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Study Session 12 Institutional Sanitation and Waste Management

Introduction

In this session you will learn about sanitation and waste management in institutions and its importance to public health. The scope of this session will be limited to schools, health institutions, prisons, public offices and religious institutions. We will consider the essential sanitation and waste management requirements for these institutions and enable you to relate this into your own locality. However, there are other public service provider institutions such as shopping centres, mill houses, slaughterhouses and market areas that may also need to be considered.

Learning Outcomes for Study Session 12

When you have studied this session, you should be able to:

12.1 Define and use correctly each of the terms printed in bold. (SAQs 12.1 and 12.3)

12.2 Identify the minimum requirements for school sanitation and waste management. (SAQs 12.1 and 12.2)

12.3 Identify the major hazardous waste components and management options for healthcare waste. (SAQ 12.3)

12.4 Describe the activities needed for planning improvements in sanitation and waste management in local institutions. (SAQ 12.4)

12.1 Sanitation and waste management in schools

  • In Study Session 2, you learned about the effects of poor sanitation and waste management. List some of the potential impacts on schools.

  • The possible answers include health problems, impacts on attendance (especially for girls) and achievement, and pollution of the school environment.

Poor school sanitation and waste management create many problems:

  • Many school children, teachers and school administration staff are exposed to increased health risks.
  • The children’s ability to learn may be affected by helminth infections which impair their physical and cognitive development. Diarrhoeal diseases and helminth infections force many school children to be absent from school.
  • Girls are likely to be affected by lack of adequate facilities for menstrual hygiene which can contribute to them missing days at school or even to drop out.
  • If school latrines are not accessible to girls and boys with disabilities, they may not eat or drink all day to avoid needing the latrine.

Conversely good sanitation and waste management in schools means that:

  • The children are more able to integrate hygiene promotion into their daily lives and can be effective messengers and agents for change in their families and the wider community.
  • The proper behaviours that children learn at school are skills that they are likely to maintain as adults and pass on to their own children.
  • You have been a school student at some time in the past. What were the components of school health services in your time?

  • You might have various memories of events. Your classroom teacher might have checked your personal hygiene. You might have learned about the common bacterial eye infection trachoma and face-washing in science class. You were probably reminded to use the latrine properly and to wash your hands afterwards.

In Ethiopia, many schools do not have water supply or latrines at all, or if they do, they may not have handwashing facilities. Even in schools that do have facilities, these are frequently not maintained or kept clean, or may be kept locked. To give guidance on how to improve this situation, a design manual has been published jointly by the Ministry of Health, Ministry of Education and Ministry of Water and Energy in collaboration with UNICEF (MoH et al, 2012). The manual gives recommendations for safe water supply in schools and the volume of water that should be available per person per day. It also establishes the principles for sanitation and hygiene provision in schools, which are outlined in the following sections.

12.1.1 Provision of improved latrines

The provision of improved latrines with attached urinals in schools is extremely important. Many of the design requirements are similar to those for domestic latrines that you learned about in Study Session 5. For example, latrines must be located a safe distance from water sources. The government guidance for schools includes the following additional requirements:

  • There should be separate latrine blocks for boys and girls that are located away from each other in the school compound. They should be near enough to the classrooms to be convenient for use but not so close that odour is a problem. The location, design and construction must provide privacy and security. Hedges can be used as screens between girls’ and boys’ latrine blocks. Latrines for male and female teachers must be separated as well.
  • Latrines must be easy to clean, well maintained and agreeable to use.
  • The number of squat holes (cubicles) should be proportional to the number of students and take account of any future increase in school population. The recommended ratio is at least one cubicle per 100 students. All schools, regardless of size, should have a minimum of two cubicles for girls and two for boys. Using appropriately designed urinals for boys and men can reduce the total number of cubicles required.
  • Facilities should be designed to be appropriate for the size of children in the school. For example, for young children door handles and wash basins need to be lower.
  • Each latrine block should have one cubicle that is accessible to students with disabilities including those who use a wheelchair (Figure 12.1). This should have additional space inside, handrails, a raised seat and an access ramp.
  • Handwashing facilities must be provided for boys and girls.
Figure 12.1  Latrine with handrails and raised position to support disabled students.
  • In Study Session 5, you learned of the different types of latrine technologies. Which of them do you think could be used in schools?

  • Schools could use improved pit latrines or VIP latrines (with lined pit, concrete slab and vent pipe). They could use composting toilets or urine-diverting toilets if they had the necessary equipment, staff and procedures in place. Pour-flush latrines or cistern-flush toilets are also possible if there was access to water and connection to a septic tank or sewer.

12.1.2 Handwashing facilities

Handwashing facilities need to be constructed very close to all latrines and urinal blocks for use by students and teachers. The minimum requirement is a basin, a way to pour or run water over the hands, and soap. In urban Ethiopia, there are many models for handwashing stations: water taps with basins or troughs (Figure 12.2); buckets of water; and tippy taps (Figure 12.3). Remember that soap should always be available.

The greywater that results from the handwashing must be drained to a soakaway pit or septic tank (or sewer, if available). If there is enough space, it is possible to use greywater in a school garden to irrigate the vegetables.

Figure 12.2  New school latrine block with handwashing facilities.
Figure 12.3  Tippy taps are easily and cheaply made from an old plastic container and the plastic tube from a used pen.

12.1.3 Menstrual hygiene management

Menstrual hygiene management (MHM) is the management of monthly menstrual periods by women and adolescent girls using a clean material to absorb or collect menstrual blood. It is essential that this material can be changed in privacy and as often as necessary for the duration of the menstrual period. MHM includes using soap and water for washing the body as required and having access to facilities to dispose of or wash used menstrual pads and towels.

In Ethiopia, as in many parts of the developing world, MHM is one of the critical challenges facing adolescent schoolgirls. Poor facilities for MHM in most schools of Ethiopia has been shown to cause worry and humiliation, contribute to monthly absenteeism and lead to poor performance (Sommer et al, 2013).

The following facilities should be provided for adequate MHM provision in schools:

  • girls’ latrines should be in a separate location from boys’ latrines
  • individual cubicles should be fitted with doors that close properly
  • disposal facilities should be available for used disposable MHM products and washing facilities for reusable products
  • handwashing facilities and soap should be provided adjacent to the latrines
  • school offices should have MHM products available for emergency use.

12.1.4 Provision of solid waste management facilities

Schools should practise the 3 Rs of waste management. Since a large proportion of schools’ waste is paper, it may be possible to collect the paper for recycling by the paper industries. Ideally, each classroom should have separate bins for the waste that is collected for recycling and for the non-recyclable waste. Children should be encouraged to keep the classrooms and other areas clean and take pride in a clean and hygienic school environment. There should also be bins in teachers’ rooms and the playground. It is helpful to encourage a culture in schools that makes dropping litter unacceptable and helps children to develop the habit of putting waste in a bin.

If the school has its own waste disposal pit, this should be in an isolated area and fenced off to prevent access by the children. The waste should be covered with soil after placing it in the pit to reduce scavenging by rodents and birds. There could also be chemical wastes from school laboratories. These should be stored separately in a secure location for collection and disposal (the kebele authority or possibly a local hospital may be able to collect this waste).

12.2 Sanitation and waste management in health institutions

Health institutions include public and private hospitals, health centres, health posts and special clinics. All these institutions have responsibilities to ensure the safety of patients and staff which means provision of sanitation facilities and proper management of healthcare waste. Similar to the guidelines for schools, a design and construction manual for water supply and sanitation facilities in health institutions has been published by the government (MoH et al, 2013). This provides full details of the recommended provision according to the type of institution and the number of people who visit or work there; it also includes recommendations for solid waste management.

12.2.1 Sanitation

Latrines and urinals should be available in each health institution with separate and clearly signed facilities for men and women. Latrines should be clean, comfortable and pleasant to use. They should also be accessible to disabled people.

Handwashing facilities need to be constructed close to all latrines and urinal blocks for use by patients and staff. Additional handwashing facilities should be provided in any place where patients are likely to be examined so that staff can wash their hands before and after the examination.

12.2.2 Managing solid healthcare waste

  • In Study Session 7 you learned about the classification of solid waste. What are the types of waste that can be generated in health institutions?

  • Healthcare waste includes hazardous waste (approximately10-25%) and non-hazardous wastes (75–90%) which is similar in composition to commercial and residential waste.

The major concern in health institutions is proper management of hazardous wastes which include sharps (needles, etc.), pathological or anatomical waste (placentas, body parts, blood or body fluids), used gauze, bandages, gloves and plasters. It may also contain expired drugs, laboratory reagents and other chemicals.

Some of the key points in managing healthcare waste before final disposal are:

  • Healthcare workers should try to reduce the amount of waste but reducing (or reusing) waste should never be carried out if it compromises patient care or creates any other risk of infection.
  • Hazardous and non-hazardous waste must be separated and stored separately. Waste should be separated immediately by the person generating it. The different wastes should be placed in containers with the appropriate colour for that particular type of waste (FMHACA, 2013). The container for each waste type is:
    • Black bins for all non-hazardous waste such as paper, packaging materials, office supplies, drink containers, hand towels, boxes, plastic bottles and food wastes.
    • Yellow bins for infectious waste, which includes any material that has been in contact with blood or body fluids such as gauze, dressings and gloves.
    • Red bins for highly infectious wastes such as anatomical wastes (e.g. teeth, placenta) and pathological wastes (e.g. sputum-containing materials, test tubes containing specimen fluids).
    • A safety box (Figure 12.4) for sharps wastes that have the potential to cause injuries and spread disease, such as needles, scalpels, syringes, blades, and broken glass.
  • Waste disposal facilities such as an incinerator and burial pits must be available, appropriate for the type of waste and health services provided. (Disposal is described further in the next section.)
  • Water supply and handwashing facilities are very important for good personal hygiene practice among health workers and patients. In addition, all staff who handle or come in contact with the waste should be provided with appropriate protective clothing including gloves, aprons and face masks.
Figure 12.4 Safety box for collecting needles and other sharps.

12.2.3 Disposal of healthcare waste

In large cities, it may be possible for healthcare waste to be collected and taken for disposal off-site by a licensed disposal firm. However, in smaller towns and cities each healthcare facility will probably have to dispose of its own waste. The two main methods are burial or incineration (described in Study Session 10).

A number of separate pits will be needed for the different types of hazardous healthcare waste. For anatomical and pathological wastes, a placenta pit should be used. These should be sited inside the health facility compound and be at least 1 m deep. The pit should be fenced and have a locked gate. The waste should be collected in a plastic or galvanised metal container with a tight-fitting cover and immediately transported to the pit using dedicated trolleys or carts. The waste should be covered with a layer of soil immediately after disposal into the pit. Care needs to be taken over the disposal of anatomical waste that consists of identifiable body parts. Burial is the best way of disposing of these wastes, but local customs and cultures of the society must be taken into account.

Sharps and the remains of incinerated sharps safety boxes should be disposed of in a sharps pit. A properly constructed sharps pit should have a cover at the surface and be lined with concrete to make it watertight in order to avoid contamination of groundwater and soil.

Incinerators can be used to treat some hazardous healthcare wastes. If the incineration process takes place at a sufficiently high temperature, it can be an effective way of destroying pathogens and sterilising sharps, but should not be used for anatomical wastes for which a purpose-designed incinerator should be used. However, you should note that incinerators are only likely to be available in the larger health facilities in major cities and towns. The ash removed from an incinerator should be buried in an ash pit.

All burial pits for hazardous waste should be properly fenced to prevent access by people or animals. The bottom of the pit must be at least 1.5 m above the water table to prevent groundwater contamination.

12.3 Sanitation and waste management in other institutions

Other types of institution you may come across are prisons, religious institutions and public or government offices.

12.3.1 Prisons

Effective sanitation and waste management are also important in prisons, jails, and temporary arrest facilities. The transmission of communicable diseases such as diarrhoea, relapsing fever, scabies and typhus is made more likely by overcrowding and poor sanitation and hygiene. Access to safe water, showers, latrines and facilities for washing clothes are essential in a prison. There should also be appropriate solid waste disposal facilities. In addition, conditions in prisons can be improved by the following interventions:

  • A sanitation committee can organise a regular cleaning schedule with the guidance of the prison authorities. Its duty is to plan and execute a cleaning and hygiene day at least once a week. Cleaning interior rooms and the prison compound, washing clothes and personal hygiene are among the priorities to maintain the health of detainees.
  • Checking for the presence communicable diseases through regular prison inspection.
  • An insanitary interior of the prison is attractive for insects such as cockroaches, fleas, lice and bedbugs. New prisoners’ clothing and bodies must be inspected for the presence of these insects when they arrive. High standards of personal hygiene through frequent body washing, maintenance of clean premises and clean clothes should be enforced.
  • The rooms for detention should have an adequate supply of indoor light and fresh air. The surface area of windows should be a minimum of 10% of the floor area in order to admit daylight and adequate air.
  • Overcrowding must be controlled as much as possible because many people living in close proximity with each other in unhygienic conditions leads to the transmission of many communicable diseases.
  • Periodical hygiene education on selected relevant topics.

12.3.2 Religious institutions

Churches and mosques areas are places where a lot of people gather. Both church servants and those attending need to have access to good environmental health services. The provision of a safe water supply and latrines with handwashing facilities in agreed sites should have priority. Proper solid waste management is also important.

12.3.3 Public offices

Various offices are organised to serve the population, such as city/town administration bureaus, municipalities, kebele administrative offices, etc. These all need a healthy office environment for the benefit of the health of the civil servants and their visitors. Particular requirements include well lit and ventilated offices/rooms, latrines and proper solid waste management facilities. The supply of safe water and handwashing facilities are important for personal hygiene.

12.4 Planning for improvements

To make improvements to the sanitation and waste management situation in any of the institutions we have described requires careful planning. If you were involved in a scheme to make improvements to institutions, there are a number of planning activities that should be done in a stepwise manner. Some of the key activities are briefly described below.

Know the scope of your activity

This requires the identification of institutions by type and number in your working area.

Identify existing WASH-related problems

A survey to assess the conditions and gather data on any existing problems should be undertaken. This is similar to the assessments you learned about in Study Session 3. It will provide baseline data that is useful for analysing any problems and setting priorities based on the local situation. An example checklist for a school is shown in Table 12.1.

Table 12.1 School safety form.
No.Question           Response
1.0   General information
        1.1Date of inspection
        1.2Name of the institution
        1.3Number of students by sex Male/female
        1.4Address
        1.5Ownership Private/public
        1.6Level of school 1st cycle/2nd cycle
2.0   School compound
        2.1Location of school, hazards such as noise, proximity to road
        2.2Compound sanitation: free from solid waste, flowing liquid waste Yes/no – indicate the subject
3.0   Classroom
        3.1Window Adequate/inadequate
        3.2Ventilation Adequate/inadequate
        3.3Lighting Adequate/inadequate
        3.4Condition of classroom and its floor
4.0   Water supply
        4.1Is water available in the school compound? Yes/no
        4.2Source Piped/well/spring/river/other
        4.3Supply of drinking water and handwashing facilities Yes/no
        4.4Number of water taps
        4.5Cleanliness around the water point Yes/no
5.0   Latrine provision
        5.1Is latrine available in the school compound? Yes/no
        5.2Type of latrine Pit latrine/VIP/other
        5.3Floor of latrine (washable slab)Concrete slab/earth
        5.4Latrine available for: Students/teachers
        5.5Separate latrines for male and female students Yes/no
        5.6Latrine superstructure
        5.7Excreta seen around the latrine Yes/no
        5.8Excreta inside the latrine Yes/no
        5.9Can a student use the latrine in its current condition? Yes/no
        5.10Doors that lock from the inside, not the outside Yes/no
        5.11Number of latrine holes
        5.12Access to disabled children Yes/no
        5.13Access to menstrual hygiene management Yes/no
6.0   Solid waste management
        6.1Is there a refuse container in the compound? Yes/no
        6.2Is there a refuse container in each classroom? Yes/no
        6.3Is there a burial pit for refuse? Yes/no
        6.4Is there an incinerator?Yes/no
        6.5Is waste collected for disposal by a contractor?Yes/no
7.0   Students’ personal hygiene (observe a few students)
        7.1Clothing Intact/torn/clean/unclean
        7.2Hair Clean/unclean
        7.3Face Clean/unclean
        7.4Nits Yes/no
        7.5Feet Clean/unclean
        7.6Fingernails Clean/unclean
        7.7Eyes Clean/unclean
        7.8Lice Yes/no
        7.9Teeth Clean/unclean
        7.10ScabiesYes/no
8.0   Handwashing facility
        8.1Basin
        8.2Source of running water for rinsing (tap, jug) Tap/jug
        8.3Soap or ashYes/no
        8.4Soak pit to avoid standing water Yes/no
9.0   Summary of main findings
10.0  Suggestions

Identify partners that you can work with

It is useful to identify partners in order to work together and bring improvements from mutual efforts. Depending on the type of institution, partners are likely to be government offices such as the kebele administration, health office, education office, water utility, school administration, school parents’ committees, school WASH clubs, traditional leaders or police and court desks. It is also important to include authorities of religious and other local institutions/organisations.

Identify and prioritise activities

In collaboration with partners and in consultation with potential beneficiaries, proposed activities can be identified and then plans developed. There will need to be careful assessment of the resources required. Improving sanitation, waste management and hygiene so that they meet recommended requirements is challenging. For example, if a school has no latrine and the school head is advised to install latrines for students, they cannot do it immediately. They need time and a budget.

If the school has latrines but they are in poor condition (Figure 12.5) then improvements can be made more easily and require fewer resources. Other activities that may not require many resources include establishing WASH clubs, hygiene education for students, and periodically conducting personal hygiene inspections.

Figure 12.5 A dirty school latrine cubicle and wash basin with a tap that is obviously not used.
  • What improvements would you suggest for the school facilities shown in Figure 12.5?

  • The priorities would be to:

    • introduce a daily cleaning schedule to keep cubicles and the surrounding area clean
    • fit doors to the cubicles for privacy
    • provide water in a by the basin jerrycan if piped water supply is not possible
    • provide soap.

Design the plan of action

This will depend on the number and type of institution. The plan should indicate the list of activities, the timescale for implementation, the frequency for regular events like inspections, and who is responsible. It should also include appropriate follow-up activities after improvements have been made.

12.5 Regular inspection and monitoring of facilities

Inspection is a tool to identify problems, to design strategies for improvement and to monitor behaviour and the impacts of interventions. Regular visits are needed to each local public institution, at least once a year, using a checklist or a questionnaire that enables you to collect data on sanitation and waste management, similar to the checklist for schools in Table 12.1. If you are taking part in an inspection, you should inform the owners or people responsible for the institution that you want to visit them at a specified date and time. It is important to be transparent and genuine when inspecting to show that you want to help the institution to attain proper hygiene and not to criticise or penalise them. You should give advice to the owners for improvement. If you do find any violations of sanitary requirements that require enforcement, these should be reported to the kebele administrator. Monitoring is an important part of any programme for improvement and is described in more detail in Study Session 15.

Summary of Study Session 12

In Study Session 12, you have learned that:

  1. Sanitation and waste management facilities are essential for all schools to ensure that students remain healthy, attend regularly and achieve educational success.
  2. All schools need separate latrines for boys and girls and handwashing facilities with soap. Latrines should be designed with the number of children, their size and needs of disable students in mind.
  3. It is essential to provide facilities in schools that enable girls to manage their monthly menstrual periods effectively and with privacy.
  4. Schools should have several bins available for waste paper and other types of solid waste.
  5. Healthcare institutions should have routine procedures for separating hazardous from non-hazardous solid waste and for the correct handling, storage and disposal of these wastes.
  6. Usual methods for disposing of hazardous healthcare waste are burial in pits or incineration. In larger towns and cities, licensed disposal firms may be available.
  7. Prisons, religious institutions and public offices should all have latrines and handwashing facilities sufficient for the number of people using them.
  8. Planning improvements for institutional WASH requires assessment of the situation to identify problems, consideration of available resources, collaboration with partners, and the development and implementation of activity plans.
  9. Regular inspection of sanitation and waste management facilities at all types of institution is important.

Self-Assessment Questions (SAQs) for Study Session 12

Now that you have completed this study session, you can assess how well you have achieved its Learning Outcomes by answering these questions.

SAQ 12.1 (tests Learning Outcomes 12.1 and 12.2)

Imagine there is a local NGO working in the town you are assigned to that wants to develop a school WASH programme. While preparing the project documents, the delegates of the local NGO come to your office and ask you to support them. List the minimum requirements that you will advise them to include in the sanitation and hygiene part of their programme.

Answer

Your advice to the NGO needs to suggest that:

  • Separate latrines for boys and girls should be provided that are located in a convenient place in the school compound, give privacy to users, are easy to clean and agreeable to use.
  • The number of latrines should be calculated based on the number of students (one cubicle per 100 students) with a minimum of two cubicles for girls and two for boys, with urinals as well.
  • Latrines should be designed and constructed to be appropriate for children of the age at the school; small children will need facilities they can reach and feel comfortable using.
  • There should be appropriate latrine and handwashing facilities for students with disabilities.
  • Handwashing facilities with soap should be provided very close to the latrines with separate facilities for boys and girls. The supply of water for handwashing must be maintained at all times.
  • There should be appropriate provision of menstrual hygiene management facilities that ensure privacy for girls and allow them to dispose of or wash used menstrual pads hygienically.

SAQ 12.2 (tests Learning Outcome 12.2)

If the same NGO wanted to extend their schools programme to include improvements to solid waste management, what further advice would you offer?

Answer

To improve management of solid waste in schools you could advise that there should be:

  • waste bins in all classrooms and teachers rooms, with separate bins for recyclable and non-recyclable waste
  • a regular cleaning schedule to keep classrooms and all other parts of the school including latrines and the outside areas, clean and tidy
  • efforts made to discourage students from dropping litter anywhere in the school and to take pride in a clean school environment
  • a disposal pit in the grounds that is fenced off, if the school has to dispose of its own waste. Waste deposited in the pit should be covered immediately with soil.

SAQ 12.3 (tests Learning Outcomes 12.1 and 12.3)

In many towns in Ethiopia, primary collection of solid waste is done by micro- and small enterprises (MSEs). Health centres and other health institutions in the town are customers of the MSEs. Imagine you were organising some technical training for the MSE employees. Describe the major hazardous waste components of healthcare wastes that you would address during the training and identify appropriate disposal methods for each of them. In particular explain how anatomical waste should be disposed of.

Answer

Firstly, you should explain to the MSE employees that they should only collect the non-hazardous waste which should be in black bins. They should not collect waste in yellow or red bins unless authorised, because this contains hazardous material and should be kept separate. Hazardous waste needs proper management starting from generation to disposal.

However, they need to be made aware of the possible hazardous wastes and appropriate disposal methods as follows:

  • Sharps (needles, syringes etc.) should be put immediately in a sharps box and then incinerated and/or burned in a sharps pit.
  • Materials contaminated with blood or body fluids such as bandages and used gloves could be infectious so should be stored in a yellow bin and incinerated and/or buried.
  • Anatomical waste including placentas, body parts, blood etc. is also infectious and should be stored in a red bin, or yellow bin if red is not available. These wastes should not be handled by the MSE employees but should be buried in a placenta pit. A placenta pit is a burial pit specifically for placentas and other anatomical waste. It should be at least 1 m deep and be surrounded by a fence with a lockable gate. Waste should be transported on a dedicated trolley or cart, deposited in the pit as soon as it is produced and covered immediately with soil.

You should also advise the MSE employees to wear gloves and other protective clothing when carrying out their duties.

SAQ 12.4 (tests Learning Outcome 12.4)

Briefly describe the main activities needed for planning improvements in sanitation and waste management in local institutions.

Answer

The following step-by-step actions are important when developing a plan for an improvement programme:

  1. Know the scope of activity by identifying the institutions to be included.
  2. Assess the existing sanitation and waste management situation and identify the main problems.
  3. Identify the possible partners that you can work with.
  4. Identify and prioritise activities taking account of available resources.
  5. Develop and implement the plan of action.