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Section 11. Science of law
https ://doi.org/10.29013/ESR-21-5.6-99-104
Megaj Stela, PhD in Law, the Faculty of Law, University "Ismail Qemali" Vlora, Albania E-mail: mecajstela89@gmail.com Llano Arjana, PhD in Law, the Faculty of Law, University "Ismail Qemali" Vlora, Albania E-mail: ariana-llano@live.com
HOSPITAL WASTE MANAGEMENT IN ALBANIA
Abstract. Hospital waste poses a serious risk and an important problem for the environment and the health of citizens. Hospital waste is produced by many medical subjects. Training of these waste in the respect of the environment is a professional and ethical duty of all the operators of the field of medicine. This treatment should eliminate the pathogen potential that these residues contain in order to reduce environmental contamination, chemical and radioactive toxicity and uncontrolled environmental pollution. About 20% of hospital waste is categorized as hazardous waste and at the moment that these residues are in contact with other objects, these objects are considered equally. Despite the fact that there are some companies licensed by the National Environmental Agency, which are contracted by state and private hospitals to attract and treat waste at incinerators, the reality is quite chaotic. Hospital wastes are easily evidenced in waste bins located in any road or in places where it is strictly forbidden. Often, hospital waste mixes with urban ones are becoming a source of the spread of a variety diseases in the population. For the first time, the issue of hospital waste management is raised to the attention of the public and decision-makers of environmental civil society. This paper aims to provide a general overview of hospital waste in the Albanian state and the measures that need to be taken to treat them efficiently.
Keywords: hospital waste, incinerator, licensed subjects, infectious waste etc.
1. An overview of hospital waste 2. Infectious waste is generally defined as waste
Medical waste can be defined as waste generated that is able to produce infectious diseases. Infectious
as a result of diagnosis, treatment, and immunization waste should be treated and decontaminated before
of humans or animals. This is useful to categorize the landfill disposal (Directive 99/31/EC).
total waste flow into four categories [2, fq. 10]: 3. Hazardous waste is defined as waste that
1. Solid wastes include recyclable material or may contribute to mortality or serious illness or
compound. pose a significant risk to human health and the
environment, whether managed or disposed of improperly.
4. Low level radioactive waste.
In 2000, the World Health Organization estimated that injections of contaminated syringes caused 21 million people infected with the hepatitis B virus (HBV), 2 million people infected with the hepatitis C virus, and 260,000 people infected with HIV worldwide. Many of these infections were shman-gshmen if needles would be disposed safely [1, fq.10]. Infectious and anatomical remains represent the majority of hazardous waste, up to 15% of total waste from health care activities. Syringes and agates represent about 1% of total waste, but they are a major source of disease transmission if not managed properly.Chemical and pharmaceutical substances make up about 3% of waste from health care activities and 1% are radioactive substances of total health care waste [1, fq. 10].
Concerns over the issue at the European level have prompted HOSPEEM, the European Association of Healthcare Employers, and the public sector union's umbrella organization to negotiate a health and safety agreement, which was later transformed into 2010/32/EU Directive on Prevention of Injuries in the Hospital and Health Care Sector. This Directive was introduced into national legislation by EU member states and entered into force in May 2013 [3]. Health and safety regulations require employers to perform risk assessment, take appropriate control measures in the country, consult with employees, and provide information. For their part, employees must participate in training in accordance with workplace procedures. The new rules impose additional duties on both the employer and employee categories, including substitution-security devices ("Safe Sharps"), where their use is necessary and risk assessment indicates that it would be convenient and "quite practical" [3].
Four basic processes are used in the alternative treatment of medical waste: thermal, chemical, radiation and biological [4, fq. 3]. Thermal processes
rely on heat to destroy pathogens. Low heating processes use moist heat (usually steam) or dry heating. Chemical processes use disinfectants to destroy pathogens or chemicals to act on waste. Radiation involves ionizing radiation to destroy microorganisms, while biological processes use enzymes to decompose organic matter. Mechanical processes, such as shredding, mixing of tools, or compactors have been added, such as supplements to make waste unknown, improve heat or mass transfer, or reduce the volume of waste treated [4, fq. 3].
Healthcare waste contains potentially harmful microorganisms that can infect hospital patients, healthcare workers and the general public. Other potential infectious risks may include the spread of environmentally resistant chemicals from their combustion; pollution poisoning emitted by pharmaceutical products, in particular antibiotics and special drugs; poisoning and pollution through sewage; poisoning and contamination by toxic elements or compounds, such as mercury or dioxins released into the air during the process of their treatment or disposal. In developing countries, additional risks also arise from the feeding of livestock with waste at landfills, as well as from the manual classification of hazardous waste by health care centers [1, fq. 11]. Of the total amount of waste generated by healthcare activities, about 80% is general waste, while 20% is considered hazardous material that can be infectious, toxic or radioactive [1, fq. 11].
2. Legal framework for hospital waste management in the Albanian state
As part of the important administrative and legal reforms that our country has undertaken to approximate the legislation with the legislation of the EU member states, the legal package related to the management of hospital waste, otherwise known as health care waste, has been developed. This legal basis has been established mainly on the European Waste Framework Directive (2008/98/EC) and continues to be supplemented, including the relevant bylaws.
Law no. 9323, dated 25.11.2004 "On drugs and pharmaceutical service". This law aims to determine
the rules for fabrication, import, export, trade, description, use, quality control and inspection of activities related to medicines used for people in the Republic of Albania [5]. This law is implemented by all entities, legal and natural persons, state and private, local and foreign, that exercise activities provided in the provisions of this law [1, fq. 12].
Law no. 9537, dated 18.05.2006 "On the administration of hazardous waste". The law aims to set norms that regulate the safe administration of hazardous waste, collection, transport, temporary storage, processing, treatment, disposal, import and export [6]. According to this law, the management of hazardous waste is carried out without endangering human health or the environment and without using processes that can harm the environment, in particular: they do not pose a risk to air, water, soil, plants and animals; do not cause annoyance, through noise or odors; do not adversely affect the rural, urban or other areas of special interest. Hazardous waste are not allowed to be mixed with other waste, except when the mixture is useful for improving safety during transport, recovery or disposal.
Law no. 10, dated 11.05.2009 "On public health". The purpose of this law is to protect the health and promote the healthy life of the population in the Republic of Albania, through organized actions, the impact of which is equally distributed in all population groups. This law defines the activities and services of public health, their implementation, the role of the state in providing public health services and the division of responsibilities between the responsible institutions [7].
Law no. 10431, dated 09.06.2011 "On environmental protection". This law aims to protect the environment at a high level, its preservation and improvement, prevention and reduction of risks to human life and health, ensuring and improving the quality of life, for the benefit of present and future generations, as well as providing conditions for the sustainable development of the country. This law stipulates that the non-treatment of hospital waste
affects the pollution of land, water, air and consequently this pollution affects human health [8].
Decision of the Council ofMinisters no. 99, dated 18.02.2005 "On the approval of the Albanian catalog for waste classification". This decision was approved by the Council ofMinisters, in support ofArticle 100 of the Constitution and point 3 of Article 3 of Law no. 9010, dated 13.2.2003 "On the environmental administration of solid waste", on the proposal of the Minister of Environment. In this decision are classified the waste produced in our country and are listed according to their nature. According to this catalog, waste is divided into hazardous and non-hazardous waste [9]. The main chapter related to hospital waste is Chapter 18, where all hospital waste is listed with the appropriate identification number.
Decision ofthe Council ofMinisters no. 798, dated 29.09.2010 "On the approval of the regulation for the administration of hospital waste". This decision was approved by the Council of Ministers, in support of Article 100 of the Constitution, points 3 and 4 ofArticle 42 ofLaw no. 10138, dated 11.5.2009 "On public health", of article 3 of law no. 9010, dated 13.2.2003 "On the environmental administration of solid waste" and articles 26 and 27 oflaw no. 9537, dated 18.5.2006 "On the administration of hazardous waste", on the proposal of the Minister of Environment, Water Administration and the Minister of HealthThis regulation sets out the procedures, rules and technical standards for the administration ofhospital waste in order to protect public health and the environment. The chapters of this regulation clearly list the obligations ofhospital waste producers; hospital waste treatment; monitoring and administration ofhospital waste, as well as control and sanctions [10]. In 2000, a national strategy for hospital waste management was developed.
3. Institutional framework for hospital waste management
Important institutions operating in the hospital waste sector are:
Council ofMinisters - Approves regulations and laws on hospital waste management.
Ministry of Health - Approves the hospital waste monitoring program, mandatory for implementation by the producers of these wastes.
Ministry of Environment - Drafts hospital waste policies. Approves the hospital waste monitoring program, mandatory for implementation by the producers of these wastes.
ISSH - Carries out the hygienic-sanitary inspection and issues the hygienic-sanitary act for the exercise of the activity.
National Agency for Drugs and Medical Devices - Specialized institution for registration, inspection of medical devices and reporting of unwanted events.
State Environmental Inspectorate - Verifies the completion by the operator of the permit conditions after its issuance by the NBC and performs inspections in installations of type A and B.
National Environmental Agency - Defines the conditions for the relevant environmental permits, creates and manages the environmental information system, provides information to the public on the decision-making process on environmental issues, ensures the implementation of the environmental responsibility principle, manages the National Environmental Monitoring Network, verifies and evaluates any report submitted by the activity operator, verifies and evaluates the monitoring of compliance performed by the activity operator, examines the requirements for environmental impact assessment, consults and cooperates with the State Environmental Inspectorate and other inspectorates pursuant to environmental legislation, including situations of incidents, accidents and environmental emergencies.
The Regional Environmental Agency - Releases the environmental permit of type C, conducts inspections in installations of type C, maintains, administers and updates the Register of Environmental Permits of type C for installations operating in the region for which it is responsible.
Local Government Unit - Through the Municipal Inspectorate exercises control over the activity of
hospital waste owners, gives permission for disposal of hospital waste treated in the landfill treated in the case when the latter is managed by the municipality, as in the case of Sharra.
4. Hospital waste management and licensed entities in their treatment
According to an update in the list of licenses issued by the Ministry of Environment, there are 10 entities, which are categorized as hospital waste treatment entities, such as: Univers Alb, "American Hospital", Hygeia, "Treatment of hospital waste", University Hospital "Shefqet Ndroqi", "Treatment of hazardous hospital waste with hydroklava capacity 38 kg waste/hour, Univers-albcorporation grinding", Euroteam(limited liability company), "Hospital waste treatment plants", Korca Hospital Service Directorate, "Hydroklava and hospital waste sterilization", Obsterik-Gynecological University Hospital, "Treatment of hazardous hospital waste with hydroklava, capacity 35-45 kg of waste/cycle", IRIDI-ANI & KADELI and Ecoteam.
From these entities licensed for the treatment of hospital waste in the country are five state hospitals, one attached to the private hospital and is an investment of the latter and four are private companies. In the case of hospitals, regardless of whether it is a private or public hospital, they only deal with a part of the hospital waste categories, so they must have a contracted service with one of the private companies. Pharmaceutical waste in the country is not treated by any of the licensed waste treatment companies. Consequently, this category in the country is not treated at all, or is treated by entities working outside the legal conditions.
The contracting of the service for the treatment of hospital waste started in 2004 and most of the contracts were concluded in 2011 and 2014. Medi-Tel (limited liability company) is the company that covers most of the country with the service of treatment of hospital waste, however for various reasons manufacturing entities over the years change these contractors. The manufacturing entities, which have
contracted the hospital waste treatment service, are equipped with special bins, which meet the standards of the World Health Organization for the collection of this waste. The rest buy the baskets themselves, or use only one basket for all hospital waste or and for all waste, which does not meet the standards.
In creating chaos in hospital waste management all manufacturers play their role, but private entities have excessive freedom and promote as much as possible the informalization of the administrative system. The costs of providing hospital waste treatment services vary depending on the amount of waste collected, although in the case of private entities, due to inaccuracies in payment, companies have also made compromises, regardless of the amount ofwaste generated, private entities will pay a fixed value. Regarding the ways of managing hospital waste, some entities manage them by contracting a third party such as private treatment companies for hospital waste, while most choose other ways outside the legal obligations for their administration such as dumping in bins public waste, incinerationor timely disposal of this waste.
5. Conclusions
In order to address the problems encountered in the hospital waste sector, an in-depth study by line institutions should be undertaken to assess the situation of hospital waste production and treatment throughout the country. This will provide a clear overview of the amount produced, the possible ways and places of treatment, the costs and fees associated with them, but will also help reduce informality in the sector. Public production entities work in conditions of lack of infrastructure and human capacity for proper management of hospital waste. The govern-
ment should prioritize real budgeting of the sector's needs for long-term investments in hospital waste management.
Based on regional and european examples, a sustainable solution must be worked out specifically for the treatment of pharmaceutical waste in the country, both in providing the institutional framework for the management of this waste stream and in providing management and education alternatives for manufacturing entities. Inspectors should be trained to conduct inspections in waste production and treatment entities, as well as to conduct frequent inspections of all public and private entities. The philosophy of inspection should stimulate law enforcement and not the culture of penalization, despite the fact that this is one of the necessary links. An important element is the strengthening of inter-institutional cooperation, as well as the need to stimulate support among local institutions that control and monitor the situation of hospital waste.
Sector information, inspection, monitoring and self-monitoring reports should be transparent and accessible to the public. The information, educational and awareness campaigns with the production entities and the community are considered as a necessity in the conditions of a high lack of information on legal obligations and negative impacts on health and environment due to non-administration ofhos-pital waste. Civil society organizations are a source of already established capacity, which can help the government in the steps it will follow to improve the sector. Strengthening cooperation and partnership between them complements the process in all its links, and strengthens democratic governance.
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