Feature Story

Streamlining hazardous waste management in Tunisia

February 7, 2018

Healthcare waste
Infectious healthcare waste represents a health hazard for healthcare facilities workers. “I used to work at the blood bank. And I was convinced that people were doing source separation, but that was not the case. They mixed everything. Once, picking up the bags, I got stung with a needle and contracted hepatitis,” said Nadia Chehab, a worker at the Sahloul hospital. Nadia is one of the thousands of individuals exposed to hazardous healthcare waste daily in Tunisia. “We used to put everything in one bag,” confirmed Dr. Wafa Koubaa Mahjoub, Senior Pathologist at the Habid Tamheur Hospital in Tunis, “including infectious waste as well as formol”.

Healthcare workers are not exactly the ones that make the top of the list of ‘most dangerous jobs’, so you might be surprised to learn just how dangerous healthcare work can be.

According to the World Health Organization, an estimated 66,000 Hepatitis B, 20 million hepatitis C, and up to 260,000 HIV infections occur each year as a consequence of occupational exposure. These accidents occur more frequently when healthcare waste is not adequately processed.

Alongside the spread of pathogens, poorly managed healthcare waste poses a global threat in potential release of dioxins and furans, two of the persistent organic pollutants (POPs) banned under the Stockholm Convention since 2004. For the most part, these chemicals are emitted unintentionally as byproducts of other chemical processes that routinely take place in the industrial and manufacturing sectors. Nevertheless, they accumulate in our food chain and have been proven to be highly carcinogenic. 

In Tunisia, the separation of waste tends to not be practiced, and hazardous waste is mixed with general municipal waste, ending up in open field dumps. Spontaneous combustion and inadequate incineration practices are responsible for 90% of the total amount of dioxins and furans emitted in the country.

To curb the emissions of these POPs and for the safety of healthcare workers, the government of Tunisia, with the support of the GEF and the World Bank Group, piloted the project ‘Demonstrating and Promoting Best Techniques and Practices for Managing Healthcare Waste and PCBs’.


Designed in close coordination with the Tunisian National Agency for Waste Management (Agence Nationale de Gestion des Dechets -ANGed) and finalized in 2017, the project has strengthened the regulatory framework for healthcare waste management from collection to storage, and has created structured programs to separate regular waste from hazardous and infectious waste in 96 public healthcare facilities spread across twelve governorates.

As pointed out by Mme. Afef Makini Siala, ANGed National Coordinator for Healthcare Waste Management, “the partnership of six ministries and the engagement of the private sector have been key in the development of the legal framework that promotes sound treatment and disposal of healthcare waste in the healthcare facilities - both public and private. Additionally the ANGed has invested on a permanent budget line dedicated solely to the treatment of infectious waste for every public hospital unit”.

While supporting the development of the legal framework, the project provided technical assistance to healthcare facilities, and built capacity for disposal technologies to reduce risks associated with the emissions of POPs, heavy metals and other hazardous chemicals. Information material and training were critical to its success. Manuals, posters, and brochures have benefitted 3,100 doctors, hospital directors, inspectors, and nurses. The project also enabled greater capacity for packing, collection, transport and storage of contaminated healthcare waste overall. The distribution of the equipment necessary to the safe-handling and sorting of waste - such as freezers for placenta storage, mobile containers for intramural transport of infectious waste, and intermediate storage rooms in hospitals - drastically improved the source separation process. “Until 2013, there was no agreed plan at the national level on how to manage healthcare waste. We visited other hospitals with waste management practices in place, but it was difficult to find an effective model because no program was very structured,” explains Prof. Aschraf Chadli-Debbiche, Director of Anatomic Pathology Services of the Habid Thameur Hospital in Tunis, one of the hospitals of the pilot project “Now [after the project] we separate hazardous and infectious waste and we have reduced the production of infectious healthcare waste from 120 to 90 tons per year,” she added.

With traceability that enables the efficiency of storage, treatment and transport to ANGed-controlled landfills, the project has surpassed expectations. 4,400 tons of infectious waste was processed in 2017 - more than the 3,200 ton annual goal established by the pilot project.

Private sector involvement was also critical for the long-term sustainability of the project by reducing financial risks associated with investment in the healthcare waste management sector.

Without a doubt, there is more work to be done: 2,000 healthcare centers still lack adequate resources, and there are gaps in the management of the chemical waste, including mercury. ANGed and partners, however, are now investing in the implementation of new healthcare management projects to further reduce negative impacts on the environment and protect healthcare workers. While Tunisia’s people will be the first to benefit from these improved practices, the benefits are far-reaching, potentially creating environmental benefits for not only the region, but the world.

As a result of the project, ANGed has developed a regulatory framework and now demands healthcare facilities to assign a budget for waste management, and to have a central location for hazardous medical waste collection and storage.