THE COSTS OF RECYCLING THE PLASTIC OF AUTO-DISABLE (AD) SYRINGES IN UKRAINE

Transcription

1 THE COSTS OF RECYCLING THE PLASTIC OF AUTO-DISABLE (AD) SYRINGES IN UKRAINE Prepared by: Rozenn Le Mentec Consultant World Health Organization Department of Immunization, Vaccines and Biologicals Geneva, Switzerland January 2005 Acknowledgements The consultant would like to thank the following individuals for their contribution in the preparation, planning and implementation of the project: Dr. Luidmila Mukharskaya, Head of Department for Prevention of Infectious Diseases, MOH Dr Olga Stelmakh, Senior Specialist, Department for Prevention of Infectious Diseases, MOH Dr Larysa Kolos, Deputy Chief, Kiev City Sanitary Epidemiological Station, MOH Dr Larysa Kaliner, Head of Department of Epidemiology, Khmelnitsky SES, MOH Ms. Roksana, General Director of Roksana Thermoplast Company Mr Anatoliy Gluzman, General Director of Polymet Thermoplast Company Dr Youri Subbotin, WHO Liaison Officer for Ukraine Dr. Chinara Aidyralieva, WHO/EURO, Medical Officer Eric Laurent, WHO/EURO, Technical Officer, Immunization Safety

2 Executive Summary The objective of this study was to estimate the of recycling the plastic of AD syringes as carried out in a pilot project launched in April 2003 in Khmelnytsky oblast and in Kiev city in Ukraine with the support of the WHO European Regional Office. The cost information is essential in order to assess the feasibility and sustainability of expanding the new waste management system to a wider scale. The main difference between the old and the new waste management system is that instead of chemically disinfecting syringes and needles and manually separating the needles from the syringes, the pilot project has introduced needle cutting and autoclaving for the decontamination process. Recycling of the plastic from syringes was already being done from some health facilities before the pilot project. In the pilot project two companies were identified to be responsible for the recycling of the AD syringes. While recycling companies normally pay for the used syringes, they were given the AD syringes free of charge during the pilot project. The analysis illustrates that the total cost per syringe treated is similar with the old and the new system. While the cost of the old system amounts to approximately US$0.035 per syringe, the cost of the new system is about US$0.036 per syringe. The cost greatly varies with the amount of waste generated and level of utilization: the more waste managed the lower the cost per syringe. From the perspective of the health facilities the new system is considerably less time consuming. With the old system, a health facility is on average spending 46 hours on waste management a month. With the new system only approximately 5 hours are required. When translated into salary, the new system is about nine times cheaper. Moreover, in terms of safety and impact on the environment, the new system offers significant advantages. As illustrated in Table A2, needle stick injuries occurred relatively frequently with the old system, but there has not been any during the pilot project. Epidemiological studies indicate that a person who experiences one needle stick injury from a needle used on an infected source patient has risks of 30%, 1.8% and 0.3% respectively to become infected with hepatitis B, hepatitis C and HIV (WHO, Safe, 1

3 health-care waste management. Policy paper Department of Protection of the Human Environment, World Health Organization, Geneva.) In the long term, it is also not environmentally safe to dispose large quantities of disinfectant solution in sewage, due to its oxidizing power. Average (in USD) per health facility of both systems are compared in table A1. Table A1: Comparison of the of waste management with the old and the new system OLD SYSTEM NEW SYSTEM RECURRENT COSTS Unit Monthly quantity Unit Monthly quantity Disinfectant (kg) Autoclaving bag Safety box Autoclave electricity Maintenance Subtotal Salaries (hours): Nurse Head medical nurse Driver Subtotal Fuel (liters) TOTAL Value from new Useful life years Value from new Useful life years CAPITAL COSTS Needle cutter Autoclave 2, Autoclave installation TOTAL GRAND TOTAL Revenue generated from sale of syringes* 12 6 NET COSTS Cost per syringe Cost per syringe (without transport) * with the following assumptions: injections a year in each facility, 200 syringes in 1 kg and a selling price of US$0.2 per kg of used syringes for the old system and of US$0.1 per kg of (not dissembled) syringes with the current system. 2

4 Table A2: Comparison of yearly needle stick injuries of the old and the new system (eight facilities reporting) OLD SYSTEM NEW SYSTEM Average number of injuries per facility 46 0 Minimum number reported 0 0 Maximum number reported TOTAL NUMBER OF INJURIES (on average)

5 Table of content 1. INTRODUCTION BACKGROUND INFORMATION DESCRIPTION AND ASSESSMENT OF THE PILOT PROJECT COSTING METHODOLOGY COSTS AND OUTCOMES OF THE PILOT PROJECT Costs from the perspective of the health care facilities Waste generated Needle cutter Time spent on waste management in the health centre Disinfecting process Transport to recycling facilities Revenue from the sale of syringes to recycling companies Total of the pilot project Comparison with the previous system Costs to be borne by health facilities Costs from the perspective of the recycling companies Roksana Polymet CONCLUSION...23 ANNEX 1. QUESTIONNAIRE FOR ESTIMATING THE COST OF WM...25 ANNEX 2. DESCRIPTION OF THE OLD PROCESS...29 ANNEX 3. DESCRIPTION OF THE PILOT PROJECT

6 1. Introduction Each year, the overuse of injections coupled with unsafe injection practices cause an estimated 8 to 16 million hepatitis B infections, 2 to 4.5 million hepatitis C infections and 80,000 to 160,000 HIV infections world wide (1). In order to prevent unauthorized reuse of disposable syringes and limit the spread of infections due to malpractices, Ukraine has followed the WHO recommendation to introduce auto-disable (AD) syringes for all immunization activities (2). For GAVI has provided financial support for the introduction of AD syringes. No decision has, however, been taken with regard to waste management of used AD syringes. Following an assessment on injection safety (3), a pilot project aiming to assess the overall safety and viability of recycling the plastic of AD syringes was launched in Khmelnytsky oblast and Kiev city in April 2003 with the support of the WHO European Regional Office. The objective of this study is to estimate the of waste management of AD syringes as carried out in the pilot project and compare these with the of the previous system. The are assessed from the viewpoint of all partners involved, including the public health sector and the recycling companies, and are reported as the per syringe and per kilo of waste managed. The cost information is crucial when assessing the feasibility and sustainability of expanding the pilot project to a wider scale. 2. Background information With an area of 603,700 square kilometres, Ukraine is the second largest country in Europe, after the Russian Federation. It is bordered by Belarus, the Russian Federation, the Republic of Moldova, Romania, Hungary, the Slovak Republic and Poland. Since independence in 1991, Ukraine has been challenged by a deep economic crisis. In 2001, the country had a population of 48.4 million and a GDP per capita of only $720 (5). Ukraine is composed of 27 oblasts (or regions), 628 rayons (or districts) and 21,216 health care facilities, which all provide immunization services. The health care system is a decentralized system where responsibilities are fragmented among the central government, the 27 oblasts and other administrative bodies at all levels (district, village, 5

7 etc.). The government health structure is also composed of State Sanitary Epidemiological Stations (SES) whose activities include epidemiological surveillance, laboratory-based investigation of outbreaks, monitoring of food and water supply and monitoring of the population health status in general. These stations were developed during Soviet times and have changed little since independence. 3. Description and assessment of the pilot project In Ukraine, incineration, open burning and land filling are prohibited by law. Prior to the pilot project, the following health care waste management system was in place: 1. Preparation of a chemical disinfecting solution 2. Decontamination of needles and syringes with the disinfecting solution prepared 3. Manual separation of the needle from the syringe with pincers 4. Transfer of syringes and needles to separate opened carton boxes 5. Final disposal in various ways, including the transport and sale of disposable syringes to recycling companies This process is illustrated in Annex 2. This was a high-risk procedure due to the extensive manipulations of syringes and needles. The pilot project was designed with the objective of improving injection safety and waste management of used syringes. The project offers the following alternative (see Annex 3): 1. Separation of the needle from the syringe with a needle cutter 2. Containment of needles in a puncture-proof safety container 3. Containment of syringes in autoclaving bags 4. Decontamination of needles in containers * and syringes in bags by autoclaving at health facilities or at central level 5. Transport of the autoclaved waste to a recycling company 6. Shredding and recycling plastic of syringes Thirteen health facilities were selected in Khmelnytsky oblast and another ten facilities in Kiev city to participate in the pilot project. The SES in Kiev and Khmelnytsky are * Containers are not emptied. They are disposed in various manners (not recycled). 6

8 supervising the project, together with the WHO European office in Copenhagen. Their role is to ensure the quality of the overall process and to provide training and supervision. Needle cutters, autoclaving bags and puncture-proof containers were provided to all facilities selected. Three types of needle cutters with different capacities (UK Balcan: 200ml, Australian Biomed: 500ml and 7.6l) were tested within the pilot project. No new autoclave was bought. If health facilities had one or several autoclaves on their premises, the waste is autoclaved on-site. If not, a centralized system, where the waste is transported to an autoclave in a larger health facility, was implemented. Out of the 13 facilities in Khmelnytsky, five do not have an autoclave and they therefore use a centralized treatment facility. In Kiev, seven facilities use decentralized autoclaving and the remaining three send their waste for disinfection to a centralized facility. Two recycling companies are involved in the process: Polymet in Khmelnytsky oblast and Roksana in Kiev. In Khmelnytsky oblast, health facilities around Kominiets-Podolsky send their waste to Polymet directly. The other facilities located around Khmelnytsky send their waste to the local SES that in turn sends the waste to Polymet. In Kiev, the recycling company collects the waste from all facilities. Some preliminary conclusions from the project are: The needle cutter is well received by health workers. It is an easy tool that is safe to use and can easily be introduced due to its small size and relative low purchase price. Increased safety and time saved were indicated as the main advantages of the new system. Autoclaving was already used in most facilities for sterilization of medical equipment. It is an easy process that medical staff are familiar with. Centralized autoclaving is acceptable in Kiev and in large cities with good infrastructure. For remote areas, decentralized autoclaving is the most appropriate system. Recycling seems a good option and seems feasible in Ukraine as the country already has thermoplast companies. In Kiev, numerous recycling experiments are being conducted by Roksana (these will be highlighted below). In Khmelnytsky oblast, however, there is no current commitment to continue with the project. Polymet is requesting financial support for research of the most optimal technologies. If 7

9 recycling is not possible, the same process - from the use of the needle cutter and autoclave up to the shredding of plastic - could be implemented anyway. 4. Costing methodology The alternatives being compared are the occurring with the pilot project versus the of the previous system. Data collection took place between 5 th and 15 th October 2004 in Khmelnytsky oblast and Kiev city. Interviews were conducted with key individuals at MOH and SES in Kiev and Khmelnytsky and with health workers involved in the project. In addition, a questionnaire was sent to all the facilities that could not be visited due to a lack of time and the too long distances to be driven between each of the facilities. In some cases, phone interviews were also conducted. Unit and quantities of all resource items used in the waste management process were assessed by reviewing expenditure records and interviewing relevant staff about their workload with respect to waste management. All activities and equipment related to waste management are included in the cost analysis. The most important items are supplies and materials used for collection, transport, storage, treatment, disposal, decontamination and cleaning, as well as the cost of labour and material for training and maintenance. If revenue is being generated by the recycling companies from recycling of waste, this amount is subtracted from the cost estimates to generate a "net cost" estimate. Costs are divided into capital and recurrent. Capital are items whose length of life is above one year, such as needles cutters and autoclaves. Recurrent are items that are used on a regular basis, such as fuel for transport, autoclaving bags, needle containers and salaries. Capital are annualized by using a discount rate of 3% per year. An estimate of the per syringe/kg is generated by dividing the total annual of waste management with the approximate number of syringes/kg managed per year. The official US dollar exchange rate (on ) of US$1 for UAH5.3 is used for all cost estimates. 8

10 5. Costs and outcomes of the pilot project 5.1 Costs from the perspective of the health care facilities The average cost and utilization data from the facilities visited are presented in Tables 1 and 2. If the pilot project is to be extended to national level, the idea is that capital could be funded by external partners, while running are borne by the health facilities. For health facilities the of the new system would therefore only consist of the cost of autoclaving bags and puncture-proof containers, as well as transport Waste generated The number of safety boxes and kilos of waste managed during the pilot project have been precisely monitored as part of the project (since April 2004 in Khmelnytsky oblast and since June 2004 in Kiev city). These numbers depend on the size of the health facility and daily number of vaccinations done in the immunization room. The average number of vaccine injections in facilities with an autoclave on their premises is 42 per day. This figure ranges from 11 to 120 vaccinations a day. For the smaller "outlet" facilities that use a centralized facility, the number of vaccinations ranges from 5 vaccinations a month to 18 vaccinations a day. For these facilities, the average monthly number of injections is 25. According to medical staff, the average capacity of an autoclaving bag is syringes and a 500ml container can contain up to 1000 needles. On average, two bags and one 500ml container (or two 200ml containers) are used a month. However, to what extent the bags are fully filled vary between facilities. In Khmelnytsky oblast, none of the "outlet" facilities had delivered any waste, i.e. bags or containers in six months. 9

11 5.1.2 Needle cutter Large Australian Biomedical 7.6l needle cutters are not considered appropriate for small health facilities and they were not much used in the pilot project. On the other hand, the smallest of the needle cutters tested for the project (Balcan 200ml, together with the appropriate safety container, manufactured in the UK) might have too low capacity. The size of the medium needle cutter (Biomedical 500 ml) seems to be the most appropriate for the average health facility Time spent on waste management in the health centre Within the pilot project, two staff members are responsible for waste management in each facility: the nurse who works in the immunization room and the senior nurse. On average, a senior nurse earns UAH260 (US$50) a month (i.e. US$0.30 per hour) and a vaccination nurse UAH204 (US$40) monthly (or US$0.23 per hour). The nurse responsible for immunization is the one who uses the needle cutter and cleans it once daily. Time needed to cut one needle and throw the syringe in the autoclaving bag is about 5 seconds. Time needed to clean the needle cutter only amounts to a few seconds as well. Depending on the number of injections a day, the junior nurse spends 1 to 3 hours per month on waste management. In facilities with an autoclave, the junior nurse might also be responsible for the autoclaving process and for delivering the waste to the senior nurse, but usually, the autoclaving process is incumbent upon the senior nurse. The senior nurse's role is to collect autoclaving bags and safety boxes in the immunization room, bring them to the autoclave, prepare indicators for the autoclaving process, collect the autoclaved waste and store it until it is sent to or collected by the recycling company. Average time spent on waste management for the senior nurse amounts to 1.5 hours a month. Total time spent on waste management with the pilot project ranges therefore from 2 to 4.5 hours a month Disinfecting process Facilities that do not have an autoclave send their waste to a central facility nearby (30 to 35 minutes away with their own transport). The autoclaving process for the syringes from the pilot project lasts for 45 minutes. The autoclave consumes 12 kwh, so 6-9 kw are needed per cycle. On average, one to two cycles are realized per month in each facility. Autoclaves used in the facilities visited were all Russian made and were at least 10

12 20 years old. At the time, 20 years ago, one autoclave of 100l capacity cost around UAH4,000, freight charges included, but nowadays prices for a similar autoclave range between UAH12,000-48,000 (US$ 2,000-9,000). We assume a low purchase price of US$ 2,000 in our analysis due to the limited budget of Ukrainian health care facilities and we assume that the autoclave has 25 years of useful life. Maintenance is needed once a year. Average maintenance cost is UAH230 (US$45) Transport to recycling facilities Transport distances and time needed for transport vary a lot between facilities. Distances to the recycling facility range from 3 to 200 km. The average distance is 120 km (2.5 hours) which amount to 15 litres of fuel at a price of UAH2.70 per litre (one way). Due to the low quantities of waste generated within the pilot project, most facilities do not even deliver their waste to the recycling company once a month, but every other month. Moreover, other transport such as drug collection or delivery of mail is normally done during the trip. However, in order to know the overall, we allocated the full recurrent cost of transport to waste management Revenue from the sale of syringes to recycling companies Within the pilot project, the used syringes are not being sold, but given for free, to the recycling companies. However, on average, each facility delivers and sells 5kg of used disposable syringes to recycling companies per month. For these, they receive a price of UAH (US$ ) per kg. It is expected that a slightly lower price can be charged for AD syringes since body and plunger of the AD syringe are not separated and, insofar as the two kinds of plastic are incompatible and as there is a metal insert to be removed, it makes the recycling process more difficult. In our analysis, we assume a price of UAH0.5 (US$0.1) per kg of syringes. 11

13 5.1.7 Total of the pilot project Table 1: Average of waste management per health facility at decentralized level, i.e. for facilities that have an autoclave on their premises (in US$) NEW SYSTEM ITEMS Unit Monthly quantity Autoclaving bag Safety box Autoclave electricity Maintenance TOTAL ITEMS 97 Nurse Head medical nurse Driver TOTAL SALARIES 15 Fuel TOTAL TRANSPORT 180 Capital Value from new Useful life years Needle cutter Autoclave 2, Autoclave installation TOTAL CAPITAL COSTS 122 GRAND TOTAL 414 Revenue generated from the sale of syringes to recycling companies* 6 NET COSTS 408 * with the following assumptions: injections a year in each facility, 200 syringes in 1 kg and a selling price of US$0.1 per kg of used (not dissembled) syringes In an average facility, total annual recurrent amount to US$292. Transportation represent 62% of this total, and operating items such as bags and containers 11%. If transport is incumbent upon the recycling company (as it is the case with Roksana in Kiev), or if transport is done during other activities (vaccines collection) the average total recurrent to the health facility would only amount to US$112 per year, and total annual to US$228. Based on the estimated average number of 42 injections daily, i.e. 925 injections a month (22 working days) and 11,100 injections a year per facility, per syringe are as follows: 12

14 Table 2: Average per syringe at decentralized level (US$) Transportation included Transportation not included Total annual recurrent in an average facility Recurrent per syringe Total annual Total per syringe The cost per syringe treated from the perspective of the health facilities ranges from US$0.020 to US$0.036, depending on whether health facilities are responsible for delivering the waste to recycling companies or vice versa. Knowing that an AD syringe approximately US$0.05, the cost of managing an AD syringe with the current system corresponds to 38%-72% of its price. If we consider recurrent only, the cost per syringe ranges from US$0.010 to US$0.026 (20%-52% of the cost of an AD syringe). Results obtained at the small outlets are similar to the calculations for the decentralized level (see Table 3): transport is the greatest expense (55% of the total recurrent ), followed by the recurrent items - bags and containers (26%). Table 3: Average of waste management per outlet facility at central level, i.e. when the autoclaving process is not performed on-site Items Unit Monthly quantity Autoclaving bag Safety box TOTAL ITEMS 6 Nurse Head medical nurse Driver TOTAL SALARIES 4 Fuel TOTAL TRANSPORT 12 Capital Value from new Useful life years Needle cutter TOTAL CAPITAL COSTS 1 GRAND TOTAL 23 Revenue generated from the sale of syringes to recycling companies* 0 NET COSTS 23 *based on the following assumptions: 25 vaccine injections a month, i.e. 300 injections a year, 200 syringes in a kg and a price of US$0.1 per kg of used syringes. The revenue generated in this case amounts to only 20 cents a year. This figure is omitted from the calculation. 13

15 Table 4: Costs per syringe from the perspective of the outlet facility (US$) Transportation included Transportation not included Total annual recurrent in an average facility Recurrent per syringe Total annual Total per syringe If the daily number of injections increased, more bags and containers would be needed. However, the cost per syringe would be lower due to economics of scale. In general, the more waste being generated, the lower the per syringe Comparison with the previous system As opposed to the new system implemented in the selected facilities, the previous system consisted of chemically disinfecting syringes and needles, and manually separating the needles from the syringes. A large part of the used syringes were sent to a recycling company, similarly to the pilot project. Transportation were therefore in the same range, and even slightly higher as waste was delivered once monthly. Approximately two hours a day were spent on disinfecting sharps. The nurse working in the immunization room was responsible for the whole process. Ten to thirty minutes were needed to prepare the disinfecting solution, in which sharps were soaked for 1 hour. 20 to 40g of disinfectant were needed daily at a price of UAH63 per kg (average quantity: 30g). Sharps were then washed in water for 10 minutes and dried for another 30 minutes. The process was therefore time-consuming. It also represented a high risk to health workers due to the extensive manipulations of needles. Some facilities reported a yearly number of up to injuries. The negative impact on the environment also needs to be considered. It is most likely that low quantities of the disinfecting solution, when disposed in sewage after having been used for disinfection of syringes, might not be a high risk to the environment as the disinfecting solution looses some of its oxidizing power when disinfecting syringes and is further diluted in sewage. However, large quantities of disinfectant could neutralize certain bacteria and have an impact on the contamination level, hence polluting the environment. 14

16 Cost comparisons between the two systems are outlined in the following table: Table 5: Comparison of total per health facility (in USD) of previous and current systems OLD SYSTEM NEW SYSTEM RECURRENT COSTS Unit Monthly quantity Unit Monthly quantity Disinfectant (kg) Autoclaving bag Safety box Autoclave electricity Maintenance Subtotal Salaries: Nurse Head medical nurse Driver Subtotal Fuel TOTAL Value from new Useful life years Value from new Useful life years CAPITAL COSTS Needle cutter Autoclave 2, Autoclave installation TOTAL GRAND TOTAL Revenue generated from sale of syringes* 12 6 NET COSTS Cost per syringe Cost per syringe (without transport) * with the following assumptions: 11,100 injections a year in each facility, 200 syringes in 1 kg and a selling price of US$0.2 per kg of used syringes for the old system and of US$0.1 per kg with the current system. 15

17 5.1.9 Costs to be borne by health facilities The following tables are the most important ones to health facilities as they show the incurring with the new system (as opposed to the previous system) to be borne by facilities. Recurrent Table 6: Comparison of recurrent cost items, excluding salaries and transport OLD SYSTEM NEW SYSTEM Unit Monthly quantity Unit Monthly quantity Disinfectant (kg) Autoclaving bag Safety box Autoclave electricity Autoclave maintenance TOTAL COSTS Recurrent cost items that are or should be borne by health facilities include disinfectant with the old system and autoclaving bags, safety boxes, electricity and autoclave maintenance with the new system. Salaries are excluded from this estimate as they are paid by the Ministry of Health. Local manufacturing of safety boxes and autoclaving bags To calculate the recurrent (as highlighted in Table 6), we used the unit prices of the bags and safety boxes as purchased for the pilot project. However, the possibility (or necessity) to locally produce autoclaving bags and safety boxes was discussed and the first estimates for local production suggest a cost of US$0.07 for a bag and a cost of US$0.4 for a safety box. for autoclaving bags would then amount to approximately US$2 and for safety boxes to US$5. These assumptions are based on quotations from a local company. 16

18 Table 7: Estimation of of new system with locally manufactured items OLD SYSTEM NEW SYSTEM Unit Monthly quantity Unit Monthly quantity Disinfectant (kg) Autoclaving bag Safety box Autoclave electricity Autoclave maintenance TOTAL COSTS Revenue generated from the sale of syringes As mentioned previously, health facilities can sell disposable syringes for between US$0.12 and US$0.29 per kg (average selling price: US$0.2) and our assumption suggests a price of UAH0.5 (US$0.1) per kg of AD syringes (not dissembled). Therefore, the annual revenue generated by the sale of syringes with the old system is US$12 per year (based on a number of 11,100 vaccine injections a year). Revenue generated with the new system would most likely be around US$6 per year. Table 8: Comparison of cost per syringe with both systems RECURRENT COSTS OLD SYSTEM NEW SYSTEM Total items (estimate based on the actual of the pilot project) Total items (estimate using potential local prices) Revenue generated from sale of syringes 12 6 Net Cost per syringe * * based on the assumption of local manufacturing 17

19 Opportunity Table 9: Comparison of salaries OLD SYSTEM NEW SYSTEM Unit Monthly quantity Unit Monthly quantity Nurse Head medical nurse Driver TOTAL Cost per syringe As seen previously, the new system is time-saving. While health workers used to daily spend two to three hours on waste management, the average time dedicated to waste management with the pilot project is three hours monthly. Staff salaries are considered as an "opportunity cost", i.e. salaries are not directly related to waste management and not directly budgeted for. However, time spent on waste management (as opposed to any other task) represents a cost. A monetary value is determined based on the salary of the person in charge and the time spent on activities related to waste management. Opportunity of the new system are 8 times lower than opportunity of the old system. Transportation In both systems, waste is transported to recycling companies. The of transport are therefore similar. The old system might actually prove more expensive since waste was transported once monthly, whereas due to the small-scale of the pilot project, waste is on average sent to recycling companies every other month. 18

20 Table 10: Comparison of transportation OLD SYSTEM NEW SYSTEM Unit Monthly quantity Unit Monthly quantity Fuel TOTAL Cost per syringe Capital Table 11: Comparison of capital equipment Value from new OLD SYSTEM Useful life years Value from new NEW SYSTEM Useful life years Needle cutter Autoclave 2, Autoclave installation cost TOTAL Cost per syringe While capital were inexistent with the old system (no capital equipment necessary), capital with the new system include the needle cutter and the autoclave. Capital must be expressed on an annual equivalent basis in order to be combined with recurrent in a useful way. They are annualized by dividing the purchase price of the different items by the appropriate annualization factor, based on their expected length of life. Average annual of the new system amount to US$122. Table 12: Health workers' safety (eight facilities reporting) OLD SYSTEM NEW SYSTEM Average number of injuries per facility 46 0 Minimum number reported 0 0 Maximum number reported TOTAL NUMBER OF INJURIES (on average) 46 0 The risk to the health care workers with the old system was relatively high. It is difficult to cost the impact of injuries, as health workers were not reported off-sick following these 19

21 injuries. However, the improved safety of the new system is not negligible (from an estimated 46 injuries yearly to no injury). 5.2 Costs from the perspective of the recycling companies Roksana The Kiev company, founded in 1990, employs 100 staff. It recycles, produces and sells various plastic products. The capacity of Roksana is 2 tons of syringes a week, i.e. 104 tons a year (when working in 3 shifts per 24 hours). However, for the pilot project, only 130kg of AD syringes (without needles) have been recycled since the beginning of the project. The first step of the recycling process at Roksana is shredding of syringes, followed by the separation of plastic and metal insert of AD syringe by electromagnetism (use of a metal detector that was purchased in 2003 for this specific project). The third step is the introduction of "additives" via an extruder into the shredded material in order to make it homogenous. This step is necessary due to the incompatibility of the two kinds of plastic used for the body and the plunger of the syringes (polypropylene and polyethylene). The of recycling the AD syringes of the pilot project are outlined in Table 10. Roksana estimated that the recycling of the 130kg of syringes from the pilot project had taken fourteen hours. This brief analysis has shown that recurrent amounted to US$51. We do not have any indication on the selling price of products manufactured by Roksana. However, if we estimate that recycled plastic can be sold at a price that is five times higher than the price paid for the used syringes (bought at a price of US$0.11), our estimates indicate a tentative revenue of US$71 generated by the sale of syringes recycled within the pilot project, i.e. a profit of US$20. We assume that Roksana had to go and collect the waste three times in 6 months and that the quantity of fuel needed was 5 liters per trip. Transportation for the pilot project amount then to US$8. Tentative profit from recycling 130kg of syringes would be US$

22 Table 13: Cost of recycling the syringes of the pilot project at Roksana Recurrent Unit Hourly Unit Costs Hours spent quantity per hour on PP Costs of PP Electricity Shredder KW Metal detector KW Extruder KW Thermoplast KW Total electricity 17 Items USD/kg Quantity Buying price of used syringes Total Items 14 Transport Fuel * Total transport 8 Salaries Monthly Hourly Worker for shredder Worker for the metal detector Worker for the extruder Worker for the thermoplast Total salaries 20 TOTAL RECURRENT COSTS for 130 kg of syringes, excl. transport 51 Cost per kg, excl. transport 0.39 TOTAL RECURRENT COSTS for 130 kg of syringes, incl. transport 59 Cost per kg, incl. transport 0.45 TENTATIVE GENERATED REVENUE from sale of 130 kg of syringes** 71 MINIMUM PROFIT from recycling 130 kg of syringes, excl. transport 20 MINIMUM PROFIT from recycling 130kg of syringes (transport included) 12 PROFIT PER SYRINGE (without transport) PROFIT PER SYRINGE (with transport) * based on the assumption that 5l of fuel were needed per trip and that three trips were necessary to collect the 130kg of syringes, transport are estimated to be US$7.5 ** based on the assumption that recycled plastic can be sold at least at a price five times higher than the price paid for the used syringes Polymet The company based in Khmelnytsky has 128 staff. Its activities consist of recycling and manufacturing plastic and aluminium products. The company's maximum recycling capacity is 1.5 tons of disposable syringes in 16 hours (2 shifts), so maximum capacity is 45 tons a month, i.e. 540 tons a year. 21

23 According to Polymet, electricity consumption of the equipment amounts to 65KW per hour, i.e. UAH17 or US$3. As the plant is processing plastic 16 hours a day, total power consumption amounts to US$52 daily at maximum capacity. The tool Polymet is planning to design (electrical motor with small cutter) would consume 2 KW/hour. Total of recycling at Polymet are summarized in Table 11. Since the beginning of the project, Polymet has recycled 25 kg of AD syringes from all the facilities in the oblast. It took only 2 hours of one worker's time to recycle these quantities. Revenue generated from the sale of the recycled plastic was reported to be US$35. Recurrent occurring for the recycling of 25 kg of syringes amounted to US$7. The revenue generated through the sale of the plastic recycled is five times higher than recurrent and ten times higher than the purchase price of the used syringes. Net profit amounts to US$28 (for 2 hours of work). Table 14: Cost of recycling the syringes of the pilot project at Polymet Recurrent Unit Quantity Unit Costs Hours spent per hour on PP Costs of PP US$ US$ US$ US$ Electricity Oven KWh Shredder KWh Thermoplast KWh Total of electricity 2 Items Buying of used syringes kg * Total items 4 Salaries Worker Total salaries 1 TOTAL RECURRENT COSTS from 25 kg of syringes, excl. transport 7 Cost per kg, excl. transport 0.28 TENTATIVE GENERATED REVENUE from sale of 25 kg of syringes 35 NET PROFIT from recycling 25 kg of syringes 28 PROFIT PER SYRINGE (without transport) * Syringes were not sold to the recycling companies within the pilot project. However, in order to assess whether the process is sustainable, all have to be incorporated in our calculations. 22

24 Conclusion This analysis has illustrated that the cost per syringe treated from the perspective of the health facilities at decentralized level ranges from US$0.020 to US$0.036 with the new system, depending on whether health facilities are responsible for waste delivery to recycling companies or whether waste is collected by recycling companies directly. The cost greatly varies with the amount of waste generated and level of utilization: the more waste managed the lower the cost per syringe. With the old system, the cost per syringe was approximately US$ For all facilities, transport is by far the most important cost item. For decentralized facilities, transport amounts to an average of 57% of total, and for centralized facilities the figure is 55%. The main difference between the two systems is with regard to personnel. With the old system, personnel amounted to 30% of the total, whereas with the new system, personnel only represent 3% of the total. It has to be added, however, that with the new system capital represent 30% of the total, while there were no capital with the old system. During the pilot project, the recycling companies did not pay for the used syringes. However, in our cost estimates, we did include a potential purchase price. The cost calculations illustrated that the companies do have potential to make a profit from the recycling of AD syringes. 23

25 References 1. Press Release WHO/14, Safety of injection, WHO-UNICEF-UNFPA, joint statement on the use of autodisable syringes in immunization services, Laurent, E. and Balasanian, M., "Injection Safety Assessment in Ukraine", WHO EURO, September Health Care Systems in Transition, European Observatory on Health Systems and Policies 5. Pilot project proposal on recycling AD syringes in Ukraine, May Product Information Sheets, WHO,

26 ANNEX 1. QUESTIONNAIRE FOR ESTIMATING THE COST OF WM I. Description of the use of needle cutter in the process of waste management 1. Does the following system apply to your hospital? a. Use of needle cutter at the hospital b. Needles inserted in puncture-proof containers, syringes in autoclaving bags c. Needles and syringes are autoclaved at the facility (hospital) d. Disinfected sharps are transported to the recycling facility 2. How many medical staff are responsible for waste management in your facility? 3. What is their position? 4. How much time a day / a week does this person (or these persons) spend on waste management with this new system? 5. What is their salary? 6. Were these persons already responsible for waste management with the previous system? 7. How much time were they spending on waste management with the previous system (manual separation of the syringe and needle, preparation of the disinfection solution, disinfection, drying, etc.) 8. How much disinfectant was needed for disinfection per day/week/month? 9. Name the disinfectant used in the previous system. Price of the disinfectant used (in kg or litres)? 10. Did any injury occur with the previous system? If yes, number of injuries (in the last 12 months) 25

27 II. Needle cutter 1. What type of needle cutter are you using at your facility? 2. Unit price of the needle cutter? 3. How many medical staff are using the needle cutter? Is it the same person who is generally in charge of waste management? 4. Number of injections per month done in the immunization room? 5. Total number of injections per month in the facility (immunization and therapeutic)? 6. Number of safety boxes used for needles per month? If volumes are too low, state how many safety boxes you've used since the beginning of the project. 7. Capacity of the safety box 8. Unit cost of a safety box? 9. Number of autoclaving bags used for syringes per month? If volumes are too low, state how many autoclaving bags you've used since the beginning of the project. 10. Capacity of an autoclaving bag? 11. Unit cost of autoclaving bags? 12. Maintenance: Is the blade sufficiently sharp after 6 months of use? 26

28 III. Disinfection process 1. Do you have an autoclave in the facility? If the answer is no, go to Q 2. Which type of autoclave? 3. What is its capacity? How many autoclaving bags and safety boxes can it contain? 4. When was it bought? 5. What is the price of the autoclave? 6. Was the autoclave manufactured locally or was it imported? 7. If imported, what are the freight charges? 8. How much did the installation of the autoclave cost? 9. Number of autoclaving cycles done per month (only for the pilot project) 10. Total number of autoclaving cycles done per month (in total) 11. Total number of functioning autoclaves in the health centre 12. How long does an autoclaving cycle last? 13. How much electricity does it use for one cycle? 14. Is maintenance needed? How often and how much does it cost? 15. If you don't have an autoclave in the facility, where do you disinfect the sharps (and distance in kilometers to the central facility with an autoclave)? 27

29 IV. Transportation 1. What is the type of transport used for waste delivery? 2. Distance in kilometers to the recycling facility? 3. How much fuel do you need to go to and from the recycling facility? 4. Unit price of fuel? 5. How often do they transport waste to the recycling facility? 6. Would any of the trips to the recycling facility have been made anyway (to deliver mail or drugs)? 7. How many autoclaving bags and safety boxes were delivered to the facility since the start of the project? 8. Who is in charge of the transport of waste? 9. What is the salary of the person responsible for the transport of waste? 10. Are all syringes and needles transported to the recycling facility, or do you use other disposal methods (land filling, encapsulating, etc)? 11. Does your hospital usually sell used syringes (beyond this project) to the recycling company? If yes, what is the price offered? 28

30 ANNEX 2. DESCRIPTION OF THE OLD PROCESS Vaccination room Chemical decontamination of syringes and needles, after preparation of disinfecting solution Separation of needle, plunger and body Needles Syringes Transfer to carton boxes Plunger and body in different bags Disposal in various ways Transportation to processing plant Recycling (plastic) 29

31 ANNEX 3. DESCRIPTION OF THE PILOT PROJECT Vaccination room Needle cutter Needles Syringes Puncture-proof containers Autoclaving bags Decontamination by autoclaving Needles Transportation to processing plant Syringes Transportation to processing plant Disposal in various ways Recycling (plastic) 30