Biomedical waste could be India’s ticking bomb—or a thriving market

Uttar Pradesh, India’s most populous state and one of its poorest, hasn’t had the best track record in terms of medical facilities. Most infamously, 30 children died in the main government hospital in the district of Gorakhpur in 2017 due to a lack of oxygen cylinders. In January, the same hospital, Baba Raghav Das Medical College, was fined Rs 5 crore ($720,000) by the National Green Tribunal for improper disposal and burning of biomedical waste this January.

The problem of biomedical waste disposal isn’t new to Gorakhpur, nor limited to it. In 2016, Gaurav Srivastava filed a Right to Information, or RTI, request to find out how many biomedical waste treatment facilities existed in Gorakhpur and three nearby districts. 34-year-old Srivastava, who formerly worked on climate change issues and as an environmental auditor in the state, received a damning response—zero.

Little has changed since. Uttar Pradesh, as on 25 July 2018, had 525 violations of the Biomedical Waste Management Rules by healthcare facilities and treatment facilities. And while it may be one of the worst offenders, biomedical waste disposal is a nationwide issue.

India has a problem—it generates more biomedical waste than it can process. According to 2017 data from the Central Pollution Control Board (CPCB), India generates 559 tonnes of biomedical waste a day. The CPCB says that 92.84% of this waste is processed properly, either incinerated or sterilised and buried by independent treatment facilities or by hospitals.

The remaining 7% or so, however, goes untreated—that’s 41 tonnes of waste a day, or nearly 15,000 tonnes a year. Without proper treatment, and with reports aplenty of biomedical waste being mixed in with municipal garbage, India is staring at a potential biohazard crisis.

Among the types of infections caused by biomedical waste are gastrointestinal transmitted by faeces or vomit, respiratory infections caused by saliva and mucous, and eye infections caused by infected eye secretions. Inadequate waste management, apart from causing environmental pollution may lead to transmission of diseases like typhoid, cholera, hepatitis and AIDS through needles contaminated with infected blood.   

Poor management of medical waste risks polluting water, air and soil.  

The environment ministry in February this year updated the 2016 biomedical waste regulations. The idea was to improve compliance and strengthen implementation as healthcare facilities are not segregating medical waste diligently and handing it over to facilities.

But there are no punishments, not even heavy fines, under the current regulations. Only a show-cause notice or suspension of licence by the district magistrate. The lack of stringent punishments is one of the reasons why these rules have been criticised as ineffective.

On the flip side, market research firm Novonous forecasts that as India’s hospital capacity expands, the biomedical waste management market will grow at an annualised 8.41% till 2025. And it will grow on the backs of Srivastava and a slew of entrepreneurs and companies across the country who have made biomedical waste disposal their business.

After the response to his RTI, Srivastava registered a startup called Gorakhpur BioSerV Energy Pvt. Ltd to cater to Gorakhpur’s district hospital, a railway hospital and, of course, Baba Raghav Das Medical College. In addition, he would also cater to smaller nursing homes and clinics that have nowhere else to treat their waste.

But for the past three years though, he has been running from pillar to post to get his business off the ground. And even as Srivastava struggles, the number of waste treatment facilities in India has remained largely stagnant. In fact, it’s been that way since 2010. Inconsistently enforced and often-amended regulations, lack of governmental support, and healthcare centres that bend the rules threaten to derail whatever opportunity the market presents, while simultaneously creating a health and environment crisis.

Little fish, big fish

“In my opinion, except for the big players, setting up facilities is extremely difficult,” says Seshi Reddy, assistant general manager at Hyderabad-based Medicare Environmental Management, India’s largest biomedical waste management company.

Owned by the Ramky Group, a conglomerate that also has interests in infrastructure, real estate and pharmaceuticals, Medicare is over two decades old and has over 50,000 clients across India. Its clientele spans government, corporate, diagnostic and pathology clinics, dental and veterinary labs, and its 18 facilities across 12 states can process 200 tonnes of waste a day.

But Medicare is an outlier. Biomedical waste management is a cutthroat business, with compliance and competition among the main challenges, says Reddy. With every change in rules and specifications, costs go up. For hospitals, clinics and labs, however, it’s just another expense to be minimised—and the lowest bidder wins. Consequently, returns on investment are low; Medicare, which was incorporated in 1997, broke even in 2005, says Reddy.

The government does offer financial aid to make it easier for companies—especially small-scale entrepreneurs—to set up common treatment facilities for biomedical waste. The environment ministry funds 25% of the total project cost—up to Rs 1 crore ($144,000). (The north-eastern states are a special category, where the central and state governments together cover up to 75% of project costs.)

But before all that, another huge hurdle—and perhaps the reason why the number of waste treatment facilities hasn’t grown in nearly a decade—is land.

No man’s land

“The most critical aspect for setting up such a facility is land availability because according to the rules, it should be far from the population and no water body should be near the plant,” says Srivastava. These facilities come under the hazardous industries category and require environmental clearance.

The regulations say that state governments have to identify appropriate land and allot it either free of cost or at a concessional rate. The bureaucratic maze, though, ensures this doesn’t happen.

To start with, project proposals go to the hazardous substances management division of the environment ministry, which decides on financial aid. Once that’s cleared, though, the buck passes to the respective state government land-owning agency. With no real coordination between the environment ministry, the CPCB and the state-level agency, many projects get stuck waiting for land.

“The procedure to acquire land to set up new facilities is so long drawn out that private companies become tired and bow out finally,” complains Vinod P, president of the Common Biomedical Waste Treatment Facilities Association of India (CBWTFAI).

But to cap it all off, what may be the biggest hurdle to the growth of the waste management industry is the simple fact that most of their potential clients just don’t follow the rules. And the government has so far done little to change that at scale.

What compliance?

The government set a deadline of 27 March this year to phase out chlorinated plastic bags and gloves, establish a barcode system for waste generators and operators, install Global Positioning System (GPS) units in vehicles transporting waste to treatment facilities, and ensure pre-treatment of unsanitary waste water through disinfection. None of this has been implemented on the ground, according to executives of waste management companies and government officials.

Additionally, before 2016, if any healthcare facility was not treating more than 1,000 patients per month, they weren’t required to get authorisation from pollution control boards. With the new rules, every waste generator had to be registered with their respective state pollution control boards.

“60% of healthcare facilities are non-bedded and previously only bedded facilities were required to take authorisation but now everybody is required to take one,” says Vinod. And according to the rules, a healthcare facility also cannot get registered or obtain licences from state authorities without tying up with common biomedical waste treatment facilities.

However, in March, the National Green Tribunal noted that non-compliance was widespread and asked states to give status reports by 30 April, or be forced to deposit Rs 1 crore every month with the CPCB. Sample this: Out of 2.38 lakh healthcare facilities in the country, only 30% have authorisation.

The application for authorisation is exhaustive and provides the authorities with all information like the treatment facility a hospital has tied up with and the waste it generates etc. A CPCB scientist said that they are yet to get data from 1.51 lakh non-bedded facilities in the country and have no idea where their waste is going.

CPCB member secretary Prashant Gargava did not respond to repeated calls from The Ken on whether the tribunal’s ruling has been enforced.

Medicare’s Reddy points out that most of his clients still haven’t been authorised by their respective state pollution control boards. “For example, 5,200 are registered as my customers in Bangalore alone and they are taking my services, but 80% have not taken authorisation from state pollution control board,” he says.

And about half of non-hospital healthcare facilities—the thousands of polyclinics and diagnostic centres across India—have not tied up with waste treatment facilities, adds Medicare’s Reddy. “Veterinary centres are worse, only 2% or 3% have tie-ups with waste treatment facilities.”

A senior environment officer from Karnataka State Pollution Control Board said that AYUSH facilities are reluctant to take authorisation as they argue that they don’t generate as much biomedical waste as allopathic ones do.

This is a particularly sticky point for waste management: The larger hospitals and healthcare facilities either work with separate treatment companies or have their own in-house treatment centres. But the smaller clinics and pathology labs continue to either dump medical waste along with other garbage or bury it without proper sterilisation.

Bad as all this is, the likes of Medicare aren’t stopping.

New prospects and a troubled future

One of the biggest potential shifts that waste treatment firms see today is residential medical waste. “All these days, we were focussing only on medical waste from healthcare facilities,” Reddy says.

“Residential sector is generating more medical waste than the healthcare sector.”

Seshi Reddy, Assistant General Manager, Medicare

A few years ago, Medicare started a pilot project in Bengaluru, which has a population of 12 million, to collect household medical waste from two zones in the city—Yelahanka and the West Zone. In these two zones alone, the company is collecting 2.5 tonnes medical waste from residences per day.

The medical waste from houses includes sanitary napkins, earbuds and nails, and objects contaminated with blood and body fluid contaminated which are otherwise mixed with solid waste. Medicare is focusing on gated communities and apartments, and is charging Rs 35 ($0.5) per house per month. The company has signed on 500,000 households, and estimates that it will get 750 grams of medical waste from one family per month on an average. (Families with diaper-wearing children generate 2.5 kg of waste per day for two children. Without children, sanitary napkins account for 500 grams of waste per month per family.)

More recently in May this year, the Bruhat Bengaluru Mahanagara Palike (BBMP) put out a tender to process biomedical waste for 9.6 million houses in the city—an estimated 40 tonnes of medical waste. Similar initiatives have also been started in Pune and Indore.

“We are submitting our bid for the tender,” Reddy said.

CBWTFAI’s Vinod, however, is more cautious about the market potential of the biomedical waste sector in India. “Day by day the rules are being tightened by the government. It wants to have limited facilities so that it can have a control,” he says.

Vinod owns a facility in Gujarat. Of 33 districts in the state, seven districts do not have more than 200 healthcare facilities. “When our investment is Rs 5 crore ($720,000) to Rs 7 crore ($1 million) and I have to spend on transportation, it is not viable.” Without scale—about 10,000 hospital beds worth of clients, by most estimates—the unit economics just don’t work for a standalone treatment plant.

Most of the facilities are not running to their full capacity and only 70% to 80% of their capacity is being utilised. “If the facilities are run to their full capacity then they will start getting a return on investment of 8-10%. Now they are either just breaking even or getting an ROI of 5-7%,” says Vinod.

Back in Gorakhpur, Srivastava and his team of four are still pushing for their planned treatment plant. “Our plan is to make this economically viable and generate additional sources of revenue apart from disposal charges from healthcare facilities so others can replicate as well,” he says.

Which brings us to India’s fundamental problem—the medical waste we produce is ballooning. By 2022, the country is projected to hit 775 tonnes of medical waste per day, up almost 40% from today. At least. Because the real numbers may be even worse.

According to a scientist working with the CPCB, the board is struggling to measure the waste generated by non-bedded hospitals—healthcare facilities that don’t have in-patient departments. “The quantity of waste generated will increase significantly once we get this data,” he said, asking not to be named.

Our insufficient supply side isn’t prepared for this, because it just isn’t a viable business. Without the government actually enforcing biomedical waste regulations, and forcing healthcare facilities of all hues to get on board, the waste treatment sector is unlikely to grow beyond the big hospitals it already covers. 

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