers, waste handlers and incinerator is assessed, hospital 3 had no evidence of having conducted IPC and HCWM training to health-care workers and waste handlers. Incinerator operators had not been trained on basic incinerator maintenance. To strengthen sharps surveillance and to ensure availability of post exposure prophylaxis and reduce health risks, this hospital had implemented all what was set as criteria. The waste handlers were not provided with heavy duty gloves, overalls, face masks, goggles and respirators. The incinerator operators lacked heavy duty gloves, boots, face masks goggles and respirators. This hospital lacked reliable data on PEP (Table 8).

5) Treatment, disposal and infrastructure

Hospital 3 was evaluated using the criteria set (Table 6) scored 45%, a ranking of 1 which was interpreted as poor (Table 1). The hospital had half of what is set as criteria for good practice. In this indicator where treatment equipment, its use, maintenance and sanitation at the infrastructure are assessed, this hospital was lacking provision of a washroom for the operator, no running water, no preventive maintenance logbook, no operators’ manual, spare parts and service contract for the waste treatment equipment were not available.

Hospital 4

1) HCW management policies and standard operating procedures

Hospital 4 was evaluated using the criteria set (Table 2) and scored 44.4%, a ranking of 1 which was interpreted as poor in this particular indicator. Availability and access of HCWM policies at the facility was assessed and national HCWM plan and guidelines were lacking making it not possible for the healthcare workers to understand their contents. This hospital had not developed its own HCWM plan leaving the healthcare workers without occupational safety and hospital staff training requirements, and IPC and HCWM audit procedures. This hospital operated without SOPs for in-house handling and transportation of infectious waste, disposal of liquid waste, incineration operation and record keeping, and incinerator maintenance and repair.

2) Management and oversight structures

Hospital 4 was evaluated using the criteria set (Table 3) and scored 64.7%, a ranking of 2 and interpreted as fair in performance of this indicator (Table 1). The hospital met most of the criteria set for assessing management and oversight structures put in place for HCWM but HCWM in charge and job description had not been identified in the hospital policy, there were no evidence of any inspections conducted in the previous two months, no IPC inspection checklist and the supervisors had not checked their employees training or occupational health requirements.

3) Logistics and budget support

Hospital 4 was evaluated using the criteria set (Table 4) and scored 88.9%, a ranking of 3 and interpreted as good (Table 1). This was the highest in this indicator when compared to other hospitals. This hospital scored well in all the criteria set for the assessment of HCW segregation and color codding practices, but only missed display of segregation charts near points of waste generation. This hospital had developed and used a waste collection schedule, dedicated transportation trolleys for general waste and infectious waste. The HCWM commodity procurement plans were available and requisite budget allocated. However, this hospital lacked a HCWM quantification tool which might have led to stock outs of essential HCWM commodities in the past six months.

4) Training and occupational health and safety

Hospital 4 was evaluated using the criteria set (Table 5) in this indicator together with hospital 5 and had the highest score of 60%, ranking of 2 and interpreted as fair (Table 1). Waste handlers and incinerator operators were provided with appropriate PPEs and healthcare workers had been trained on IPC. Incinerator operators had been trained on safe management of HCW and final disposal of HCW. However, IPC training had not been documented, healthcare workers had not been trained on handling HCW, new hires had not been trained on waste management, and incinerator operators had not been trained on operation and maintenance of the waste treatment equipment. Hospital 4 performed well in the criterion on sharps surveillance and availability of post exposure prophylaxis to ensure occupational safety. They maintained a sharps injury surveillance register, had a documented procedure in case of injury, the hospital had a logbook register to document needle stick injuries and other incidents, there was evidence of documented PEP protocols, employees were knowledgeable of PEP procedures, and PEP was available to staff for 24 hours per day. Use of PPEs by the waste handlers was assessed and it was found that only heavy duty boots were provided leaving out heavy duty gloves, overalls, facemasks, googles and respirators which are important to ensure occupational safety and health. Use of PPEs by waste handlers was the opposite for incinerator operators who were availed and used all the PPEs.

5) Treatment, disposal and infrastructure

Hospital 4 was evaluated using the criteria set (Table 6) and scored 10%, a ranking score of 1, which was interpreted as poor (Table 1). Out of all the criteria set for this indicator, this hospital missed all of them except having a functional incinerator which was on a concreate floor.

Hospital 5

1) HCW management policies and standard operating procedures

Hospital 5 was evaluated using the criteria set (Table 2) and scored 44.4%, a ranking score of 1, which was interpreted as poor (Table 1). This hospital missed HCWM national plan and guidelines and therefore the interviewees were not aware of the contents of the two policy documents. Hospital 5 had not developed its own HCWM plan leaving the healthcare workers without occupational safety and hospital staff training requirements and HCWM audit procedures. The hospital had developed SOPs for handling, treating and disposal of infectious waste, chemical decontamination of laboratory waste, and one for disposal of blood and blood products leaving out all other set out in the criteria (Table 2).

2) Management and oversight structures

Hospital 5 was evaluated using the criteria set (Table 3) and scored 35.3%, a ranking of 1, which was interpreted as poor (Table 1). This hospital missed most of the set criteria (Table 3). There was an IPC committee in place which had conducted HCWM audit in the past six months and addressed the gaps identified in the audit tool. The hospital had identified a HCWM in charge and departmental in charges had conducted inspections and ensured that employees were trained on HCWM and that they meet occupational health and safety requirement.

3) Logistics and budget support

Hospital 5 was evaluated using the criteria set (Table 4) and scored 55.6%, a ranking of 2 and interpreted as fair (Table 1). In the area of segregation and color coding practices of HCW by the healthcare workers, sharps containers were not place at arm’s length and color coded bins were not matched with bin liners. There were no dedicated trolleys for general and infectious waste, HCWM commodity procurement plans and requisite budget allocation.

4) Training and occupational health and safety

Hospital 5 was evaluated using the criteria set (Table 5) and scored 60%, ranking of 2 and interpreted as fair (Table 1). The criteria set to assess healthcare workers, waste handlers and incinerator operators training on occupational health and safety were missed with this hospital only training incinerator operators on safe management and final disposal of HCW together with basic incinerator maintenance. This may explain the high numbers (121) of occupational exposures recorded in hospital 5 (Table 8). The hospital scored all the criteria set for assessment of sharps surveillance and availability of PEP to ensure occupational safety. There was a low uptake of PEP in this hospital with only 47 receiving out 84 whom been exposed (Table 8). Waste handlers were not provided with any of the PPEs except boots. The incinerator operators were provided with all the PPEs assessed except goggles.

5) Treatment, disposal and infrastructure

Hospital 5 was evaluated using the criteria set (Table 6) and scored 10%, a ranking score of 1, which was interpreted as poor (Table 1). Out of all the criteria set for this indicator, this hospital missed all of them except having a functional incinerator and running water at the waste treatment site.

The introduction of the indicator set allows the hospitals to be compared in a simple scheme. The results of the scores obtained for the five hospitals in Kenya, are in agreement with the previous section, and are reported in Figure 1 (Hospital 1), Figure 2 (Hospital 2), Figure 3 (Hospital 3), Figure 4 (Hospital 4), Figure 5 (Hospital 5) and Figure 6 that presents average score of the five hospitals when all the indicators are combined. Moreover, in Table 9, the quality of the data collected is reported for each of the indicators and for each of the hospitals.

In hospital 1, the indicator on logistics and budget support scored the highest (77.8%), a rank of 3 which was interpreted as good level of HCWM while the indicator on treatment, disposal and infrastructure scored the least (20%), a rank of 1 which was interpreted as poor level of HCWM. According to the assessment criteria set (Table 1), this hospital scored poorly in the other three indicators with scores ranging from 20% for treatment, disposal and infrastructure to 44.7% for training of healthcare workers, waste handlers and incinerator operators on HCWM handling, health risks and safety requirements. This hospital had an overall score of 43.4%, ranked as 1 and interpreted as poor, when all the indicators were combined to form an integrated criterion of assessing the level of HCWM systems (Table 9). In Hospital 2, all the indicators assessed scored poor with scores ranging from 5% to 44.4%, ranked as 1 and interpreted as poor (Table 1) and scoring 25.72% as overall for HCWM system, ranked as 1 and interpreted as poor (Table 1) when the five indicators were combined to form an integrated criterion of assessing the level of HCWM systems (Table 9).

Hospital 3 had a fair level of HCWM system with an overall score of 53.56% (Table 9), ranking of 1 (Table 1). This hospital had indicator scores ranging from 40% in indicator D to 70.6% in indicator B. Hospital 4 had an overall score of 53.6%, ranked as 2 and interpreted as fair with score ranging from 10% in indicator E to 88.9% for indicator C (Table 9). Hospital 5 had an overall score of 41.06% ranked as 1 and interpreted as poor in HCWM systems. This hospital had scores ranging from 10% for indicator E to 55.6% for indicator C (Table 9).

Hospital 3 scored fairly (55.5%) in indicator A while the rest of the hospitals scored poorly (<50%). Hospital 3 and 4 scored fairly in indicator B with 70.6% and 64.7% while other hospitals scored poorly. Hospital 1 and 4 were rated good

in indicator C with 77.8% and 88.7% respectively while hospital 3 and 5 were rated to be fair. Hospital 2 was poor in indicator C with score of 44.4%. Hospital 4 and 5 were rated fair in indicator D with a score of 60% each, while the rest of the hospitals were poor with a score of <50%. All the hospitals assessed scored poorly in indicator E (Table 9).

Hospital 2 scored poorly in all the indicators according to the criteria set (Table 1) with scores ranging from 5% for the indicator on treatment, disposal and infrastructure to 44.4% (Table 8) for the indicator on logistics and budget support (Figure 2).

Hospital 3 scored 40% for training and occupational health indicator and 45% (Table 8) for treatment, disposal and infrastructure, a ranking of 1 which was interpreted as poor while this hospital scored between 50% - 74% which was interpreted a fair (Table 1) level of HCWM (Figure 3).

Hospital 4 scored the poorest (10%) in the area of HCWM treatment, treatment equipment management, disposal and infrastructure. The hospital was also poor in the area of policies and standard operating procedures and scored 44.4%, (Table 8) a ranking of 1 and interpreted as poor (Table 1). However, this hospital was good (88.9%), a ranking of 3, in the area of planning for HCWM logistics and providing the necessary budget support. Management and oversight, and training and occupational health and safety scored fairly with scores of 64.7% and 60% respectively (Figure 4).

Hospital 5 also had the lowest score in the area of HCW treatment, disposal and infrastructure (10%), ranking score of 1 and interpreted as poor (Table 1). Policies and SOPs, and management and oversight indicators were also rated poor with scores below 50%. Indicators of logistics and budget support for HCWM, and HCWM training and occupational health and safety scored fairly (Table 1) with scores of 55.6% and 60% (Table 8) respectively (Figure 5).

Figure 6 presents the average indicator scores form each hospital when all the scores for all the indicators were added together. Hospitals 1, 2 and 5 scored below 50% which was ranked as 1 and interpreted as having a poor level of HCWM. Hospitals 3 and 4 scored in between 50% and 74%, (Table 8) which has a ranking score of 2 and interpreted as a fair level of HCWM. The hospitals can be ranked from highest to lowest level of HCWM as follows; Hospital 4, 3, 1, 5 and 2.

HCWM in Kenya can be considered poor due to inadequate national policy dissemination to the county level and consequently affecting development of specific standard operating procedures, lack of development of management and oversight structures in hospitals poor treatment and disposal infrastructure. However, the five hospitals studied in Kenya could be considered a good example regarding provision and use of HCWM commodities that facilitate provision of PPEs for handling HCW during segregation of waste at generation points, collection, transportation, treatment and final disposal. Further, it’s still a good example in training of healthcare workers, waste handlers and incinerator operators on HCWM and infection prevention and control to ensure safety to human health and the environment as compared with other developing cities [2] [77] [78] . The lack of national policy dissemination, inadequate development of HCWM and IPC management and oversight structures, and environmental friendly on-site treatment plants, are the main barriers for implementing sustainable HCWM systems in Kenya. Some of the policy documents found to be in place at the National level in Kenya included Environmental Management and coordination Act [79] ; Environmental Management and Coordination (Waste Management) regulations [80] ; National HCWM strategic plan, 2015-2020, [81] ; National HCWM Implementation plan, 2016-2021, [82] and Kenya National Guideline for Safe Management of HCW, [83] . While this study found that Kenya has developed requisite policy and guidelines at the national level, several other studies have found lack of clear policies and legislation from governments of Cameroon [49] , Haiti, [84] , and Iran [85] and attributed non treatment of hazardous waste and anatomical waste being left undisposed to lack of clear policies and legislation from government bodies. The findings indicate that the current management of HCW is not capable of adequately preserving public health and may cause environmental contamination and infection. This finding agrees with [86] who concluded the same from their systematic review on health and environmental impact of hospital wastes. This study agrees with the recommendation made by [77] , that the quantities of HCW generation and consequently requirements for its disposal are increasing.

The study revealed that only 2 (40%) of the hospitals studied were rated fairly while the rest were poor in having put in place management and oversight structures for HCWM and IPC. that lack of IPC committees affected resource allocation to facilitate management of HCW and also hindered accessibility and establishment of reliable HCWM plans and Standard Operating Procedures. This is in agreement with [87] in their study in Nigeria which found that the activities of waste managers in HCW facilities are rarely subjected to administrative scrutiny or supervision.

This finding concurs with a qualitative rapid assessment of Infection Prevention and Control (IPC) practices in twelve HCW facilities in five provinces which revealed significant differences which were attributable to the presence or absence of Infection Prevention and Control Committee (IPCC) and an IPC lead person [88] . Another finding which concurs with our study was that presence of sharps containers, waste bins, incinerators, and personal protective equipment (PPE) did not necessarily lead to their correct use in the absence of functional IPCCs and active IPC lead persons who acted as catalysts, trainers, and role models [88] .

All the five hospitals studied had practiced segregation, used the recommended color codes, color coded bins and liners and sharps containers were available at service delivery points during the time of study. This may have been contributed to by low knowledge on HCW segregation practices. These finding agree with another study in Nigeria, which found that poor or no training of healthcare workers on the management of HCW can be a pointer to poor funding available in the country for health sector in the country [89] . However, all the hospitals in this Kenyan study had a challenge in provision of dedicated trolleys to transport HCW from generation points to the treatment sites which may be due to lack of dedicated budgets. In two (40%) out of five hospitals, waste segregation was not done according to guidelines provided, sharps containers were not positioned at arm’s length and coded bins not matched with bin liners. A study done in Nigeria reported that non adherence to HCW management guidelines was as a result of absence of specific budgets and financial allocations to cater for waste management within hospitals [90] . Majority (80%) of the hospitals in this study indicated that lack of adequate waste bins and liners was the greatest challenge that hindered waste segregation.

This is in agreement with a study on HCW management carried out in Ethiopia which noted that there was a general lack of basic knowledge of HCW solutions and segregation was not practiced [28] . Further, it is reported in Malaysia that even after provision of a HCW policy and training of healthcare workers, poor waste segregation continued in the healthcare facilities because of the absence of tools required for the segregation [91] .

This study established that all the five hospitals appraised had all their waste handlers wearing PPEs that were in good condition, had a sharp injury surveillance system in place, needle stick and incidents documented in a logbook register, employees were knowledgeable of post exposure prophylaxis (PEP) procedures and that PEP was available to staff for twenty-four hours a day. This is contrary to a study done in Nigeria that found that majority of workers handling waste without working tools and infection control materials, which exposed them to infection [92] . The disagreement could be due to the fact that we studied all the health workers while they studied only the dental workers. It was only in one out of four hospitals (hospital 4) that incinerator operators used all recommended PPEs (heavy duty gloves, boots covering feet, overalls or aprons, face masks, eye goggles and respirators while waste handlers in hospital 1 used none of the PPEs while handling HCW. Only hospital 1 had IPC training documented, induction training on HCWM done to new employees and documented; and had trained more than sixty healthcare workers. This may be the reason only 5 had needle stick injuries in one year out of 26,419 outpatient attendants.

The study concurs with another study that emphasized training of healthcare workers, waste handlers and incinerator operators to equip them with knowledge in handling of HCW to ensure safety measures are observed and protects them from the risk of infection that would emanate from handling of HCW [93] .

Incineration was the technology used in the five county hospitals studied as a HCW treatment method. This concurs with the findings of a study done in Portugal where they found similar results [94] . This study found that although there was segregation being practiced at the point of HCW generation, general, infectious, highly infectious waste and sharps all ended up in the treatment facility. This finding concurs with that of another study in Botswana which concluded that due to lack of formal training, non-clinical waste was often transported for unnecessary internal incineration with hazardous clinical waste leading to over-crowding, overuse and overwhelming of staff and incinerator [95] .

In this study, type of incinerator, functionality of incinerator, provision of temperature regulation device and its functionality, existence of standard operating procedures for the waste treatment facility, availability of equipment manufacturer’s operators manuals, readily available equipment spare parts, preventive maintenance logbook for the local biomedical engineers or a proof of a service contract for the equipment, presence of backup procedures in case of equipment failure and that waste treatment equipment that was in use posed no harm to incinerator operators, local community and the environment were important issues studied. On-site incineration of HCW was favored in the five hospitals studied. This is because it is seen as fast and cost-effective, but its thoroughness attracts speculations and major concerns relating to design, operation and maintenance. All the hospitals visited used a de-montfort type of incinerator which had no temperature monitoring gauges except hospital 3, which had a diesel fired incinerator. It has been recommended that low temperature incinerators should be banned if incineration was seen as the solution to HCW treatment [85] . However, hospital 3 incinerator though a more recent technology lacked pollution control devices for cleaning gaseous emissions from HCW incineration. All the incinerators assessed did not meet the national guidelines for waste management as set standards by the National Environment Management Authority, 2006.

A study on Environmental impacts of the US concluded that, pollution is the greatest environmental cause of disease and premature death around the globe and the healthcare sector has been noted for being a significant contributor to acid rain, greenhouse gas emissions, air pollutants, stratospheric ozone depletion and carcinogenic air toxics [96] . Further, other studies found that pollutants such as carbon monoxide, nitrogen oxides and Sulphur dioxide from HCW treatment led to global warming and as such many related diseases have affected global populations and that global warming has also led to the emergence of numerous parasitic diseases often in parts of the world never previously seen [97] [98] .

The HCWM management indicators introduced in this article allowed HCWM system to be compared among five hospitals in Kenya. Moreover, through the comparison with the data quality, the indicators can be assessed in terms of their reliability. The indicators and the methodology applied can be useful for providing suggestions to local hospitals’ stakeholders and policy-makers both at national and county governments on improvements required for obtaining the highest score and for taking into account management issues that have not been considered. The indicators presented in this article can be used to monitor and track improvements in HCWM systems, compare hospitals and for providing benchmark for baseline that can be used by the management internally or by an external evaluator. Therefore, the indicator set can be a tool for contributing to the improvement of the awareness about HCWM issues and management requirements for boosting sustainability and health at a global level. This method will require to be applied in other case studies in Kenya, in order to compare other realities in terms of quality of the HCWM system. The results of the application of this management tool will provide suggestions about which specific criterion requires to be prioritized in an indicator leading to improvement in waste segregation, storage, collection, treatment and final disposal. spreading the awareness about health risks and introducing new options regarding prevention and monitoring systems.

The research conducted in Kenya was implemented only in five hospitals which only provides a minimal indication of the Kenyan HCWM system. Therefore, it is suggested that the tool be applied in more hospitals and that the indicators should be continually improved. Moreover, the indicators were implemented only in Coast, Eastern, Rift Valley regions in Kenya while more research should be done in all regions to assess if there would be differences and whether the indicators can be applied in all levels of hospitals. The approach was not replicated in other countries. The research should be repeated in other contexts with different regulations and social behaviour, in order to assess the reliability of the indicators for other case studies. The generation rates for the hospitals assessed were not included since this data was missing. The last limitation of the study is its implementation over a limited period. The indicators should be implemented in a hospital as a baseline, all HCWM actors in a hospital should then be trained and equipped with necessary tools and reassessed after implementing HCWM for a period of time in order to provide a dynamic view of the HCWM system implemented at hospital.