Memorandum of Understanding Pilot Study Healthcare by sge21080

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									National Waste Management Strategy Implementation
                                                            DANIDA
                              DEPARTMENT OF ENVIRONMENTAL
                                  AFFAIRS AND TOURISM

                                   DEPARTMENT OF HEALTH



             NATIONAL WASTE MANAGEMENT STRATEGY
                   IMPLEMENTATION PROJECT
                        SOUTH AFRICA


       EKURHULENI METROPOLITAN
     MUNICIPALITY (NORTHERN REGION)

       MINOR HEALTH CARE RISK WASTE
         GENERATORS PILOT PROJECT

 DRAFT ONLY - PILOT PROJECT DESIGN
                          (DISCUSSION DOCUMENT)


                             SEPTEMBER 2005
                          Health Care Waste Component
                          Ekurhuleni Project Task Team




             NATIONAL WASTE MANAGEMENT STRATEGY
                   IMPLEMENTATION PROJECT
                        SOUTH AFRICA
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National Waste Management Strategy Implementation




       EKURHULENI METROPOLITAN
     MUNICIPALITY (NORTHERN REGION)

       MINOR HEALTH CARE RISK WASTE
         GENERATORS PILOT PROJECT

 DRAFT ONLY - PILOT PROJECT DESIGN
      (DISCUSSION DOCUMENT)

                             SEPTEMBER 2005
                          Health Care Waste Component
                          Ekurhuleni Project Task Team


Ref:
Report no:     0                               Prepared by:   JRM
Version no:    Draft                           Checked by:    KO, TJ,
Date:          05 September 2005               2005-06-20     Approve by: PMG




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                                                 Index

          Background
 1.       Introduction
 2.       Purpose of the Pilot Test
 3.       Objectives of the Pilot Test
 4.       Background to the selection of the pilot test design
          4.1 Key influences for the pilot design
          4.2 Key aspects to consider in the pilot project design
 5.       Comparisons of the status quo with the alternative options
 6        Outline of the two systems
          6.1 Outline of the drop-off system
          6.2 Outline of the collection system
 7.       Possible Service Scenarios for the EMM
 8.       The agreed outline for the pilot project design
 9.       The requirements for the drop-off system
          9.1 Estimated HCRW quantities and time allocations for operating the
               drop-off centre
          9.2 Criteria for selection of a drop-off centre
          9.3 Anticipated impact on the clinic
          9.4 Qualifications and terms of reference for the clinic responsible person
 10.      The requirements for the collection system
          10.1 Criteria for the allocation of the MG’s to the system
          10.2 Identification of the MG’s to the Collection System
          10.3 Methodology for contacting the Minor Generators and MoU’s signed
          10.4 Awareness raising and motivation
 11.      The appointment of a HCRWM Service Provider for the Pilot Project
          11.1 Motivation to use Sanumed
          11.2 Scope of work for Service Provider
          11.3 Formal documentation required before the pilot test can proceed
 12.      Estimated equipment quantities and costs.
 13.      Roles and Responsibilities
          13.1 Responsibilities of Ekurhuleni Metropolitan Municipality
          13.2 Responsibilities of the Service Provider
          13.3 Responsibilities of the NWMSI Project
 14.      Activity Plan for the Implementation of the two systems to test




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Background

1.     Introduction

       (To be added with reference to the Findings of the Survey report).

2.     Purpose of the Pilot Test
       The purpose of the pilot test is to provide a cost effective and sustainable Health Care Waste
       (HCW) Management System for the collection, transport, treatment and disposal of HCRW
       from Minor Generators (MG). Two principally different options are tested, namely:

       1. A HCRW Collection System, based on periodical collection, treatment and disposal of
          HCRW by a service provider from the premises of the Minor Generators (e.g. a GP); and
       2. A HCRW Drop Off System, based on the availability of some drop-off facilities possibly
          located at municipal clinics, where HCRW correctly containerised can be dropped off by
          the Minor Generators for collection, treatment and disposal by a service provider at
          dedicated times.

3.     Objectives of the Pilot Test:
       To compare the two systems for the following:

        Applicability and relevance of the system for the Ekurhuleni Metropolitan Municipality
         (EMM), with a view of future duplication in similar environments;
        The acceptability of the system for the users (MG’s) and other stakeholders;
        The user-friendliness and appropriateness of the equipment for the MG’s, Metropolitan
         Municipalities and other stakeholders.

       Any new container designs that may be developed during the pilot will also be tested and
       evaluated.

       It is assumed that the cost structure of operating the two principally different services would
       be significantly different. For the drop off system, the MG’s take their HCRW to the drop-
       off point themselves with the associated indirect costs in terms of transport and time. The
       costs for the collection system will however, be in the form of direct costs incurred for
       having the full service rendered by the service provider. Since it will not be possible to
       measure all costs related to the two systems in detail during the execution of the pilot
       project, a feasibility study will be conducted to determine the likely cost of the two systems
       piloted, should they be rolled out throughout Ekurhuleni MM. The pilot project will
       therefore inform this feasibility study.

4.     Background to the selection of the pilot test design
4.1    Key influences for the pilot design;

           a. The status quo report indicated that 90% of the target group of Minor Generators does
              use commercial sharps containers that are collected on a “call basis” when full.
              Present contracts between the Minor Generators and the service providers need to be
              considered and the actual extent of this service needs to be confirmed.



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           b. It is anticipated that the quantities of HCRW generated are very small and the
              frequency of collection is therefore expected to be low. As the pilot project will only
              run for 6 months, smaller containers must be used to ensure a more frequent turnover
              with filled containers being returned during the course of the 6-month pilot project;

          c. The reusable container concept would be very cumbersome for the anticipated small
             quantities generated by the pilot sample size of minor generators taking part in the
             pilot project, particularly with regard to the drop-off system. Reusable containers may
             be considered, depending on the availability of such containers from the Service
             Provider.

          d. The minor generator market is considered by the Service Providers not to be profitable
             due to small volumes of HCRW generated and high operational costs associated with
             long travelling distances between collection points. This is resulting in the service
             costs exceeding the limit considered a reasonable cost by the minor generators. It is
             therefore currently not a market being pursued actively by most of the service
             providers

          e. There are both commercial (those generating an income from treating patients) and
             non-commercial (those not generating an income from treating patients) minor
             generators operating within the pilot test area.

          f. From the Survey it is evident that there is no system in place for the non-commercial
             (home based care and private patients). Other minor generators with no formal
             systems in place are the traditional healers and the mortuaries.

          g. The laboratories and blood banks presently have an effective privatised HCRW
             collection system in place.

          h. The pilot project should strive to achieve a balance between cost and efficiency. A
             Feasibility Study that is to be commissioned urgently will assist in extrapolating the
             relevant information based on a desktop study of selected service scenarios. Where
             possible, information generated by the pilot projects will be used to verify the results
             from the Feasibility Study.

          i. The introduction of economic instruments (financial incentives) is not considered
             relevant for the Pilot Project. The financial impact of the scenarios will be assessed in
             the Feasibility Study with the focus moving from economic instruments to funding
             mechanisms. Sustainability of the selected service option would be obtained through a
             ring-fenced budget.

          j. Where possible the requirements of SANS 10248 will be applied. The Gauteng Health
             Care Waste Management Regulations of 2004 also applies. The pilot project will test
             also, to some extent, the appropriateness of such standards.

4.2    Key aspects to consider in the pilot project design

          a. The pilot project will be financed by the DEAT NWMSI project funds for duration of
             6 months only. There will be a budget ceiling that cannot be exceeded and all
             procurement is to be done in accordance with DEAT procurement procedures. Hence,
             in the event of higher consumption of receptacles than expected, the duration of the
             pilot project may have to be reduced if more funds cannot be provided.


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          b. The pilot project will also be testing the Gauteng Healthcare Waste Management
             Regulations promulgated in 2004 as well as SANS 10248:2004. The Regulations place
             the responsibility for ensuring that a collection service is provided to the minor
             HCRW generators with the Local Municipality. The pilot project will therefore, seek
             to draw conclusions and make recommendations as to the implications and
             practicalities of the Gauteng HCW Management Regulations as well as the SANS
             10248 Code. This will be useful both in the context of Gauteng, where EMM will be
             the first to address minor generators for the benefit of other local governments, as well
             as in a national context, where alternative ways of addressing HCRW from minor
             generators may be considered.

          c. The reusable as well as the disposable HCRW containers for the storage, collection,
             and transport of HCRW from minor generators will be in accordance with existing
             SANS 10248 Code and the Regulations

          d. The systems to be pilot tested include both a drop-off and a collection system for
             HCRW.

          e. A formal drop-off system will be introduced, using 2 – 3 municipal clinics, managed
             and controlled by the municipality. The exact hours and days for drop-off will be
             agreed with the EMM and the relevant clinics. The existing clinic contracts with a
             HCRW Service Provider will be honoured and agreements will be drawn up for the
             management of the additional HCRW delivered to such drop-off centres for the
             duration of the pilot project.

          f. The categories of HCRW to be included in both the drop-off and the collection system
             are (i) sharps and (ii) general infectious waste only. However, anatomical waste
             (veterinarian) will also be handled, although only by the collection service.

          g. In the selection of minor generators to participate in the pilot project, attempts will be
             made to ensure, wherever possible, that the demographics and geographies, the
             number and type of generators of the two systems tested are similar.

          h. The HCRW Service Provider will be a partner in the pilot, seeking to find solutions
             for a more efficient, effective and sustainable HCRW management system. There will
             be a service contract between DEAT and the selected Service Provider.

          i. To ensure fairness and compliance with existing service agreements, the Service
             Provider servicing most of the minor generators will be invited to be a partner in the
             pilot project. It is therefore not possible to invite tenders for a service provider in this
             instance, as that would disrupt current service agreements between the main service
             provider and the minor generators. To ensure fairness in terms of access to
             information, the experience gained from the pilot project will be disseminated to all
             stakeholders including other potential service providers and there will be periodical
             information sessions to ensure that no single service provider will get an unfair
             competitive advantage from participating in the pilot project.

          j. The supply of containers and rendering of the collection, transport, treatment and
             disposal service will be provided by means of a contract with the service provider
             already providing a service to the minor generator.

          k. Various means will be investigated to inform, educate, train and motivate the minor
             generators.

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5.     Comparison of the status quo with the alternative options
       Comparisons of the status quo against the anticipated impact of a drop-off system and a
       collection system are summarised in Annexure 1.

6.     Outline of the Two Systems

6.1     Drop-off System

       In this system, the minor generators containerise the sharps and general infectious waste in
       suitable disposable rigid plastic HCRW containers at the point of generation. The minor
       generators will take the full HCRW containers to an identified drop-off point where the
       number of containers is recorded and a clean disposable container given in return for each
       full container delivered. The HCRW is stored in 2 – 4x 240 litre wheelie bins at the drop-
       off point until collected by a bona fide service provider. The full wheelie bins containing
       the HCRW will be removed off site and replaced with clean bins. Alternatively, a single
       steel bin or a ZoZo type hut could be used to store the HCRW containers. The service
       provider will ensure that the HCRW is treated at a permitted treatment plant. The residue of
       the treatment process is to be disposed of to a permitted landfill site.

       Table 1:     Detail of the system at each step in the cycle for the Drop-off System.

        Step in the Cycle           System detail                  Equipment Specification
       Segregation and       Disposable containers:        Rigid, polyethylene or polypropylene
       containerisation       4 litre sharps container     plastic sharps container with a non-
                              7.6 litre sharps             reversible sealing lid. Preferably with
                               container                    horizontal loading
                              25 litre leak proof         Rigid, leak proof polyethylene /
                               disposable general           polypropylene plastic container with
                               infectious waste             non-reversible sealing lid.
                                                           Spare container of each type kept on
                                                            site to be used when full container is
                                                            taken to drop-off facility.
       Storage on site of     In the disposable          Quantities are small enough not to require
       the Minor               containers                 special storage requirements
       Generator
       Collection             Transported by the         Own transport. Containers equipped with
       methodology             minor generator to the     non-reversible seal to prevent accidental
                               nearest drop-off point     spillage
       Storage at Drop-       240 litre wheelie bins,    Metal bin to a maximum of 1000 litre or
       off point               metal container or Zozo    up to 4 x 240 wheelie bins. Both to be
                               hut                        lockable and secured. (Storage area
                                                          required is approximately 4 sq metres)
       Treatment              Permitted HCRW             Thermal or non-thermal HCRW treatment
                               treatment plant            technology
       Disposal               Residues to an             Class H:H landfill site for ash from
                               appropriately permitted    thermal treatment plant and GLB+ for
                               landfill site              residues from non-thermal treatment
                                                          plant.


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6.2    Outline of the Collection System

       In this system, the minor generators containerise the sharps and general infectious and in
       some cases, anatomical (animal carcasses at Vets) waste either in disposable plastic HCRW
       containers or in reusable plastic HCRW containers. The sharps and general infectious waste
       is stored in the containers on the premises. The Service Provider records the numbers of all
       reusable and disposable containers on collection of the HCRW. The processes would be as
       follows:

           o If reusable HCRW containers are used, the Service Provider collects the full
             containers and clean reusable containers are left in exchange for each full container
             removed. The Service Provider will clean the reusable containers.
           o For disposable HCRW containers a new disposable container is left in return for each
             full container removed by the service provider. The containers are then destroyed
             with the HCRW.
           o The anatomical waste from vets is double bagged in 80-micron red plastic liners
             before it is refrigerated until collected by a bona fide service provider.

       The contracted Service Provider will ensure that all categories of HCRW is treated at a
       permitted HCRW treatment plant, with all anatomical waste being treated an approved and
       permitted thermal treatment processes. The residue of the treatment process is disposed of
       to an appropriately permitted landfill site.

       Table 2:     Detail of the system at each step in the cycle for the Collection System.

         Step in the             System detail                   Equipment Specification
            Cycle
       Segregation &     Disposable containers:           Rigid, polyethylene or polypropylene
       containerisation.  4 litre sharps containers;      plastic sharps containers with non-
                          7.6 litre sharps container;     reversible sealing lid. Preferably
                          25 litre leak proof             horizontal loading;
                           disposable infectious          All disposable containers to be of
                           waste container                 polyethylene or polypropylene plastic,
                          85 litre, 80-micron red         rigid, puncture proof, leak resistant
                           disposable plastic liners       with non-reversible sealing lid;
                           for animal carcasses           Additional container of each type
                           (Vets).                         available as backup when first
                                                           container becomes full.
                           Reusable Containers:
                            40 litre reusable plastic
                             infectious HCRW
                             container.
                            68 litre reusable plastic
                             infectious HCRW
                             container.
       Storage on site.     In the disposable            Quantities are small enough not to
                             containers                    require special storage requirements.
                            Refrigeration on the site    Anatomical waste from vets stored at -2
                             for anatomical waste from     degrees C.
                             vets.
       Collection           Collected by a permitted    Vehicles must comply with the Road
       methodology.          HCRW Service Provider.      Traffic Act and other regulations and

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                                                        standards for the collection and transport
                                                        of hazardous waste.
       Treatment.           Permitted HCRW             Thermal or non-thermal HCRW treatment
                             treatment plant.           technology for general infectious and
                                                        sharps . Thermal treatment technology for
                                                        anatomical waste from vets.
       Disposal.            Residues to an             Class H:H landfill for ash from thermal
                             appropriately permitted    treatment and GLB+ for residues from
                             landfill site.             non-thermal treatment.

7.     Possible Service Scenarios for the EMM
       In terms of the Gauteng Health Care Waste Regulations, the Municipality is required to
       provide a service for the minor generators. This service can be provided in four basic ways.

       1. Municipality provides a full collection, transport, treatment and disposal service. (In-
          house HCRW management service delivery).
       2. Municipality provides a partial service with the management of drop-off points. (Partial
          outsourcing of HCRW management services)
       3. Municipality outsource the service to HCRW management industry through formal
          tender process. (Full outsourcing of HCRW management services)
       4. Service Providers have individual contracts with the minor generators. (Privatisation of
          HCRW management services)




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       Table 3:     Summary of Scenarios:


                                     Municipality to ensure a
                                     service is provided:

                                       By-laws and Gauteng
                                       HCWM Regulations


     Municipality to provide the service                Municipality to outsource the service.


     Total collection /        Partial service             Go out on           Individual
     transport service      (Operating a drop-          tender with one    contracts between
     (In-house HCRW          off point and then           or more SP’s       SP and minor
     management               outsourcing the                 (Full           generators.
     service delivery)       collection to a SP          outsourcing of     (Privatisation of
                                                             HCRW                HCRW
                                                          management          management
                                                            services)           services)



        Municipality         Partial service –             Municipality      Private contracts
        provides full          Municipality                 outsource           with the SP
         collection,         provide drop-off            service through     (existing system)
       transport and              points                  tender process
     treatment service
      Requires             Requires                    Only one SP       Requires
       infrastructure by     administration and           contracted for a   incentives for
       the                   resources at                 particular area.   minor generators
       municipality;         identified clinics;         Could increase     to take out
      Capacity issues;     Number of drop off           the costs to the   contracts with the
      Need to interact      points needs to be           minor              SP;.
       and consult with      assessed;                    generators as     Municipality will
       the minor            Storage of HCRW              MG will not be     have to have
       HCRW                  will need to be              in a position to   greater monitoring
       generators. This      assessed;                    negotiate his      of the minor
       is very time         If large HCRW                own rate.          generators;
       consuming.            quantities are              Tender            Contracts with
                             collected, the drop-         procurement        non-commercial
                             off points may be            and contract       minor generators is
                             considered as                management         not possible
                             transfer stations.           by
                                                          municipality
                                                          required.

      Greater control      Easily accessible           Municipality      Control of the
       by the                for the non-                 will have to       service by the
       municipality          commercial                   monitor and        municipality is
      Can control the       generators                   control            limited.

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       costs as it is                                        conformance        Higher costs could
       managed                                               by the SP           result as
       internally                                           Costs to minor      economies of scale
                                                             generators may      is not achievable.
                                                             be contained
                                                             through
                                                             economies of
                                                             scale.


8.     The agreed outline for the pilot project design
      The Pilot Project task team have agreed to test a combination of the service options available.
      The Pilot Project will therefore consist of the following:

       a. The Metro will test a partial service to the Minor Generators by providing 2-3 identified
          drop-off points at clinics.
       b. A service provider will be contracted to collect the HCRW accumulated at the clinic.
          The increase in the quantity of HCRW at the drop off points is assumed to be limited
          when compared to the current estimates.
       c. The existing collection system of private minor generator contracts with a Service
          Provider will be improved upon through a formal contract with a service provider and the
          pilot project.
       d. Awareness training and other educational material will be developed and distributed to
          all minor generators participating.

       Estimated number of minor generators per pilot test:

       Collection System      50 - 90
       Drop-off System        30 - 60


9.     The requirements for the drop-off centres
        Box No. 1 summarises the requirements for a drop-off system.

       Box No. 1: Brief Outline of the requirements for a Drop-off Centre:

            Two to three clinics selected as drop-off points.
            A selected group of minor HCRW generators (approximately 25 per each drop-off
             point) will agree through a Memorandum of Understanding (MoU) to participate in
             the piloting of a drop-off centre.
            The NWMSI will provide disposable sharps containers and disposable rigid plastic
             containers for general infectious waste for a 6-month period. A minimum of 2 x
             240 litre wheelie bins (or an alternative storage as agreed with the clinics) will be
             stationed at the drop-off point to receive the full containers from the minor HCRW
             generators. Estimated maximum storage area required is 4 sq. metres.
            Three sizes of new containers (4litre and 7.6 litre sharps containers and 25 litre
             disposable plastic containers for general infectious waste) will be available in
             exchange for the full containers. .Estimated storage space for new containers is 1 -
             2 sq. metre as the containers can be stacked.

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            A clinic staff member is required to receive the full containers, record the
             quantities etc. and issue a new disposable container for each full container dropped
             off.
            The NWMSI will contract a HC waste service provider for a period of 6 months to
             remove the full 240 wheelie bins and replace with clean, empty containers at a
             frequency determined by the rate at which HCRW from minor generators is
             collected. (A maximum of 1 x weekly collections)
             Note: The frequency of collections will impact on the storage capacity. At no time
              may the HCRW collected exceed 20% of what the clinic produces.
            As part of the contract, the HC waste service provider will take the full disposable
             containers to a treatment plant for destruction.


9.1    Estimated HCRW quantities and time allocation for operating the
       drop-off centre.

       As the quantities of waste generated by minor generators has not previously been calculated
       and as there have been no accurate recording of statistics, the estimates given below have
       been calculated using average quantities and international rates for converting kg to litres.

       Box No. 2: Summary of the calculations used to estimate the quantities.
            The project is working on the following estimates:
             o 6 grams of HCRW is produced per patient
             o Doctors Surgeries process 10 – 20 patients per day (6 grams x 15 patients = 90
               grams / day)
             o Converted to litres by a density factor of 0.15 (0,090 kg divided by 0.15) = 0,6
               litres / day. One doctor will therefore produce on average 0,6 litres per day of
               sharps and infectious waste,
             o For the number of drop-offs per minor generator per month, the 0,6 litre/day can
               be translated into containers of sharps and infectious waste = 4litre for sharps
               and 25 litre container for general infectious waste = a total of 29litre @ ¾ full =
               23 litre. Number of days used to fill their containers = 23 litre / 0.6 litre per day
               = 38 generating days before they need to make a drop-off.
             o Translated into wheelie bin capacity and taking into account the shape of the
               containers, the bin will only be 50% effective. It will take approximately 8 days
               to fill one bin. Say 1 week.
             o Assuming a drop-off per minor generator of 1 x monthly and assuming a drop-
               off window period of 2 x 3 hours per week: 25 Minor generators dropping off
               once per month will translate into 2/3 Minor Generators per open period. With
               ten minutes per Minor Generator to exchange the full for the empty and record
               the data = approximately 30 minutes per open period x 2 = 60 minutes per week.
             o Frequency of collection by SP is estimated at an effective loading capacity in
               the wheelie bin of say 50% (see above) the waste will be able to be
               accommodated in 2 x 240 litre wheelie bins collected once a week. More
               wheelie bins will be delivered as required to a maximum of 4 wheelie bins
               (approximately 4 sq. metres)



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9.2    Criteria for Selection of a drop-off centre

       1. A person nominated to receive the full HCRW containers from minor generators and
          exchange for a new container. (see Terms of Reference in paragraph G)
       2. The clinic must be centrally situated for a group of minor HCRW generators to gain easy
          access and for the drop-off to be available apart from the normal patient queue
       3. The Service Provider must be able to gain easy access to the area for collection of the
          accumulated HCRW from the minor generators.
       4. There must be 24-hour security for the storage of the HCRW, similar to that applied for
          the clinics itself.

9.3    Anticipated Impact on the clinic

        o Provide lockable storage of (1-2 sq. metres) for new disposable containers for infectious
          HCRW and sharps.
        o Provide storage space (approximately 4 sq metres) for the placement of lockable
          containers for the full sharps containers and infectious HCRW containers in an easy
          accessible place.
        o Agree on suitable frequency and times for the full HCRW containers to be dropped off
          by the Minor Generators during office hours.
        o Ensure that both the equipment and the storage areas are secure.
        o Nominate one person part time to manage the new stock, receive the full HCRW
          containers, record the type and quantities of HCRW containers received and exchange a
          new for a full HCRW container. (approximately 60 minutes per week)
        o The consultants will coach and assist the receiving personnel to ensure that they
          understand the requirements for accurate data recording.
        o Allow staff to be available for small, interactive training sessions, meetings and
          inspections for the purpose of analysing and presenting the results and lessons learnt
          from the pilot project.
        o Make the clinic available for monitoring of the project and assist the project team by
          giving input and suggestions for improvements.
        o Be available for site tours (by appointment only).

9.4. Qualifications and Terms of Reference for the Clinic responsible
     person.
       The person nominated to receive the full containers and exchange for a clean would need to
       be able to read and write, do simple arithmetic calculations (calculations of numbers of
       containers) and accurately record the information required for the pilot test. They would be
       interfacing with the general public, so must be proficient in English and be able to converse
       in an African Language of the region.

       The tasks that the clinic person will have to perform include:
          o Keep the small store of new containers neat and be able to keep stock of the
             containers received from the SP and exchanged with the minor generator
          o Record the containers (to be numbered) given to the Minor Generators with the
             container number, name of generator, type of container and the date exchange took
             place.
          o Inspect the full containers and ensure that the containers are adequate sealed, not
             overfilled and not damaged to the extent that there is a risk when handling.
          o Only receive HCR waste from Minor Generators in the containers made available.

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National Waste Management Strategy Implementation
             o Record the full containers from the Minor Generators and record the container
               number, name of generator, type of container and the date exchange took place
             o Be present when the SP collects the waste and ensure that the SP records the
               quantities received, weighs and records the containers, exchanges clean wheelie bins
               (if used) for the full wheelie bins and signs the manifest with date and time of
               collection.
             o Ensure that the HCR waste area is kept clean.
             o Ensure adequate security for both the full HCRW and the new stock.
       The Pilot Project Team will train the person nominated to perform the above tasks and a
       team member will be available for one-on-one tuition until they feel confident to manage the
       centre in an efficient manner.

10.    The requirements for the collection system
       The collection system is summarised in Box 2.

       Box No. 2: Brief Outline of the requirements for a Collection System:

            A maximum of 90 Minor Generators will be allocated to the collection system.
            The NWMSI will provide 2 sizes of disposable sharps containers and 25 litre
             disposable rigid plastic containers for general infectious waste for a 6-month
             period. 85 litre (80 micron) disposable plastic liners will be provided for
             anatomical waste (animal carcasses) to Vets
            Reusable containers may also be used, depending on what the SP can provide
            Refrigeration will be provided on site for anatomical waste at Vets
            The SP will provide a new disposable container in exchange for a full container. If
             reusable containers are used, the SP will exchange a full reusable container for a
             clean reusable container. The SP will ensure that the reusable containers are
             cleaned.
            The NWMSI will contract a HC waste service provider for a period of 6 months to
             provide the containers, collect the full sharps containers and general infectious
             containers directly from the minor generator’s premises at a maximum frequency
             of bi-weekly. The volume of HCRW generated will determine the frequency of the
             collection.
            As part of the contract, the HC waste service provider will take the full disposable
             containers or reusable containers to an appropriate thermal or non-thermal
             treatment plant for final destruction and the residues will be taken to an
             appropriately permitted landfill site.


10.1 Criteria for the allocation of the Mg’s to the system

10.2 Identification of the MG’s to the Collection System

10.3 Methodology for contacting the MG’s / signing of MoU’s

10.4 Awareness raising and motivation of MG’s



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11.    The appointment of a HCRW Management Service Provider for the
       Pilot Project

       The National Waste Management Strategy Implementation will appoint a service provider
       to:

           a. Collect the accumulated HCRW from minor generators at the drop-off centre (clinic)
           b. Collect the HCRW directly from a selected number of minor generators

       The service will be for the period of the pilot test (approximately 6 months)

       The Survey indicated that by far the greater proportion of minor generators surveyed have
       either a formal or an informal agreement with Sanumed to collect their HCRW. Sanumed
       are also presently servicing several of the clinics for the removal of their HCRW. In order
       not to run contrary to these existing agreements, the pilot project team would like to propose
       that the appointment of Sanumed does not go our to tender.

11.1   Motivation to use Sanumed

       By far the greater portion of the commercial minor generators identified within the pilot test
       area are using disposable HCRW containers supplied by Sanumed and the cost for removal
       for treatment and disposal of the HCRW in full containers is included in the cost of the
       container and is undertaken on-call. Although in many cases there is no formal contract
       signed between the Minor generator and the Service Provider, the Minor Generators have
       informal agreements with Sanumed. It is for this reason that Sanumed have been
       approached to enter into a partnership for the pilot project as the service provider. A
       meeting was held on ……….. with 3 other service providers who agreed in principle with
       Sanumed being contracted to supply the HCRW management service to minor generators
       during the pilot project. The following agreements and authorization documents are
       required:

11.2   Scope of the work for the Service Provider

       Sanumed will service both the drop-off clinics and the collection of HCRW from the Minor
       Generators on the collection system. Key requirements include:

          The geographical area for the pilot is in the N1, N2 and N3 areas of Ekurhuleni
           Metropolitan Municipality.
          The contract will be for a period of 6 months with the option to extend should this be
           required.
          DEAT will be responsible for all costs associated with the supply of reusable (with such
           costs being included in the cost of rendering the service) and disposable HCRW
           containers as well as for the collection, transport, treatment and disposal of HCRW
           generated by the minor HCRW generators forming part of the Minor HCRW generator
           Pilot Project;
          For the duration of the 6-month pilot project period there will be no price escalations
           unless the cost can be documented to have increased by more than 15%.
          Price escalations can be negotiated in the event of an extension to the pilot project
           period;
          Agreed prices to be invoiced per unit by Service Provider to the NWMSI Project;

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National Waste Management Strategy Implementation
             All prices are to be exclusive of VAT.

             The prices of the items listed below include complete service delivery (supply of new
              disposable and disinfected reusable HCRW containers as well the collection, transport,
              treatment and disposal of all HCRW generated by the minor generators )
             Invoices must be submitted monthly.

11.3      Formal documentation required before the pilot test can proceed

          Signed agreement from Service Providers operating in the area that they had no objection
           to Sanumed being appointed as the service provider for the pilot period;
          Signed agreement between DEAT and Sanumed for both the drop-off and the collection
           system for HCRW
          Signed agreement between DEAT and EMM and/or the clinics identified to participate
           during the pilot project as drop-off points.
          Authorisation from DEAT for the pilot project team to approach the Minor HCRW
           Generators to participate in the pilot;
          A memorandum of understanding between the Minor Generators and Sanumed.

8.        Estimated equipment quantities and costs
          The quantities given below are estimate only as there is no reliable information available on
          the quantities of waste that is generated by the minor generators. The costs quoted are the
          cost of the disposable container inclusive of the collection, treatment and disposal of the full
          containers. The costs for the reusable containers include maintenance, cleaning and return
          to the minor generator

              Equipment                        Specifications                 Est. No.    Est. unit    Total Cost
                                                                                           price
     4 litre sharps               Rigid puncture proof, polyethylene               300      R25,00      R9,000.00
     7.6 litre sharps             plastic container with sealing lid.              500      R32,00     R16,000.00
     25 litre plastic container   Horizontal loading                               300      R70,00     R21,000.00
     50 litre disposable box      Cardboard box with 80 micron liner               300      R40,00     R12,000.00
     40 litre reusable            40 litre reusable plastic container with         350             ?
                                  60 micron liner
     68 litre reusable            68 litre reusable plastic container with         210      R45.00      R3,150.00
                                  80 micron liner
     85 litre red disposable      750 mm x 950 mm 80 micron red plastic            100            ?
     plastic liner                liner
     240 litre wheelie bin        Red 240 litre wheelie bin without liner –          12           ?
                                  Rental
                                  Replacement                                                     ?
     Animal carcasses             Disposed in red 80 micron disposable         3000 kg            ?
                                  plastic liners – Cost per kg.
     Wall bracket for sharps                                                         80     R30,00      R2,400.00
     Sub Total
     Contingencies
     Total




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National Waste Management Strategy Implementation
13      Roles and Responsibilities

13.1    Responsibilities of Ekurhuleni Metropolitan Municipality

        1. Provide reasonable meeting venues at intervals for the conduction of meetings in relation
           to the pilot projects.
        2. Cover any costs incurred by its own personnel involved in the planning, monitoring and
           implementation of the Pilot Project including meetings and cost of venues.
        3. Actively participate in the planning, implementation and monitoring of the Pilot Project.

13.2    Responsibilities of the Service Provider:

        1. The Service Provider shall collect safely containerised HCRW at the agreed intervals.
           The Service Provider is already collecting HCRW from the Clinics and the waste
           received via the particular drop off facility shall be removed at the same intervals (or at
           intervals agreed with the parties) at which HCRW is collected from the Clinic before the
           commencement of the Pilot Project.
        2. All HCRW collected from the clinics will be transported, treated and disposed off by the
           Service Provider in accordance with the Gauteng HCW Regulations.
        3. The Service Provider shall keep separate records as required by the pilot project for the
           HCRW collected via the drop off facility and the other HCRW generated by the Clinic
           and arrange for separate invoicing for these two services.
        4. The Service Provider shall invoice for the HCRW collected via the Drop Off system to
           the NWMSI Project, whereas the invoicing for the HCRW generated at the Clinic shall
           be invoiced to the Clinic as before the Drop Off Pilot Project commenced.
        5. The Service Provide accepts that information and lessons learned during the pilot project
           will be made available to the general public via reports, presentations at workshops etc.
           by the NWMSI Project.
        6. Relevant Service Provider personnel will be reasonably available for meetings,
           presentations etc. for the purpose of analysing and presenting impacts of the Pilot
           Project.

13.3.   Responsibilities of the National Waste Management Strategy Implementation Project.

        1. The NWMSI Project will cover the cost of collection, transport, treatment and disposal
           of the HCRW collected via the Drop-Off component of the Minor HCRW Generator
           Pilot Project.
        2. The project will also pay for the empty receptacles for HCRW such as Sharps Containers
           and Containers for General Infections Waste (disposable plastic container) required for
           the operation of the Pilot Project as well as for any bulk storage facilities (e.g. 240-litre
           wheelie bins) for the pilot project duration.
        3. The project will be responsible for overall Pilot Project Coordination including
           monitoring, planning and convening of meetings.
        4. Relevant NWMSI Project personnel will be reasonably available for meetings,
           presentations etc. for the purpose of analysing and presenting impacts of the Pilot
           Project.


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14.      Activity Plan for the Implementation of the two systems to test

   No.                         Activity                  Completion     Comments
                                                            Date
   1.     Decision on process for agreements to be       Mid Oct    S. Molefe
          formulated and who to sign with DEAT
   2      Details of PP design agreed with SP            Mid Oct       J. Magner to
                                                                       confirm and finalise
   3.     Quote obtained from SP for the service to be   Mid Oct       J. Magner to obtain
          rendered                                                     and finalise cost
                                                                       estimates
   4.     Agreement with SP drafted and signed by        Mid Nov      S. Molefe and KO to
          DEAT personnel                                 depending    obtain signatures
           Specifications and Pricing agreed            on the       from DEAT
           Letter from other SP’s                       signing by
                                                         DEAT
   5.     Specs for MOU with MG drafted                  End Oct      TOK
   6.     Agreement with EMM clinic management           End Oct      Mr. Dube to
          and EMM solid waste management                              arrange and finalise
          department is to be finalised. Clinics
          identified and service level agreement
          signed between Solid Waste Management
          and the Family Health Department.
   7.     Minor Generators allocated to systems          End Oct      KD with Sanumed
   8.     Documents required for the management of       Mid Nov      JM to finalise
          both systems drafted
   9.     Contact made with Minor Generators             End Nov      JM to draft required
          allocated to each system where terms of                     documents.
          reference discussed and agreed and MoU’s                    RN and KD to visit
          signed.                                                     and obtain
                                                                      agreements
   10.    Contact made with Associations, Home           End Nov      JM to set up
          Based Care and Diabetic Association to
          include private persons in the drop-off
          centre
   11.    Monitoring framework developed                 Mid Dec.     All to contribute
   12.    Information documents drafted for              End          JM to arrange
          circulation (Aids / Komanani)John Snow –       January
          safe injection
   13     Capacity Building and hands on training with   End Nov      KD to conduct
          Clinic Staff
   14.    Training of EHP’s                              Mid Feb      On the
                                                                      requirements of the
                                                                      regulations
   15.    Information dissemination to community         End Jan




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National Waste Management Strategy Implementation
14.    Killer Assumptions and possible barriers
       The progress of the Minor Health Care Risk Waste Generator Project has been slow, as the
       pilot project requires a great deal of communication and interaction with a wide range of
       stakeholders. However, the planning is on track to have both a drop-off system and a
       collection system for the effective management of the HCRW running by the beginning of
       December with the proviso that there are no delays in the following:

        That the decision from the DEAT legal department on the process to formulate the
         agreements is reached before the 31st October 2005
        That consensus is reached on who in DEAT is to sign the agreements by the end of
         October
        That the agreements, when drafted and agreed are signed by the 15th November 2005
        That the clinic management of the Family Health Department of Ekurhuleni MM agree to
         manage the drop-off centres at selected clinics.
        That the SLA’s within the Ekurhulene MM and MoU’s with the Minor Generators are
         agreed and signed by the 28th November 2005.




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National Waste Management Strategy Implementation

                                                                                                                                                      Annexure 1
                 Comparison of Status Quo with anticipated impact of the proposed improvements of the two options to test
                                                          On Minor Generators

                       Present status as            Anticipated Impact of Proposed improved            Assessed motivation to             Required Action
                      assessed by survey                            systems                             participate in the pilot
     Minor
   Generators                                      Collection System         Drop-off system
Blood transfusion    Have a drop-off system                              Improvement can only        Little understanding of the    Monitor and evaluate the
& Laboratories       in place where                                      be assessed once            Gauteng Regulations.           existing drop-off system
                     commercial containers                               present system
                     are used. Waste is                                  evaluated
                     transported to their main                           .
                     depots where it is
                     collected by a SP.
Pharmacies           Have a system in place      Improvement can only    Legal implications of       Use contractors for            Monitor and evaluate the
                     for the collection of       be assessed once        larger quantities dropped   accumulated stock. Not         existing collection system
                     waste at a cost to them.    present system          off at a clinic             aware of the Gauteng
                                                 evaluated                                           Regulations
                                                 Costs can be reduced
Small                20% of the doctors did      Improvement on the      Doctors used to             Some indicated a desire to     Monitor and evaluate the
practitioners        not have a system in        present collection      collection may not want     participate                    existing collection system
                     place. All the rest had     system can only be      to drop off
                     commercial sharps, lined    assessed once present   Reduced costs may be
                     boxes and a collection of   system evaluated        an incentive
                     a SP arranged.              20% will have a safer
                                                 disposal
                                                 Costs can be reduced
Small Institutions   Most have a system in       Improvement can only                                Hoping that the project will   Monitor and evaluate the
                     place with commercial       be assessed once                                    address present poor service   existing collection system
                     sharps containers and       present system                                      delivery.
                     lined boxes and an          evaluated                                           Did generally know about the
                     external contractor to      Costs can be reduced                                Gauteng regulations
                     collect
Tattoo               All have an arrangement     Door collection         Improvement only            Are presently happy with       Monitor and evaluate the
                     with a local pharmacy for   Increased costs         assessed once present       their own arrangements         existing drop-off system
                     sharps containers that                              system evaluated. May
                     are returned to the                                 be inconvenient to drop
                     pharmacy for removal                                off at a clinic

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National Waste Management Strategy Implementation


                     Present status as              Anticipated Impact of Proposed improved                Assessed motivation to              Required Action
                    assessed by survey                              systems                                 participate in the pilot
      Minor
   Generators                                      Collection System           Drop-off system
Traditional        No safe containers used.     Safer system                Safer system                 Would appreciate a
Healers            Disposed of with             Increase in costs           Cheaper than collection      controlled waste
                   General Waste on the                                                                  management system and
                   day of collection                                                                     there is an expectation of
                                                                                                         some costs
Mortuaries         90% do not segregate         Safer system                Safer system                 Are keen to improve their
                   and dispose of risk          Increase in costs           Large quantities of          standards. Not aware of
                   waste with general.          No need for freezer if      anatomical waste will        their responsibilities with
                                                collected daily             require refrigeration        regard to regulations

Private Patients   50% do not segregate.        Safer system                Safer system                 Are keen to participate as
                   Only one patient makes       Increased costs             May not be motivated to      they have a genuine fear of
                   use of a sharps              No logistically viable to   drop off                     the health hazards for
                   container and drops it off   collect from each                                        children and see the pilot as
                   at the pharmacy when         patient’s home                                           a solution to a big problem
                   he gets his medication.                                                               for them
                   The rest do not use
                   commercial containers
                   and disposed of their
                   HCRW into newspaper
                   for disposal with the
                   general refuse,, down
                   the toilet or in a pit
                   latrine.
Vets               All use commercial           Improvement on the          Largely anatomical                                           Monitor and evaluate the
                   containers and an            present collection          waste would not be safe                                      existing collection system
                   external contract to         system can only be          to drop off unless
                   collect.                     assessed once present       refrigeration is available
                                                system evaluated
                                                Costs can be reduced




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National Waste Management Strategy Implementation

     Comparison of Status Quo with anticipated impact of proposed improvements of the two options to test

                                                                    On Ekurhuleni Metro

 Present status at Ekurhuleni Metro                    Anticipated Impact of Proposed improved systems                                Required Action


                                                    Collection System                Drop-off system at a Clinic
90% of the minor generators do have           Greater costs incurred with      Storage at the drop off centre (clinic)   Need to work with the SP so that the
some system in place for the risk waste        door collection                  Legally compliant for the transfer        existing systems are not derailed and
and make use of SP to collect. Some           Manage the contract with the      centre                                    ensure that 100% have an effective
have their own “drop-off” system. The          SP or minor generators must      Additional staff to man the station       system for the collection of HCRW
critical areas are with the traditional        have individual contacts with    Additional responsibility for the waste
healer, private patients, mortuaries and       SP                               Manage the contract with the SP for
some of the private practitioners             Less responsibility for the       collection
                                               waste                           Cheaper option for the Minor
                                                                               Generators
The Ekurhuleni Metro is presently aware       Will meet the requirements of    Depending on the quantities stored        Assist the metro in meeting the
of the requirements of the Gauteng             the Gauteng Regulations           at the clinic, will have to meet the      requirements of the regulations.
regulations that requires them to ensure                                         requirements of a “transfer station”
that a safe system is provided for Minor                                         and may require an EIA
generators
There is presently no registration system     The SP can record the           The SP can record the quantities of
in place at the metro of minor generators      quantities of waste collected   waste collected from the transfer
                                               from the MG’s and report        station and report monthly
                                               monthly
No training carried out with minor            Little training would be         Additional training on the safe
generators                                     required with the minor           handling and transporting of HCRW
                                               generators other than
                                               segregation at source
The EHP carry out some monitoring of         Monitoring of the system can be   The monitoring of this system will be       Training of the EHP’s in the
the institutions within their jurisdiction   improved through the              more difficult as the system relies on      requirements of the regulations with
and are aware of many of the problems        requirements situated in the      the MG’s bring their waste to the           regard to minor generators.
with incorrect disposal                      contract with the Metro           transfer station.
There are presently no financial              Financial options to be          Cost to the metro to run the transfer     Include the financial personnel in
implications to the metro for the              required                          stations                                  devising financial options
management of minor generators                                                  Financial options required



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National Waste Management Strategy Implementation

    Comparison of Status Quo with anticipated impact of proposed improvements of the two options to test

                                                                   On Service Providers

     Present status with Service                      Anticipated Impact of Proposed improved systems                               Required Action
              Providers

                                                  Collection System                     Drop-off system
Four service providers have minor           Pick up frequency not             Consolidated pick-ups                    Need to work with the SP so that the
generators recorded on their books           determined if on call.            Less frequent collections                existing systems are not derailed
within the Northern Districts of            Frequent small quantities
Ekurhuleni
There are formal contracts only with the    Different contracts with the      One contract for the collection of       Possible consolidation of the contract
commercial minor generators. The other       minor generators or one            waste only from the transfer station     with the SP that can be monitored by
minor generators only have on-call           contract with the Municipality                                              the metro
agreements.                                  for the collection from the
                                             minor generators
Service Providers are aware of the          SP required to report on the      SP required to report on the             Possible partnership with the SP in
regulations                                  quantities of waste collected      quantities of waste collected from the   meeting their duties
                                             from the minor generators          transfer stations

No training presently being conducted by    SP training could be              Additional training required for the     Could include training by the SP
Service Providers.                           conducted with minor               safe handling and transport of HCRW
                                             generators on segregation
There are several complaints about poor     More difficult to monitor the     Monitoring of the service easier from    Formal contract with defined outputs
service delivery and long periods            service at all the minor           the transfer stations                    are easier to monitor
between collections                          generators


The SP charges a collection fee and a       Costs could be reduced if         Would be cheaper as collection will      Consolidation of collection rounds and
service charge. Reported to be               collection rounds are              only be from the transfer stations       reduction in individual costs
approximately R200 – R300 per month          consolidated




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