Waste Management 29 (2009) 1370–1375

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Waste Management
journal homepage: www.elsevier.com/locate/wasman

Hospital waste management in Libya: A case study

M. Sawalem, E. Selic *, J.-D. Herbell
Department of Mechanical Engineering, Waste Management Engineering, University of Duisburg-Essen, Bismarckstr. 90, 47057 Duisburg, NRW, Germany

a r t i c l e i n f o a b s t r a c t

Article history: In Libya, as in many developing countries, little information is available regarding generation, handling
Accepted 21 August 2008 and disposal of hospital waste. This fact hinders the development and implementation of hospital waste
Available online 25 November 2008 management schemes. The specific objective of this study is to present an appraisal of the current situ-
ation regarding hospital waste management in Libya. Procedures, techniques, methods of handling, and
disposal of waste are presented, as well as the amounts and compositions of hospital waste. This research
was conducted in the form of a case study. Fourteen different healthcare facilities in three cities, Tripoli,
Misurata, and Sirt, all located in the northwestern part of Libya, were selected for investigation. The
investigation showed that the hospitals surveyed had neither guidelines for separated collection and clas-
sification, nor methods for storage and disposal of generated waste. This deficiency indicates the need for
an adequate hospital waste management strategy to improve and control the existing situation. The aver-
age waste generation rate was found to be 1.3 kg/patient/day, comprised of 72% general healthcare waste
(non-risk) and 28% hazardous waste. The average general waste composition was: 38% organic, 24% plas-
tics, and 20% paper. Sharps and pathological elements comprised 26% of the hazardous waste component.
Ó 2008 Elsevier Ltd. All rights reserved.

1. Introduction 2. Aim of the study

Over the past two decades, healthcare waste has been identified
as one of the major problems that negatively impact both human
health and the environment. For many years, the World Health
Organization has advocated that hospital waste be regarded as spe-
cial waste (WHO, 1985), and it is now commonly acknowledged
that certain categories of medical waste are among the most haz-
ardous and potentially dangerous of all waste arising in
communities.
In Libya, the early 1980s witnessed the passage of a number of
environmental laws and decrees, the most important of which
were: law of environment No. 7 (1982), law of atmosphere and
air protection (1992), and law of transport of hazardous materials
(2005). These legal instruments cover municipal waste manage-
ment and pollution control, but they do not include specific man-
dates regarding the management of medical waste. In fact, there
are no clearly defined regulations about the proper management
of hospital waste in Libya.
In the last few years, the Environmental General Authority in Li-
bya has worked together with the ministry of health to create reg-
ulations and instructions for medical waste management. These
are still in development because there is minimal information
available regarding generation (quantities and compositions), han-
dling and disposal of hospital waste. An appraisal of the current sit-
uation regarding hospital waste management in Libya is essential.
* Corresponding author. Tel.: +49 203 379 3625; fax: +49 203 379 3017.
E-mail address: eva.selic@uni-due.de (E. Selic).
The aim of this study is to derive an accurate description of ac-
tual hospital waste management as the basis for an appropriate
waste management strategy. The specific objectives of this study
include conducting a survey of present practices (e.g. available pro-
cedures, techniques, and methods of handling and disposing of
hospital waste), and determining the components and generation
rates of the various types of hospital waste. Taking into account
the environmental impacts, our evaluation of this data will help
to assess and propose possible treatment processes.
3. Materials and methods
Libya extends over 1,759,540 km2 and is divided into 22 dis-
tricts (shabiats). The study was conducted in the cities of Tripoli,
Misurata, and Sirt, situated in the central and northwestern parts
of Libya. These cities were selected due to their differences in size
and population. Tripoli is the capital and the largest city in the
country, Misurata is representative of medium-sized cities, and Sirt
is a typical small city. These cities serve a community of about 1.9
million inhabitants (approx. 31% of the total population of Libya)
and provide a broad range of clinical and medical services.
There are 179 hospitals in Libya (95 governmental hospitals and
84 private hospitals) with a total of 21,590 beds. There are 1424
primary healthcare facilities (Libyan Ministry of Health, 2006).
Fourteen healthcare facilities were selected for surveying on the
basis of stratified random sampling from the three cities. This sam-
ple was considered representative of different types of hospitals

0956-053X/$ - see front matter Ó 2008 Elsevier Ltd. All rights reserved.
doi:10.1016/j.wasman.2008.08.028
 M. Sawalem et al. / Waste Management 29 (2009) 1370–1375 1371

because it included two university teaching hospitals, two central
hospitals, two general hospitals, two specialist hospitals, two pri-
vate hospitals, two private clinics, and two rural health centres.
Several methods were used to collect data. Survey question-
naires were distributed by the author to various departments in
each hospital. In addition, the author assisted respondents in com-
pleting the surveys. These questionnaires (in Arabic) were based on
those recommended by the World Health Organization for the
assessment of hospital waste management practices (Pruess
et al., 1999). Certain modifications were made for relevance to
the organization of health establishments in Libya. The question-
naires contained information regarding the generation of waste
and the core aspects of segregation, collection, internal and exter-
nal storage, transport, treatment, and ultimate disposal. Table 1
summarizes the different aspects of hospital waste management
and the questions related to each aspect.
On-site inspections and interviews were conducted by the
author after being authorized by hospital management. To support
and supplement information collected in the survey, interviews
were conducted with those managers responsible for environmen-
tal healthcare in each hospital, as well as with all levels of employ-
ees who work in collection, handling and disposal of hospital
waste.
In each department of the surveyed healthcare facilities, differ-
ent-colored plastic bags were distributed for waste collection. The
following day, in the early morning, these plastic bags were
weighed before disposal to calculate total waste production. For
waste analysis, 20% of the total collected waste from each facility
was randomly chosen. The waste was analyzed and classified
according to the WHO definition by hand sorting using protective
equipment.
4. Literature survey
The World Health Organization (WHO) defines all waste gener-
ated by healthcare establishments, research facilities, and health
laboratories as healthcare waste. This healthcare waste is classified
as non-risk or general healthcare waste, which is comparable to
domestic waste, and as hazardous waste, which has the potential
to pose a variety of health risks. Hazardous healthcare waste
may also include infectious waste, pathological waste, sharps,
pharmaceutical waste, genotoxic waste, chemical waste, waste
with high heavy metal content, pressurized containers, and radio-
active waste (Pruess et al., 1999).
Waste produced in healthcare facilities in developing countries
has raised serious concerns because of inappropriate treatment
and disposal practices (Diaz et al., 2005). An increase in the under-
standing of health hazards posed by poorly managed healthcare
waste has influenced many countries to develop national and local
strategies in an effort to better manage their waste (Al-Zahrani
et al., 2000). However, in developing countries, hospital waste
Table 1
Number of questions related to aspects of hospital waste management.
has not received sufficient attention. In many countries, hazardous
and medical wastes are still handled and disposed of together with
domestic waste, thus creating a great health risk to municipal
workers, the public, and the environment (Bdour et al., 2007).
Hospital waste management and the associated pollution prob-
lems have attracted significant attention, and a great deal of re-
search has been conducted on these topics in countries such as
Kuwait (Hamoda et al., 2005), India (Patil and Pokhrel, 2005), Brazil
(Da Silva et al., 2005), Saudi Arabia (Almuneef and Memish, 2003),
Iran (Askarian et al., 2004a,b), Jordan (Oweis et al., 2005), Mauri-
tius (Mohee, 2005), and the United Kingdom (Tudor et al., 2005).
Hamoda et al. (2005) and Mohee (2005) offer a comparison of
waste generation rates reported in different countries (Table 2).
This comparison shows that developing countries have low waste
generation rates when compared to industrialized countries in Eur-
ope or the Americas. The difference is consistent with different liv-
ing habits and standards, and due to the availability of treatment
facilities.
Very few studies on hospital waste have been conducted in Li-
bya (Altabet, 2004; Alhamroush and Altabet, 2005). Accordingly,
research is required to establish a database, information and statis-
tics on healthcare waste generation, collection, transportation,
treatment and disposal. This will form the basis of planning, de-
sign, technology development and implementation of waste man-
agement facilities.
5. Results
5.1. Generation and classification of hospital waste
Solid waste generated by each hospital was weighed, and the
average quantity of waste was determined. A summary of genera-
tion rates from different types of hospitals is presented in Table 3.
The highest generation rate of 1.5 kg/patient/day was found in the
Tripoli Medical Center, followed by 1.4 kg/patient/day in the Trip-
oli Central Hospital. The lowest rates were found in the clinics and
the rural health centers. The average generation rate of hospital
waste was 1.3 kg/patient/day.
The hospital waste analyzed was comprised of 28% hazardous
waste and 72% general waste. The qualitative analysis of general
waste (Fig. 1) determined organics as the primary component
(38%), followed by plastics (24%). The high plastic content is due
to the widespread use of disposables rather than reusables for var-
ious purposes (e.g. bottles, packaging materials and bags used for
food). Paper had the third highest percentage (20%). Classification
of hazardous waste indicates that sharps and pathological waste
represents about 26% of all hazardous waste as shown in Fig. 2.
5.2. Evaluation of the survey questionnaires and on-site inspections
5.2.1. Waste collection, separation and on-site transport
Solid waste generated at all hospitals is collected by private
companies, packaged primarily in black plastic bags, and then
transported to on-site storage containers via uncovered trolleys.

No. Subject No. of questions

1. Demographic data about hospital 3 Table 2
2. Waste management regulations 8 Comparison of waste generation rates at hospitals in other countries.
3. Waste management in hospitals 10
Country Generation rate (kg/patient/day)
4. Hospital staff and their training 8
5. Waste generation 4 Saudi Arabia 1.1
6. Waste separation 3 Iran 2.7
7. Waste collection-onsite transport 5 France 3.3
8. Temporary waste storage 3 Spain 4.4
9. Waste treatment 6 United Kingdom 3.3
10. Off-site transport of waste 5 Canada 4.1
11. Final disposal of waste 6 USA 4.4
1372 M. Sawalem et al. / Waste Management 29 (2009) 1370–1375

Table 3
Hospital waste generation rates in the surveyed 14 hospitals.

Generation rate (kg/patient/day) Generated waste (kg/day) Number of patients Number of beds Type Hospital name
1.3 477 370 480 Teaching Misurata hospital
1.5 1160 800 920 Teaching Tripoli medical center
1.3 168.75 135 223 General Ibn Sina hospital
1.2 105.60 88 120 General Beni waled hospital
1.2 272.80 220 370 Central Zliten central hospital
1.4 714 510 600 Central Tripoli central hospital
1.3 107.50 80 115 Private Alsaeed hospital
1.2 82 66 85 Private Alshefa hospital
1.2 92 77 120 Specialist Thoracic hospital
1.1 108 95 133 Specialist Eyes hospital
0.9 32.80 38 – Clinic Alekha clinic
0.8 38.15 50 – Clinic Almowda clinic
0.9 42.40 45 – Rural health center Algeran rural health center
0.9 28.50 32 – Rural health center Tawerga rural health center
3429.50 2606 Total
1.3 Average

40% 38%

Average general healthcare waste

35% composition in Libya [mass%]

30%

25% 24%
[mass %]

20%
20%

15%

10% 9%
8%

5%
1%
0%
plastics textiles glass metals paper organic waste

Fig. 1. Classification of general healthcare waste in Libya (mass%).

80%
74%
Average hazardous healthcare waste
70%
composition in Libya

60%

50%
[mass %]

40%

30%
21%
20%

10%
5%

0%
other hazardous wastes sharps pathological waste

Fig. 2. Classification of hazardous healthcare waste in Libya (mass%).

This practice exposes visitors and patients to possible contamina-
tion. In only two (14%) of the surveyed hospitals, a basic hospital
waste management policy had been implemented. Sharps and nee-
dles, and waste from the operating theaters are collected in closed
plastic containers and plastic bags, respectively. They are then
transported to nearby incinerators.
5.2.2. On-site storage
The inspected on-site storage containers at all hospitals were in
poor condition. In eight hospitals (57%), the containers were placed
near the main street within the hospital buildings or were located
outside, at the street-side curb (Fig. 3). Furthermore, these contain-
ers were mostly uncovered, creating another potential hazard. Six
 M. Sawalem et al. / Waste Management 29 (2009) 1370–1375
Fig. 3. On-site storage at one healthcare facility in Libya.
hospitals (43%) had no temporary storage area, and waste was sim-
ply dumped in the corner of a hospital room until it could be trans-
ported off-site.
5.2.3. Hospital waste treatment
Six hospitals (43%) were equipped with incinerators. However,
only two (14%) were operational. The working incinerators exhib-
ited operational problems and skilled workers were often unavail-
able. The incineration process was not subject to internal or
external monitoring.
5.2.4. Off-site transport
The municipality is responsible for off-site transportation of the
waste to the final disposal site. The frequency of collection varied
from daily to three times a week. Municipal waste workers collect
the solid wastes from on-site storage containers and transport
them along with general domestic waste. In general, trucks and
(in some cases) open tractors were used for off-site transportation
(Fig. 4). The open tractors passed through residential areas, thereby
increasing potential risk to the public and the environment.
5.2.5. Final disposal
All hospitals disposed of their waste, along with general domes-
tic waste, in an open dumping site outside of the city. In these open
Fig. 4. Transportation of hospital waste in Libya.
1373
dumping sites, hospital waste was randomly mixed with general
domestic waste and was then buried or occasionally incinerated.
5.2.6. Training and education
Of the personnel surveyed, 85%, including managers, cleaning
staff, and environmental workers, were not trained in hospital
waste management and did not have a detailed description of their
duties in respect of waste handling; 55% of doctors and nurses
were unaware of hospital waste management protocols and
showed insufficient knowledge of the potential hazards; and 90%
of municipal workers responsible for transportation of hospital
waste to final disposal sites had not been alerted to hazards asso-
ciated with hospital waste. Complete protective equipment was
used in four hospitals (30%), while in five hospitals no protective
equipment was used at all (36%).
5.2.7. Hospital waste management and regulations
This study revealed that no regulations regarding the disposal of
hospital waste exist in any of the hospitals surveyed. No reference
literature on hospital waste management was available in the job
description documents of hospital staff, and there were no clearly
defined procedures for collection and handling of waste in hospi-
tals. No regular reports were compiled in any of the hospitals. No
documentation was available concerning the collection and dis-
posal of waste, nor the methods used to perform these tasks.
6. Discussion
Waste generation rates depend upon several factors, such as the
type of healthcare establishment, level of instrumentation, and
location. The higher generation rates at Tripoli were due to the
medical centers in the capital of Libya being more developed gen-
eral public facilities, and thus serving a larger number of patients
in comparison with other hospitals. It should be noted that the
average waste generation rate obtained in this study lies within
the range of values estimated by WHO (1.3–3 kg/patients/day)
for countries in North Africa and the Middle East (Alhamroush
and Altabet, 2005).
In general, no WHO-recommended appropriate and adequate
waste containers were used in the majority of hospitals.
As previously mentioned, incineration is the only existing treat-
ment system used for infectious waste and sharps. Operational ele-
ments including temperature control, height of smokestack, and
rates of smoke production were inappropriate. In Libya, proper reg-
ulations, standards and guidelines do not exist.
The dumping sites received negative assessments: lack of fences
to prevent access by stray animals; burying of the wastes randomly
without any precautions related to the types of waste; and dump-
ing sites located near agricultural areas and occasionally near res-
idential areas.
Because of the hazards of medical waste, it is important to take
precautions in handling, separating, collecting, and storing this
type of waste. In addition, sterilization methods are required to
prevent contamination of landfill sites. The methods must be
cost-effective, easily implemented, and low-maintenance. Small,
simple, and decentralized solutions for rural sites are as important
as waste incineration facilities in larger cities.
7. Conclusions
Nearly all hospitals in the studied area practice poor waste
management. Regulations regarding proper methods of waste han-
dling and disposal do not exist. Studies and reports on waste man-
agement were missing in all surveyed hospitals. Typically,
handling of hospital waste was assigned to poorly educated work-
1374 M. Sawalem et al. / Waste Management 29 (2009) 1370–1375

ers who perform all activities without proper protection, training 19. Are there any waste management responsibilities included
and guidance. Insufficient segregation, classification and treatment in the job descriptions of hospital supervisory staff?
of waste were noted at all surveyed hospitals. For the most part, 20. Are there any instructions from hospital managers to work-
hospital waste was still being dumped and mixed with domestic ers for dealing with hospital waste?
waste, which was collected, transported and disposed of in a sim- 21. Are there any defined procedures for collecting and handling
ilar manner as general municipal solid waste. Environmental mea- waste from specific units in the hospital?
sures or recycling programs were not available. 22. Are there regular reports about waste that must be provided
Our study reveals a serious need to establish and implement a to the hospital management?
proper medical waste management strategy to control and im- (c) Staff and their training
prove the current situation in Libya. Necessary steps include pro-
tecting the safety of employees, in-patients, and out-patients. 23. What is your job and responsibility?
Just as important is training regarding the handling and managing 24. Is there a job description detailing the tasks of the waste
of waste for all personnel in contact with medical waste. Waste management staff?
must be classified into hazardous and general medical waste. Ade- 25. What is their qualification and level of education?
quate interim waste storage facilities must be installed, and these 26. Does the waste management staff have information about
must include designated separate hazardous waste storage con- the dangers of hazardous waste?
tainers. In addition, sterilization methods are essential to stop con- 27. Do they use protective equipment during handling of waste?
tamination of landfill sites by infectious waste. Complete () some () none ()
This study will be followed by further investigations to examine 28. Did they receive any training on hospital waste management
landfill usage of hospital waste under desert conditions, and to de- at the time they started their job in the hospital?
velop new and improved sterilization methods that are compatible 29. Did they receive any training on hospital waste management
with the available resources in Libya. during their job?
(d) Waste generation and separation
Annex (1) Translation of survey questionnaire for managers
responsible for environmental healthcare 30. How much waste is produced daily in each department?
31. How much waste is produced daily in the hospital?
32. What type of waste is produced generally?
1. Are you aware of any environmental legislation in Libya? If yes, 33. Are there any previous statistical data regarding waste gen-
please list. eration rates in your hospital?
2. Are you aware of any specific legislation applicable to hospital 34. Are there defined separation methods for the waste
waste management? If yes, please list. produced?
3. Are you aware of any regulations, guidelines, and documents on 35. If yes, how?
management of hospital waste in Libya? 36. Are there different color codes for bags or containers for
4. Who is responsible for enforcing and controlling the legislation waste collection?
and regulation? 37. Is there any labeling on waste bags or containers?
5. Does a hospital waste management plan exist in Libya? (e) Waste collection and on-site transport
6. Are there special administrative departments for hospital waste
management in the ministry of health? 38. Who is responsible for waste collection?
7. Does your hospital compile regular reports regarding hospital 39. How often is waste collected?
waste management? 40. Are open or closed trolleys used for collection and transport?
41. Are there special trolleys to transport hazardous waste?
42. Are there defined routes for transportation of waste in the
(2) Translation of survey questionnaire for employees in hospital?
hospitals (f) Storage and waste treatment

43. Is there temporary waste storage in the hospital?

(a) Hospital data 44. Are wastes mixed together in the storage area?
8. Name of hospital............................................................................... 45. How long does the waste stay in the storage area?
9. Location............................................................................................. 46. Are there defined procedures for waste treatment in the
10. Type of hospi- hospital?
tal.................................................................................No. of beds 47. Are there any instructions for waste treatment in the
(total) ........................No. of daily patients................................. hospital?
(b) Hospital waste management 48. What kind of waste treatment facilities are available in the
hospital?
11. Are you aware of any legislation applicable to hospital waste 49. Are there incinerators in the hospital?
management? 50. Which types of waste are sent to incinerators?
12. If yes, please list: 51. Is there any control of the operating conditions of
13. Are you aware of any guidelines for hospital waste manage- incinerators?
ment in Libya? (g) Off-site transport and final disposal
14. If yes, please list.
15. Are there manuals or guidelines for hospital waste manage- 52. Who is responsible for waste transportation to final disposal
ment in your hospital? sites?
16. Does your hospital have a waste management plan? 53. What kind of trucks are used to transport waste from the
17. Who is responsible for waste management in your hospital? hospital?
18. Does your hospital have a waste management team? 54. Are there special trucks to transport hazardous waste?
 M. Sawalem et al. / Waste Management 29 (2009) 1370–1375
55. Are there any defined routes for transportation of waste to
final disposal sites?
56. Where are the locations of final disposal sites?
57. Are there special disposal sites for hospital waste?
58. What kind of landfill is used as the final disposal site?
59. Are there defined procedures for the disposal of waste?
60. Are all types of waste mixed together at this site?
61. How is hazardous waste disposed of?
References
Alhamroush, A., Altabet, A., 2005. Hospital waste in Misurata (problems, effects and
methods of disposal), Master’s thesis, Medical Technical College, Alfatih
University, Libya.
Almuneef, M., Memish, Z.A., 2003. Effective medical waste management: it can be
done. American Journal of Infection Control 31 (3), 188–192.
Altabet, A.I., 2004. Medical and chemical waste in dental clinics. In: Proceedings of
the Third Arabic Conference of Environmental Administration: New Trends in
Management of Environment Contamination Waste, Arab Administrative
Development Organization, November 23–24, 2004, Sharm Alshik, Egypt.
Al-Zahrani, M.A., Fakhri, Z.I., Al-Shanshouri, M.A., Al-Ayed, M.H., 2000. Healthcare
risk waste in Saudi Arabia. Saudi Medical Journal 21 (3), 245–250.
Askarian, M., Vakili, M., Kabir, G., 2004a. Hospital waste management status in
university hospital of the Fars province, Iran. International Journal of
Environmental Health Research 14 (4), 29–305.
1375
Askarian, M., Vakili, M., Kabir, G., 2004b. Results of a hospital waste survey in
private hospitals in Fars province, Iran. Waste Management 24, 347–352.
Bdour, A., Altrabsheh, B., Hadadin, N., Al-shareif, M., 2007. Assessment of medical
waste management practice. A case study of the northern part of Jordan. Waste
Management 27, 746–759.
Da Silva, C.E., Hoppe, A.E., Ravanello, M.M., Mello, N., 2005. Medical waste
management in the south of Brazil. Waste Management 25, 600–605.
Diaz, L.F., Savage, G.M., Eggerth, L.L., 2005. Alternatives for the treatment and
disposal of healthcare waste in developing countries. Waste Management 25,
626–637.
Hamoda, H.M., El-Tomi, H.N., Bahman, Q.Y., 2005. Variation in hospital waste
quantities and generation rates. Journal of Environmental Science and Health
A40, 467–476.
Ministry of health-Libya, 2006. Statistical annual report.
Mohee, R., 2005. Medical waste characterisation in healthcare institutions in
Mauritius. Waste Management 25, 575–581.
Oweis, R., Alwidyan, M., Al-limoon, O., 2005. Medical waste management in Jordan:
A case study at the King Hussein Medical Centre. Waste Management 25, 622–
625.
Patil, G.V., Pokhrel, K., 2005. Biomedical solid waste management in an Indian
hospital: a case study. Waste Management 25, 592–599.
Pruess, A., Giroult, E., Rushbrook, P., 1999. Safe management of waste from health
care activities. World Health Organization, Geneva, Swisse.
World Health Organization, 1985. Word Health Organization management of waste
from hospitals, EURO Reports and Studies: 97, Copenhagen.
Tudor, T.L., Noonan, C.L., Jenkin, L.E.T., 2005. Healthcare waste management: a case
study from the National Health Service in Cornwall, United Kingdom. Waste
Management 25, 606–615.