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

Executive Summary The objective of this study was to estimate the costs 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 costs, 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,

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health-care waste management. Policy paper. 2004. 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 costs (in USD) per health facility of both systems are compared in table A1.

Table A1: Comparison of the costs of waste management with the old and the new system

OLD SYSTEM NEW SYSTEM

RECURRENT COSTS

Unit costs

Monthly quantity

Annual costs

Unit costs

Monthly quantity

Annual costs

Disinfectant (kg) 12 0.66 95 Autoclaving bag 0.4 2 10 Safety box 2.0 1 24 Autoclave electricity 0.12 1.35 19 Maintenance 44 44 Subtotal 95 97 Salaries (hours): Nurse 0.23 44 120 0.23 1.5 4 Head medical nurse 0.4 1.5 5.4 Driver 0.23 2 5 0.23 2 5.5 Subtotal 125 15 Fuel (liters) 0.5 15 180 0.5 15 180 TOTAL 180 180

CAPITAL COSTS

Value from new

Useful life

years Annual costs

Value from new

Useful life

years Annual costs

Needle cutter 15 15 1.3 Autoclave 2,000 25 115 Autoclave installation 100 25 5.7 TOTAL 0 122 GRAND TOTAL 400 414 Revenue generated from sale of syringes* 12 6 NET COSTS 388 408 Cost per syringe 0.035 0.036 Cost per syringe (without transport) 0.018 0.020

* with the following assumptions: 11100 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.

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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 160 0 TOTAL NUMBER OF INJURIES (on average) 46 0

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Table of content

1. INTRODUCTION ..............................................................................................5

2. BACKGROUND INFORMATION .....................................................................5

3. DESCRIPTION AND ASSESSMENT OF THE PILOT PROJECT....................6

4. COSTING METHODOLOGY ............................................................................8

5. COSTS AND OUTCOMES OF THE PILOT PROJECT....................................9

5.1 Costs from the perspective of the health care facilities ....................................................................... 9 5.1.1 Waste generated ...................................................................................................................... 9 5.1.2 Needle cutter........................................................................................................................... 10 5.1.3 Time spent on waste management in the health centre................................................... 10 5.1.4 Disinfecting process............................................................................................................... 10 5.1.5 Transport to recycling facilities ............................................................................................. 11 5.1.6 Revenue from the sale of syringes to recycling companies............................................. 11 5.1.7 Total costs of the pilot project............................................................................................... 12 5.1.8 Comparison with the previous system ................................................................................ 14 5.1.9 Costs to be borne by health facilities................................................................................... 16

5.2 Costs from the perspective of the recycling companies ..................................................................... 20 5.2.1 Roksana................................................................................................................................... 20 5.2.2 Polymet .................................................................................................................................... 21

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 ......................................30

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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 2004-2007

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 costs of waste management of AD syringes

as carried out in the pilot project and compare these with the costs of the previous

system. The costs are assessed from the viewpoint of all partners involved, including the

public health sector and the recycling companies, and are reported as the costs 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,

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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

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

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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 costs occurring with the pilot project versus the

costs of the previous system. Data collection took place between 5th and 15th 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 costs 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 costs. 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 costs. Capital costs are items whose length

of life is above one year, such as needles cutters and autoclaves. Recurrent costs are

items that are used on a regular basis, such as fuel for transport, autoclaving bags,

needle containers and salaries. Capital costs are annualized by using a discount rate of

3% per year. An estimate of the costs per syringe/kg is generated by dividing the total

annual costs of waste management with the approximate number of syringes/kg

managed per year. The official US dollar exchange rate (on 6.10.2004) of US$1 for

UAH5.3 is used for all cost estimates.

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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 costs

could be funded by external partners, while running costs are borne by the health

facilities. For health facilities the costs of the new system would therefore only consist of

the cost of autoclaving bags and puncture-proof containers, as well as transport.

5.1.1 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 500-700

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.

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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.

5.1.3 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.

5.1.4 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

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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).

5.1.5 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 costs, we allocated the full

recurrent cost of transport to waste management.

5.1.6 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

UAH0.65-1.5 (US$0.12-0.29) 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.

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5.1.7 Total costs of the pilot project Table 1: Average costs 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 costs Monthly quantity Annual costs

Autoclaving bag 0.4 2 10 Safety box 2.0 1 24 Autoclave electricity 0.12 1.35 19 Maintenance 44 44 TOTAL ITEMS 97 Nurse 0.23 1.5 4 Head medical nurse 0.4 1.5 5.4 Driver 0.23 2 5.5 TOTAL SALARIES 15 Fuel 0.5 15 180 TOTAL TRANSPORT 180

Capital costs Value from new Useful life years Annual costs

Needle cutter 15 15 1.3 Autoclave 2,000 25 115 Autoclave installation 100 25 5.7 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: 11100 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 costs amount to US$292. Transportation

costs 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 costs to the health facility would only amount to US$112 per year, and total

annual costs 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,

costs per syringe are as follows:

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Table 2: Average costs per syringe at decentralized level (US$)

Transportation costs included

Transportation costs not included

Total annual recurrent costs in an average facility 292 112 Recurrent costs per syringe 0.026 0.010 Total annual costs 408 228 Total costs per syringe 0.036 0.020

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 costs 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 costs 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 costs),

followed by the recurrent items - bags and containers (26%).

Table 3: Average costs of waste management per outlet facility at central level, i.e. when the autoclaving process is not performed on-site

Items Unit costs Monthly quantity Annual costs Autoclaving bag 0.4 0.2 1 Safety box 2.0 0.2 5 TOTAL ITEMS 6 Nurse 0.23 0.5 1.5 Head medical nurse 0.4 0.5 1.8 Driver 0.23 0.25 0.6 TOTAL SALARIES 4 Fuel 0.5 10 12 TOTAL TRANSPORT 12 Capital costs Value from new Useful life years Annual costs Needle cutter 15 15 1 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.

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Table 4: Costs per syringe from the perspective of the outlet facility (US$)

Transportation costs included

Transportation costs not included

Total annual recurrent costs in an average facility 22 10 Recurrent costs per syringe 0.072 0.032 Total annual costs 23 11 Total costs per syringe 0.075 0.035

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 costs per syringe.

5.1.8 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 costs 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 100-160 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.

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Cost comparisons between the two systems are outlined in the following table:

Table 5: Comparison of total costs per health facility (in USD) of previous and current systems

OLD SYSTEM NEW SYSTEM

RECURRENT COSTS

Unit costs

Monthly quantity

Annual costs

Unit costs

Monthly quantity

Annual costs

Disinfectant (kg) 12 0.66 95 Autoclaving bag 0.4 2 10 Safety box 2.0 1 24 Autoclave electricity 0.12 1.35 19 Maintenance 44 44 Subtotal 95 97 Salaries: Nurse 0.23 44 120 0.23 1.5 4 Head medical nurse 0.4 1.5 5.4 Driver 0.23 2 5 0.23 2 5.5 Subtotal 125 15 Fuel 0.5 15 180 0.5 15 180 TOTAL 180 180

CAPITAL COSTS

Value from new

Useful life

years Annual costs

Value from new

Useful life

years Annual costs

Needle cutter 15 15 1.3 Autoclave 2,000 25 115 Autoclave installation 100 25 5.7 TOTAL 0 122 GRAND TOTAL 400 414 Revenue generated from sale of syringes* 12 6 NET COSTS 388 408 Cost per syringe 0.035 0.036 Cost per syringe (without transport) 0.018 0.020

* 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.

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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

costs incurring with the new system (as opposed to the previous system) to be borne by

facilities.

Recurrent costs

Table 6: Comparison of recurrent cost items, excluding salaries and transport

OLD SYSTEM NEW SYSTEM

Unit

costs Monthly quantity

Annual costs

Unit costs

Monthly quantity

Annual costs

Disinfectant (kg) 12 0.66 95 Autoclaving bag 0.4 2 10 Safety box 2.0 1 24 Autoclave electricity 0.12 1.35 19 Autoclave maintenance 44 44 TOTAL COSTS 95 97

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 costs (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. Annual costs 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.

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Table 7: Estimation of costs of new system with locally manufactured items

OLD SYSTEM NEW SYSTEM

Unit

costs Monthly quantity

Annual costs

Unit costs

Monthly quantity

Annual costs

Disinfectant (kg) 12 0.66 95 Autoclaving bag 0.07 2 2 Safety box 0.4 1 5 Autoclave electricity 0.12 1.35 19 Autoclave maintenance 44 44 TOTAL COSTS 95 70

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 costs of the pilot project) 95 97 Total items (estimate using potential local prices) 95 70 Revenue generated from sale of syringes 12 6 Net costs 83 63 Cost per syringe 0.0074 0.0057*

* based on the assumption of local manufacturing

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Opportunity costs

Table 9: Comparison of salaries

OLD SYSTEM NEW SYSTEM

Unit

costs Monthly quantity

Annual costs

Unit costs

Monthly quantity

Annual costs

Nurse 0.23 44 120 0.23 1.5 4 Head medical nurse 0.4 1.5 5 Driver 0.23 2 5 0.23 2 5 TOTAL 125 14 Cost per syringe 0.0113 0.0013

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 costs of the new system are 8 times lower than opportunity costs of the old

system.

Transportation costs

In both systems, waste is transported to recycling companies. The costs 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.

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Table 10: Comparison of transportation costs

OLD SYSTEM NEW SYSTEM

Unit

costs Monthly quantity

Annual costs

Unit costs

Monthly quantity

Annual costs

Fuel 0.5 15 180 0.5 15 180 TOTAL 180 180 Cost per syringe 0.016 0.016

Capital costs Table 11: Comparison of capital equipment costs

OLD SYSTEM NEW SYSTEM

Value from new

Useful life

years Annual costs

Value from new

Useful life

years Annual costs

Needle cutter 15 15 1 Autoclave 2,000 25 115 Autoclave installation cost 100 25 6 TOTAL 0 122 Cost per syringe 0.011

While capital costs were inexistent with the old system (no capital equipment necessary),

capital costs with the new system include the needle cutter and the autoclave. Capital

costs must be expressed on an annual equivalent basis in order to be combined with

recurrent costs 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 costs 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 160 0 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

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

5.2.1 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

costs 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 costs 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 costs for the pilot

project amount then to US$8. Tentative profit from recycling 130kg of syringes would be

US$12.7.

20

Table 13: Cost of recycling the syringes of the pilot project at Roksana Recurrent costs

Unit Hourly quantity

Unit costs

Costs per hour

Hours spent on PP Costs of PP

Electricity Shredder KW 11 0.05 0.55 2 1 Metal detector KW 0.1 0.05 0.005 2 0 Extruder KW 40 0.05 2 2 4 Thermoplast KW 30 0.05 1.5 8 12 Total electricity 17 Items USD/kg Quantity Buying price of used syringes 0.11 130 14 Total Items 14 Transport Fuel 0.5 15 8* Total transport 8 Salaries Monthly Hourly Worker for shredder 150 0.85 2 2 Worker for the metal detector 200 1.14 2 2 Worker for the extruder 200 1.14 2 2 Worker for the thermoplast 300 1.70 8 14 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 costs included) 12 PROFIT PER SYRINGE (without transport) 0.0008 PROFIT PER SYRINGE (with transport) 0.0005

* 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 costs 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.

5.2.2 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

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

costs 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 costs 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 costs 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 costs

Unit Quantity Unit costs

Costs per hour

Hours spent on PP Costs of PP

US$ US$ US$ US$ Electricity Oven KWh 35 0.05 1.75 0.5 1 Shredder KWh 5 0.05 0.25 0.5 0 Thermoplast KWh 25 0.05 1.25 1 1 Total costs of electricity 2 Items Buying of used syringes kg 25 0.15 4*

Total items 4 Salaries Worker 85 0.5 2 1 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) 0.0055

* Syringes were not sold to the recycling companies within the pilot project. However, in order to assess whether the process is sustainable, all costs have to be incorporated in our calculations.

22

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$0.035.

For all facilities, transport is by far the most important cost item. For decentralized

facilities, transport amounts to an average of 57% of total costs, 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 costs amounted to 30% of the total costs, whereas with the new

system, personnel costs only represent 3% of the total costs. It has to be added,

however, that with the new system capital costs represent 30% of the total costs, while

there were no capital costs 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

References

1. Press Release WHO/14, 2000

2. Safety of injection, WHO-UNICEF-UNFPA, joint statement on the use of auto-disable syringes in immunization services, 2003

3. Laurent, E. and Balasanian, M., "Injection Safety Assessment in Ukraine", WHO

EURO, September 2002

4. Health Care Systems in Transition, European Observatory on Health Systems and Policies

5. Pilot project proposal on recycling AD syringes in Ukraine, May 2003

6. Product Information Sheets, WHO, 2000

24

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

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

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)?

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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?

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ANNEX 2. DESCRIPTION OF THE OLD PROCESS

Chemical decontamination of syringes and needles, after preparation of disinfecting solution

Vaccination room

Needles Syringes

Transfer to carton boxes

Plunger and body in different bags

Separation of needle, plunger and

body

Transportation to

processing plant Disposal in various

ways Recycling

(plastic)

29

ANNEX 3. DESCRIPTION OF THE PILOT PROJECT

Vaccination room

Syringes

Autoclaving bags

Needles

Puncture-proof containers

Needle cutter

Decontamination by autoclaving

Transportation to processing plant

Needles Syringes

Transportation to processing plant

Disposal in various ways

Recycling (plastic)

30