Public-Private Partnerships: Trends, Perspectives and Opportunities 9781685072926, 1685072925

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BUSINESS ISSUES, COMPETITION AND ENTREPRENEURSHIP

PUBLIC-PRIVATE PARTNERSHIPS TRENDS, PERSPECTIVES AND OPPORTUNITIES

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BUSINESS ISSUES, COMPETITION AND ENTREPRENEURSHIP

PUBLIC-PRIVATE PARTNERSHIPS TRENDS, PERSPECTIVES AND OPPORTUNITIES DIEGO MONFERRER TIRADO AND

BEATRIZ IRÚN MOLINA EDITORS

Copyright © 2021 by Nova Science Publishers, Inc. https://doi.org/10.52305/EXYV3481 All rights reserved. No part of this book may be reproduced, stored in a retrieval system or transmitted in any form or by any means: electronic, electrostatic, magnetic, tape, mechanical photocopying, recording or otherwise without the written permission of the Publisher. We have partnered with Copyright Clearance Center to make it easy for you to obtain permissions to reuse content from this publication. Simply navigate to this publication’s page on Nova’s website and locate the “Get Permission” button below the title description. This button is linked directly to the title’s permission page on copyright.com. Alternatively, you can visit copyright.com and search by title, ISBN, or ISSN. For further questions about using the service on copyright.com, please contact: Copyright Clearance Center Phone: +1-(978) 750-8400 Fax: +1-(978) 750-4470 E-mail: [email protected].

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Library of Congress Cataloging-in-Publication Data ISBN: HERRN

Published by Nova Science Publishers, Inc. † New York

CONTENTS Preface Chapter 1

Chapter 2

Chapter 3

Chapter 4

ix Public–Private Partnerships for Socio-Technical and Environmental Transitions in Spain Vanessa Roger-Monzó and Fernando Castelló-Sirvent Accountability Challenges in PPPs: Are Partners Being Democratically Accountable? The Case of Transport Infrastructure in Portugal Sandra I. Firmino and Sílvia M. Mendes Analysis of the Efficiency of Environmental Protection Activities: Public versus Private in European Union Countries Patricia Carracedo, José Manuel Guaita Martínez, Luisa Martí and Rosa Puertas Hierarchical SPICE-Models of Public-Private Partnerships Olga I. Gorbaneva, Guennady A. Ougolnitsky and Anton D. Murzin

1

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vi Chapter 5

Chapter 6

Chapter 7

Chapter 8

Chapter 9

Contents The Energy and Industry 4.0 Sectors and their Opportunities in the Chinese Market. The Key Role of Clusters in the Current Context of Technology Transfer Beatriz Irún Molina, Diego Monferrer Tirado and Miguel Ángel Moliner Assessing People’s Concerns and Attitudes towards Solid Waste Management Facilities Implementation in Nablus and Jenin Districts of Palestine Noor M. Al-Subu, Issam A. Al-Khatib and Fathi M. Anayah Developing a Sustainable Management Model for Healthcare Solid Waste: Nablus Hospitals as a Case Study Issam A. Al-Khatib, Yasmeen Shanaa and Abdelhaleem I. Khader Qualitative and Quantitative Analysis of Generated Dental Waste in Northern West Bank, Palestine Clinics Sameer M. Al-Qorom, Issam A. Al-Khatib, Majed I. Al-Sari’, Stamatia Kontogianni and Fathi M. Anayah Medical Laboratories Generated Waste Management in West Bank, Palestine Rami A. Banishamseh, Issam A. Al-Khatib, Majed I. Al-Sari, Stamatia Kontogianni and Fathi M. Anayah

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Contents Chapter 10

Waste Electrical and Electronic Equipment Management: A Case Study in Hebron District, Palestine Fathi M. Anayah, Issam A. Al-Khatib and Mohammad W. Hashlamoun

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About the Editors

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Index

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PREFACE There is no legal meaning of the term public-private partnership and this concept can be used to describe a wide variety of arrangements involving the public and private sectors working together in some way (Farquharson, de Mastle, Yescombe, & Encinas, 2011). The key elements for a project to qualify as a PPP are: Long term contract between a public sector party and a private sector party; Design Construction, financing and operation of public infrastructure by the private sector party; Payments over the lifetime of the project to the private sector party for the use of the facility made either by the public sector party or by the general public as users of the facility; and Facility remaining in the public sector ownership or reverting to public sector ownership as the end of the PPP contract (Yescombe, 2007). In this book we go through this concept by analyzing, not only the opportunities in that field, but also the trends and new perspectives. Therefore, this book captures the results of some of the recent research that is being carried out on the public private cooperation. Chapter 1: Public–Private Partnerships for Socio-Technical and Environmental Transitions in Spain. This chapter analysed public–private participation in the design and promotion of socio-technical and environmental transitions in Spain.

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Focusing on the evaluation of refracted reality, a database (N = 12647) of news, opinion articles, and other content published in the media was constructed for the study. The evaluation period began on 1 January 2014 with recovery in Spain after the economic crisis, and ended on 31 December 2019 before the health crisis caused by the COVID-19 pandemic. The information search was carried out using Factiva®, a database owned by Dow Jones ©, which analyses content from more than 33000 media and news agencies. In this chapter, the information from 264 Spanish media and the news agencies EFE and Europa Press was analysed. This study had three objectives: First, to understand the discourse projected in Spain by its companies and public administrations on sociotechnical transitions and green transformation. Second, to identify the importance of public–private partnerships in the design and promotion of environmental transformation. Finally, we analysed the main issues addressed by the media as a refracted reality of Spanish society in the context of the 2030 Agenda. Chapter 2: Accountability Challenges in PPPs: Are Partners Being Democratically Accountable? The Case of Transport Infrastructure in Portugal. For the past few years, accountability processes have become more pluralistic and complex, joining traditional vertical mechanisms with newer horizontal and diagonal instruments. Such a transformation was the result of the recognition of the insufficiency of traditional accountability mechanisms with the emergence of new governance arrangements, such as Public-Private Partnerships (PPP). However, the literature is indicative of the possibility of persistence of an accountability deficit with serious democratic implications. Portugal, a fairly recent democratic country, began adopting a very intensive program of PPPs in the 1990s. The projects were mostly of an infrastructurecontractual type of service delivery in transports, health, water and waste disposal, and energy sector. With skyrocketing costs coming to light in the past years, politicians and the public at large have thrown the sustainability of Portuguese PPPs into question. Despite the Court of Auditors reports

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and several experts alluding to the existence of problems in Portuguese PPPs for some years now, public accountability of this governance scheme in this country remains a vastly unexplored research theme. In this chapter, we seek to shed some light on public accountability of Portuguese PPPs. We ask if partners are accountable and, if so, to whom. What mechanisms have been used? How are accountability mechanisms of Portuguese PPPs dealing with democratic liabilities? Against a new-institutionalism framework backdrop, we conduct a qualitative approach to study the case of roads infrastructure in Portugal. We perform a careful analysis of documents, audio, and video records of the Parliamentary Commission of Inquiry into PPPs in Road and Rail Transports hearings, as well as in-depth interviews with relevant actors. We use several examples among PPPs with different financing models: availability payments, toll instruments and shadow toll devices (formerSCUT). Contrary to other studies, the Portuguese case reveals a failure to fulfill the performance function of accountability. It also shows the malfunction of democratic and legal controls. Given the paucity of Portuguese studies on PPPs, particularly from a public management perspective, and the inexistence of any form of accountability appreciation, Portugal proves to be a pertinent study and a valuable contribution to literature. Chapter 3: Analysis of the Efficiency of Environmental Protection Activities: Public versus Private in European Union Countries. Climate change requires a global commitment, with the implementation of urgent measures to cut emissions of gases that are harmful to living beings. The various international conventions have encouraged the development of activities aimed at combating global warming, reducing air pollution and ensuring the preservation of biodiversity. In this context, the objective of this research is to measure the efficiency of environmental protection activities carried out by public and private entities in European Union countries. By applying data envelopment analysis and the Malmquist Index (MI), the pattern of performance during the period 2014-2017 can be determined. This in turn

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can help guide the implementation of sustainable policies to meet the challenges established. The first part of the analysis explains the performance of the two types of policy (private and public) in European Union countries, showing the different outcomes achieved through expenditure on public and private activities. The second part involves a comparative analysis of the different countries and their environmental protection policies in the period 20142017. The results show that, with the exception of Switzerland—where overall a high level of efficiency is found for the activities in both the private and public sectors—there are major differences in the efficiency levels of private companies and the public sector in European countries. For example, Ireland's private sector activities are among the most efficient, but it registers some of the lowest values at state level, along with the United Kingdom and Spain. Moreover, the MI shows that, on average in the years under study, private environmental protection activities have not achieved increases in productivity, while public sector advances in this regard barely exceed 0.8%. Proposals for improvement place the emphasis on a symbiosis between the two policies (private and public), and their coordination through the European Union as a supranational body. Chapter 4: Hierarchical SPICE-Models of Public-Private Partnerships. The chapter describes hierarchical models of coordination of social and private interests (SPICE-models) with application to the projects of public-private partnerships. In SPICE-models, it supposed that the agents divide their resources between social and private purposes. Respectively, the payoff functions consist of two summands: an income from the private activity and a share in the social utility. The considered models have a three-level hierarchical structure that includes a center of influence, or Principal (a public partner), an agent of influence (a private partner), and basic agents (consumers). The center of influence cares for some quality conditions of the project. To provide these conditions, it uses economic and administrative control mechanisms. Game theoretic models of the

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hierarchical control built and investigated. The proposed concept and results of model investigation illustrated on the specific example of publicprivate partnership in the South of Russia. Chapter 5: The Energy and Industry 4.0 Sectors and their Opportunities in the Chinese Market. The Key Role of Clusters in the Current Context of Technology Transfer. This chapter analyses the opportunities in the Chinese market for European companies from the energy and industry 4.0 sectors, in the current context of technology transfer, and the key role of clusters in this relationship. The strategies and policies adopted by China since the beginning of the global economic crisis of 2007–08 are first summarised. It is important to begin here in order to analyse the macroeconomic and sector trends that have emerged as well as the strategies that, through its five-year plans, have been shaping China as a political economy with great ambitions to become a technological leader. In a post-COVID scenario in which all countries are likely to suffer significant reductions in GDP, European companies have identified the enormous potential of the Chinese market due to its healthy economic data. To take advantage of these opportunities, companies must be familiar with the Chinese economy and the country’s political plans and priorities. This chapter analyses the way in which the country has opened up to foreign investment in specific sectors that have clear competitive advantages and that represent an enhanced business network. Preferential access zones are also detailed. Specifically, this chapter analyses the Chinese strategy of ‘technology transfer’, first from a general perspective, identifying where the main opportunities for European companies lie; and second, by examining the need to coordinate this strategy through clusters. The next section examines the energy and industry 4.0 sectors, before drawing key conclusions for a changing global context such as the current one, conditioned by technology advances, climate change and dwindling resources, social and demographic changes, the displacement of global economic power and accelerating urbanisation. Disruptive dynamics are

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being promoted and the Chinese market offers numerous opportunities for European companies in these sectors. However, our research warns of the need to approach the Chinese market in the appropriate way, by (1) explaining the importance of clearly showing the competitive advantages of European companies, (2) favouring the approach to Chinese partners through sectoral clusters, and (3) highlighting the importance of collaborating with a Chinese partner. Partners should be either Chinese state-owned enterprises, which are supervised by the government, or large private listed companies, which, despite their growing activity and openness to international cooperation, continue to show little participation in foreign markets. Chapter 6: Assessing People’s Concerns and Attitudes towards Solid Waste Management Facilities Implementation in Nablus and Jenin Districts of Palestine. Accurate determination of solid waste generation, treatment and disposal options strongly is crucial for an effective planning of solid waste management (SWM) systems. Successful planning of the SWM system is highly influenced by the social acceptance of local residents to the environmental challenges they have to tackle. This is the main scope of this chapter that presents the outcomes of an extended field survey in two Palestinian districts; Nablus and Jenin. The residents concerns and attitudes towards implementing SWM facilities were addressed via 381 structured questionnaires in each district. The respondents were able to highlight the major concerns and attitudes and provide feedback on the level of perceived acceptance or opposition to any future implementation of SWM facilities. The main parameters used to correlate the concernattitude findings of the research were the age, gender, locality type and number of previous visits to a SWM facility. In effect, a discriminant analysis was conducted to assess the influence of concerns on the respondents attitudes towards SWM facilities. Overall, 65% of the respondents felt pessimistic about the future of the SWM systems and the ability of the local authorities to address the emerging major issues. Only 38% of the respondents were concerned about the recycling practices undertaken locally. Rural respondents displayed the highest concern levels

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and by far perceive unfair implementation of a new SWM facility in their proximity. In particular the opposition levels were 69% for incinerators, 70% for landfills and 65% for recycling facilities. The stated denial to any kind of SWM facilities, as well as the high levels of not concerned people describe the lack of environmental culture and the limited dissemination of environmental information the Palestinian community needs for a better future. The public-private partnerships might be one of the key elements for a successful SWM system that can promote environmental sustainability for the domestic society. Chapter 7: Developing a Sustainable Management Model for Healthcare Solid Waste: Nablus Hospitals as a Case Study. Medical waste in Palestine continues to pose a threat to public health and the environment, although there has been some improvement in its management. However, this improvement has not reached the required level. Medical waste is collected mixed with municipal waste in most communities in the West Bank, Palestine. There is a treatment for infectious medical waste in some hospitals through sterilization or by uncontrolled incineration in incinerators that do not meet the specifications required for burning waste. Management of medical waste in the city of Nablus needs further study and analysis particularly, the sustainable management of solid waste in the city’s hospitals. The aim of this chapter is to identify sustainable development opportunities in managing medical solid waste in Nablus hospitals, and create sustainable management model for managing hospitals healthcare waste. It utilized a qualitative investigation to collect data for the study that was carried out in two hospitals in Nablus city (a governmental hospital: Rafidia hospital, and a charitable hospital: St. Luke’s hospital). Qualitative methods were used to evaluate and understand the medical waste management process and the healthcare waste management (HCWM) in the selected hospitals. Furthermore, Interviews were conducted with key persons related to healthcare waste management in the Ministry of Health (MOH), Nablus Municipality (NM) and Environmental Quality Authority (EQA) for identification of strength points which lead to switching to a sustainable waste management system, and to design a system that deals with the

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healthcare waste generated from the studied facilities. Healthcare solid waste is dangerous and affects human health and the environment. Hence, development of appropriate management system is necessary. In the selected hospitals in the study area there was no budget for medical waste management system, which means shortage of tools and equipment for the sustainable medical waste management system. There are no training plans as well as medical waste learning materials. There is no medical waste management department or committee, even on the governmental level, despite the Palestinian Cabinet's decision No. 10 of 2012 on the medical waste management. It was found that the targeted hospitals in the research do not segregate all the medical wastes or treat the hazardous wastes. They suffer from absence of treatment and disposal ways. Analytical hierarchy process (AHP) was used to develop model for sustainable management for medical waste solid waste. AHP as Multi Criteria Decision Making (MCDM) process was used to develop sustainable management model for healthcare solid waste in Nablus city hospitals. The sustainable model using AHP shows that waste treatment before disposal has the highest priority among main criteria (42.3%), followed by social and environment aspects (27%) and waste management cost with (16.1%). In sub criteria, in waste handling procedure, waste segregation had the highest priority (70%); in waste management cost, recycling cost had the highest priority (46%), and in waste treatment the sub criteria with the highest priority is treatment before disposal (50%). Lastly, in terms of overall ranking of subcriteria with respect to goal, treatment before disposal had the highest priority (21.1%), followed by social and environment aspects (27%), and waste segregation (10.9%) are the top three sub-criteria. Using AHP, the model found that Plasma Pyrolysis is the best method to treat medical wastes. Chapter 8: Qualitative and Qualitative Analysis of Generated Dental Waste in Northern West Bank, Palestine Clinics. This study focuses on dental solid waste (DSW) management in central and northern Palestine, in particular Nablus and Salfit governorates. Qualitative and quantitative data was retrieved to serve the overall investigation through structured questionnaires and on-site sampling. The

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overall results showed that dentists attitude towards sustainable DSW management is positive. In particular 71% are willing to participate in future waste separation and recycling programs. However, 60% of the dentists do not own the appropriate equipment to perform waste separation, recovery and recycling. Age, gender, location of the clinic, and level of education, are significantly affecting dentists waste management behavior. The DSW generation rate is 57.2 g/patient/day. Infectious/potentially infectious waste represents 68.3% of total fraction, whereas non-infectious 4.8% and domestic-type waste 26.9% (by weight). The infectious and potentially infectious waste fraction is composed mainly by: sharps (13.1%), amalgam (0.8%), blood soaked dressings (43.3%), paper (11.3%), plastic and rubber (0.3%) and extracted teeth (31.3%). Chapter 9: Medical Laboratories Generated Waste Management in West Bank, Palestine. This field research focuses on the evaluation of healthcare waste (HCW) management practices applied in Medical Laboratories (MLs) in Nablus and Ramallah governorates, Palestine. Totally 100 MLs were selected representing a variety of legal statuses (governmental, private and Non-Governmental Organization’s). Eight out of 100 MLs were further selected to participate into a HCW sampling research that measured and characterized the generated waste fraction. Overall results showed that less than half of the MLs present an excellent environmental performance (as per a predetermined set of indicators) and approximately two thirds of them pre-treat HCW prior to final disposal. MLs HCW comprises of household-like wastes (45.50%), waste mixed with infectious waste (21.07%), tissues and pathological waste (18.48), plastic waste resulting from medical processes (7.18%), sharps (4.88%) and absorbent waste (2.89%). Following that and having identified that two parameters, namely the number of (i) samples taken from the patients and (ii) the number of tests performed, largely affect the overall HCW generation, a HCW generation pattern was developed for the study area. Chapter 10: Waste Electrical and Electronic Equipment Management: A Case Study in Hebron District, Palestine.

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Developing countries suffer from high rates of population growth and consequently greater amounts of waste electrical and electronic equipment (WEEE) are generated. In Palestine, WEEE is typically shipped from Israel for reuse, recycling, or disposal, yet these processes are costly, unsafe, and sometimes illegal. Three towns in Hebron District, namely Idhna, Deir Samit, and Beit Awwa, currently receive large amounts of WEEE. Information were collected from these service workshops, and respective municipalities and non-governmental organizations in the area. More specifically, 14 workshops were visited, representative persons from the three municipalities were interviewed, and two experts in the field were met. Almost 90% of the WEEE comes from Israel through local traders who sell the WEEE to service workshops. Recycling of WEEE is often carried out by a manual and primitive separation of aluminum, copper, and iron. These materials are sold back to Israeli businesses through local traders. Safety of workers, facilities, and surrounding environments is not a priority for existing service workshops. Open burning is the common practice for recycling and disposal of WEEE in the study area. Open burning pollutes air, soil, and groundwater, and therefore, local municipalities conduct campaigns to raising awareness of local community towards environmental consequences. However, this WEEE industry becomes a major income source for local residents. Necessary governmental interventions to manage the WEEE system are suggested. The composition of WEEE for several equipment existing in the local market is described to promote responsible investors make this sector environmentally sound and economically profitable.

In: Public-Private Partnerships ISBN: 978-1-68507-184-4 Editors: D. Monferrer Tirado et al. © 2021 Nova Science Publishers, Inc.

Chapter 1

PUBLIC–PRIVATE PARTNERSHIPS FOR SOCIO-TECHNICAL AND ENVIRONMENTAL TRANSITIONS IN SPAIN Vanessa Roger-Monzó* and Fernando Castelló-Sirvent ESIC Business and Marketing School, Valencia, Spain

ABSTRACT This chapter analysed public–private participation in the design and promotion of socio-technical and environmental transitions in Spain. Focusing on the evaluation of refracted reality, a database (N = 12647) of news, opinion articles, and other content published in the media was constructed for the study. The evaluation period began on 1 January 2014 with recovery in Spain after the economic crisis, and ended on 31 December 2019 before the health crisis caused by the COVID-19 pandemic. The information search was carried out using Factiva®, a database owned by Dow Jones ©, which analyses content from more than 33000 media and news agencies. In this chapter, the information from 264 Spanish media and the news agencies EFE and Europa Press were analysed. This study had three objectives: First, to understand the discourse projected in Spain by its companies and public administrations on socio*

Corresponding Author’s Email: [email protected].

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Vanessa Roger-Monzó and Fernando Castelló-Sirvent technical transitions and green transformation. Second, to identify the importance of public–private partnerships in the design and promotion of environmental transformation. Finally, we analysed the main issues addressed by the media as a refracted reality of Spanish society in the context of the 2030 Agenda.

Keywords: public–private partnerships (PPPs), socio-technical transitions, environmental transformation, 2030 agenda, sustainable development goals (SDG), public opinion

INTRODUCTION For decades, sustainability has been at the centre of a public long-term development strategy. The Brundtland Report (WCED, 1987) was the first step that allowed us to rethink how modern societies wanted to carry out the intergenerational pact in economic, social, and environmental terms. In recent years, multiple models have been developed that act as drivers of innovation strategies from environmental sustainability (Orlitzky et al., 2011). Green strategies have fuelled new business models and connect with an increasingly better-informed consumer who understands their own purchasing habits as responsible instruments, consistent with the construction of the future (Stubbs and Cocklin, 2008; Clinton and Whisnant, 2019). The drive for sustainability-oriented innovations (SOIs) is essential for economic, environmental, and social development (Fernandes et al., 2019). In addition to driving efficiency and long-term growth, SOIs build market opportunities that connect with the needs of consumers and public administrations. The challenge of future sustainability is so important that, to achieve its goal successfully, it must involve collaboration between different actors. Thus, adherence to reality for solving sustainability problems increases (Lozano, 2007), and the risk of failure is reduced. Specifically, public–private partnerships (PPPs) improve long-term efficiency and facilitate the fit between decision-making and results (Margerum and Robinson, 2015). Public–private partnerships have been

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studied as an important development vector for green strategies, both in large companies and SMEs (Hansen and Klewitz, 2012). The increasing complexity in the management of natural resources suggests the use of this type of partnership as it could transform the sustainable development of all industries with the impulse of radical innovations (Hoffrén and Apajalahti, 2009). However, PPPs require the development and use of collaboration networks that make it possible to reduce information asymmetry (McNamara, 2012). Another limitation may arise in its contribution to the improvement of the public procurement process, understood as a validation mechanism for intermediate and final organisational promises (Campagnac and Deffontaines, 2012). In addition, high transaction costs that are not made explicit in the short term could result from the planning and execution of this type of collaboration agreement (Robinson et al., 2014) which, as a consequence, poses latent risks of discretion and inequity. In recent times, academia has shown an emerging interest in the study of the moral hazard of public–private partnership projects (Owusu-Manu et al., 2018), paying special attention to the strategies that facilitate its reduction (Owusu-Manu et al., 2020) and the prevention of negative externalities in the project selection process (Di Bari, 2021). In addition to moral hazard, many authors have identified limitations in PPPs for the validation of intermediate and final organisational promises, understood as a system for improving the public procurement process. In fact, the difficulty of this type of collaboration project between public and private economic agents arises from the interaction of multiple external conditions (regulation and self-regulation of the industry) and internal conditions (specific structure and process elements of the PPP) (Spraul and Thaler, 2019). These partnerships are vulnerable to changes in political and leadership trends (Lurie, 2011). The purpose of this research is to identify the discourse projected by the media in relation to socio-technical and environmental transitions as drivers of the green strategy in public–private partnerships (PPPs).

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To do this, the discourse of the news and other content published in the press, such as analysis and opinion articles and reports on the subject under study during the period 2014–2019, were analysed using a hybrid qualitative and quantitative methodology, examined through a lexicographical analysis using T-LAB software. Thus, the objectives of this study are specified as follows: 1. Analyse the public discourse of Spanish companies and public administrations regarding consumer behaviour and new sociotechnical and environmental transition projects. 2. Learn the importance of PPPs in the design and promotion of the green strategy under the paradigm of the 2030 Agenda and the Sustainable Development Goals.

SOCIO-TECHNICAL TRANSITIONS PROJECTED IN THE MEDIA Following Lippmann’s (2003) concept of refracted reality, the media provides citizens with information that integrates different versions of reality. In this way, the media constitute a central ‘interpretive system’ of modern societies (Schmidt et al., 2013), since they play a fundamental role in the construction of the frames of reference that are used to interpret issues of public interest. (Scheufele, 1999). In addition, they are essential elements in structuring the social fabric and shaping public opinion (McQuail, 2000). Not surprisingly, agenda-setting theory is established as the main hypothesis that there exists a phenomenon of relevance transfer from the media agenda to the public agenda (Ardèvol-Abreu et al., 2020). As has already been mentioned, the objective of this work was to analyse the discourse of the media in reference to socio-technical and environmental transitions as drivers of PPPs. Thus, a search for publications on these topics was conducted using the Factiva® tool, a database of information belonging to Dow Jones & Company with the right

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to use more than 33,000 sources, providing access to 264 national media agencies, including the EFE and Europa Press agencies. The period of analysis commenced on 1 January 2014 with the start of Spain’s recovery after the economic crisis, and ended on 31 December 2019 before the COVID-19 crisis. Initially, a search was conducted using the terms ‘socio-technical transitions’ and ‘environmental transformations’ which are commonly accepted in the academic field. However, given the limited media representation reached by these academic terms in the Spanish press, to avoid type II errors, the terms sustainability, innovation, and technology were concurrently used as a search strategy, using the Boolean operator ‘AND’, both for the headline and summary of the articles. The first categorizing of the results set up a database of 12647 news items. The subsequent textual analysis was carried out using T-LAB version Plus 2020, a data analysis software that offers statistical, graphical, and content analysis applications by identifying word patterns. This software has been used for the exploratory study of sustainability in various studies (Cerón et al., 2020; Sesini et al., 2021) and the results obtained made it possible to examine information about PPPs. Information analysis with T-LAB is based on two types of textual units: elementary and lexical. Elementary contexts are proportions of the corpus text that correspond to phrase units of one or more sentences. For their part, lexical units are records that integrate two pieces of information: word and lemma. The word is displayed and listed exactly as it appears in the linguistic corpus. The lemma constitutes the label that is given to the lexical units grouped and classified according to linguistic criteria, personalised dictionaries, or semantic categories that collate terms with the same meaning for the investigation. In this way, the terms sustainable and sustainability are grouped under the same slogan called sustainable. This process is called lemmatization. The initial automatic normalisation provided by T-LAB for the database yielded 2,280 lexical units. After completing the lemmatization process, 447 lexical units (lemmas or keywords) were selected.

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Based on these quantitative characteristics, a classification of clusters or thematic groups was established. This tabulation allowed us to determine which topics are covered in the news, their relationship, and the frequency of appearance in the media. The process was carried out through an unsupervised clustering method (k-averages bisecting algorithm) of the T-LAB software that first performs a co-occurrence analysis and, later, a comparative analysis. Four clusters related to the following contexts were identified: ‘university’, ‘public policies and energy’, ‘industrial production’, and ‘services.’ Table 1 shows the 10 main lemmas for each cluster analysed from the linguistic corpus that comprises 12647 news items studied. The data suggest that public–private partnership relations are transversal to the discourse projected in Spanish media by different economic agents. On the one hand, clusters 1 (University) and 2 (Public policy and energy) articulate their discourse from public–private innovation ecosystems led by public administrations (Joyce & Paquin, 2016). Both clusters represent collaborations driven by the public sector and are supported by the private sector for the digitisation and transfer of knowledge. Collaborative activities are based on the design and development of public policies aimed at energy efficiency and water management, among others. On the other hand, clusters 3 (Industrial production) and 4 (Services) originate from the collaboration between private agents and the administration for the development of new business models, the latter being of great importance for sustainability. Both clusters represent cooperation for the design and promotion of infrastructures, their financing, and the design of a process of dissemination of this type of innovation in society. In a detailed analysis, Cluster 1 revealed the importance of innovation driven by universities and the science and technology system in Spain. Some important aspects of the discourse generated in the media arise from the lemmas science, technology, academia, research, education, knowledge, and transfer.

1

See Annex I for details.

Lemma research University technology innovation science scientific knowledge education digitization society

Cluster 1: University Cluster 2: Public policy and energy C.E. In Chi² p Lemma C.E. In Chi² 11.296 17.887,830 0,000 energy 12.359 31.381,80 8.717 12.237,220 0,000 euros 6.680 12.963,39 23.380 12.093,720 0,000 government 5.719 12.842,92 20.617 8.550,098 0,000 renewable 3.525 10.852,46 4.524 6.868,257 0,000 Spain 7.238 7.212,91 3.238 4.966,124 0,000 water 3.872 6.254,20 4.257 4.457,592 0,000 efficiency 4.526 4.777,40 3.605 3.386,642 0,000 politics 2.511 4.199,92 6.924 2.766,796 0,000 budget 1.400 3.307,06 4.380 2.133,181 0,000 saving 1.548 2.976,41 Cluster 3: Industrial production Cluster 4: Services Lemma C.E. In Chi² p Lemma C.E. In Chi² business 26.081 28.880,960 0,000 tourism 13.435 36.039,900 product 10.848 16.364,760 0,000 city 11.946 31.702,400 market 8.211 10.717,550 0,000 Europe 13.710 30.669,620 client 6.268 10.614,260 0,000 health 5.472 8.566,246 deal 6.663 8.491,472 0,000 sustainability 12.722 5.875,568 entrepreneurship 5.270 5.480,057 0,000 urban 2.650 5.499,431 prize 5.406 3.904,373 0,000 mobility 2.873 4.328,798 start-ups 3.094 3.655,594 0,000 healthy 4.118 3.224,307 consumer 2.909 3.601,955 0,000 congress 2.108 2.218,453 manufacturing 2.742 2.112,595 0,000 transport 2.186 2.069,090 Note: EC. In: number of elementary contexts that include a given lemma. Chi2: statistic that helps to verify the significance. p: probability that the calculated statistical value Chi2 is possible given a true null hypothesis. The required significance value has been set at p < 0.05. Source: Own elaboration.

Table 1. Main lemmas for the four clusters of the linguistic corpus1

p 0,000 0,000 0,000 0,000 0,000 0,000 0,000 0,000 0,000 0,000

p 0,000 0,000 0,000 0,000 0,000 0,000 0,000 0,000 0,000 0,000

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The most relevant technologies suggest that socio-technical transitions are led by blockchain, artificial intelligence, connectivity, and robotization and allow the transformation of industrial ecosystems in cutting-edge technological sectors (telecommunications, cybersecurity, videogames and audiovisual), industry (aerospace, chemistry, computing and digitalization), agri-food (phytosanitary, farming, wine, and horticulture), and medical and pharmaceutical innovation (biomedicine, molecular engineering, diseases, oncology, and vet). Following the Sustainable Development Goals (SDGs), the transversality of these transitions was oriented toward the economic challenge of social transformation. Using this approach, public opinion was configured from the mechanisms of integration of human development, learning, and excellence from a gender perspective. The cluster analysis shows the link between the different public and private agents for thematic group 1 (University). (a) Universities (Complutense University of Madrid, Polytechnic University of Madrid, Polytechnic University of València, Miguel Hernández University of Elche, Jaume I University, Deusto University and Menéndez Pelayo International University). (b) Agents of the national public ecosystem (CSIC, COTEC and EOI). (c) Agents of the autonomous public ecosystem (Eurecat and IFAPA). (d) Public financing systems (CDTI and ERDF). (e) Companies of national and international private ecosystems (Cajamar, Cisco, Samsung and Ericsson). In Cluster 2, aspects of policy design are conspicuous, fundamentally oriented towards promoting renewable energies and efficiency in the use of natural resources, highlighting the role of the government in the fight against climate change. This cluster is driven by the public sector and allows the activation of private innovation ecosystems and their capillarity until they reach the consumer. In this thematic group, public–private collaborations gravitate around environmental innovation projects for the generation of new models of sustainable economic growth and the fight against poverty. Major public

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(Adif) and private companies (Iberdrola, Endesa, Fenosa, Petronor, BP, CEPSA, Nissan, LG, Ciemat, Inditex, Mahou, Heineken, Sacyr and CocaCola), and public and private innovation hubs participate in these projects (Ciemat and Farmaindustria), international institutions (UN), financing mechanisms (ERDF) and social agents (UGT). Some prominent lemmas of this cluster are politics, parliament, growth, GDP, poverty, taxation, grants, reindustrialization, debt, carbon, oil, residue, transparency, biomass, IBEX, China and exports. For Cluster 3, industrial production was described by digitisation and new sustainable business models. This cluster arises from the private impulse and collaborates with the public sector in technology transfer and financing to improve eco-efficiency. The thematic groups evaluated from the linguistic corpus integrate lemmas oriented to the transformation of the supply chain and social and environmental responsibility for SMEs and large companies in sectors such as sustainable manufacturing and the circular economy in respect of packaging, food technology, composting, cooperativism, textile, banking, B2B, business schools, entrepreneurship and start-up ecosystems. Private companies and institutions related to different sectors are highlighted: (a) (b) (c) (d) (e) (f) (g) (h)

Distribution (Carrefour, Amazon, Mercadona, India). Food (Nestlé). Technology (Google, HP, Huawei, CISCO and Philips). Advisory and consultations (Indra and Deloitte). Logistics (DHL). Production (Porcelanosa). Mobility (Iberia, Volkswagen, Uber and Cabify). Banking and insurance (BBVA, Sabadell, Bankia, Caixa, Bankinter, Cajamar and Mapfre). (i) Business schools and start-up ecosystems (IE, IESE, ESADE and Lanzadera). (j) Public sector (ICEX, CDTi).

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Cluster 4 concentrates on environmental transformation projects in the service sector. It includes socio-technical transition initiatives for sectors such as health and tourism, highlighting from the linguistic corpus lemmas such as sustainability, smart cities, transport, airport, governance, bicycle, bioclimatic, connectivity, and depopulation. Public and private entities related to mobility services (Cabify, Nissan, BMW, Uber and Renfe), tourism (OMT, Meliá, Fitur and Segittur), financing (Ibercaja), and the private business sector (Asociación Valenciana de Empresarios-AVE) are highly relevant. On the other hand, the ‘Mediterranean Corridor’ stands out for its defence of the sociotechnical and environmental transition that it represents for mobility and eco-efficiency. Thus, the cluster analysis shows new perspectives of sustainability that, in recent years, have also developed in the same direction at an international level. In this sense, the reality refracted in the Spanish media for the period under study represents topics of interest related to the green strategy driven by socio-technical transitions, in tune with the transformation observed in other countries after the enactment of the 2030 Agenda.

PUBLIC–PRIVATE PARTNERSHIPS TO PROMOTE ENVIRONMENTAL TRANSFORMATION The challenges posed by the European debt crisis caused high pressure on the reduction of the public deficit as a consequence of the global crisis of 2008. This situation has influenced infrastructure and public services PPP projects (Slijepčević, 2019). Following data from the European Investment Bank (EIB), Figure 1 shows the total value of European PPP projects by sector for the period analysed in this chapter (EPEC, 2021).

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A detailed study of the linguistic corpus under study made it possible to evaluate the PPPs carried out for socio-technical transitions and the environmental transformation of the Spanish economic model. From the 447 lexical units established for this study, an analysis of word associations was conducted focusing on lemmas that had the highest occurrence in the corpus, which enabled an examination of the relationship between slogans or keywords and subsequently co-occurrences of the public–private lemma to be analysed. Figure 2 represents the association of slogans to the central slogan of public–private partnerships. The lemmas closest to the centre of the diagram present a higher level of co-occurrence, since each of them is located at a distance proportional to their degree of association. Similarly, slogans B furthest from slogan A (public–private) show lower levels of cooccurrence. This initial analysis is complemented by identifying the slogans with the highest level of co-occurrences, which are also statistically significant. Thus, Table 2 shows the relationship between the sustainable slogan and other slogans or keywords with statistically significant co-occurrences (Chi2 test, p < 0.05). They represent the quantification of these relationships according to the selected association coefficient (Coef; cosine coefficient), the co-occurrence values between lemmas A and B (AB), the Chi2 statistic, and the p-value, showing only the B lemmas that are statistically significant (p < 0.05). There was a strong concurrence of public–private cooperation strategies around socio-technical and environmental transitions in terms of university, research, health, medicine, technology clusters, industry, agriculture and farming, infrastructure development, and sustainable cities. These are multiple tracks that highlight the difficulty that PPPs represent when faced with the challenge of harmonising the diversity of interests and institutional cultures concentrated in each collaboration (Warsen et al., 2020).

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Source: Own elaboration. Figure 1. Total value of European PPP projects by sector – Spain (2014–2019).

Table 2. Word association analysis for slogan A (public-private) Original Lemma (Spanish) sanidad

Lemma

COEFF

CE_AB

Chi2

health

0,062

120

cooperación

cooperation

0,056

55

clústeres

clusters

0,043

33

agropecuario

agricultural

0,031

11

financiación

financing

0,037

67

presupuesto

budget

0,032

35

ciudad

city

0,039

104

Latinoamérica infraestructura farmacéutico competitividad innovación ciudadanía saludable

Latam infrastructure pharmacist competitiveness innovation citizenship healthy

0,026 0,030 0,024 0,029 0,043 0,022 0,029

14 48 23 54 196 17 60

460,68 6 428,74 0 248,70 0 145,29 9 126,37 3 110,00 3 105,08 4 88,820 78,241 59,452 58,886 51,663 51,467 48,036

pvalue 0,000 0,000 0,000 0,000 0,000 0,000 0,000 0,000 0,000 0,000 0,000 0,000 0,000 0,000

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Original Lemma pLemma COEFF CE_AB Chi2 (Spanish) value nacional national 0,028 54 46,859 0,000 dólar dollar 0,020 11 45,470 0,000 hospital hospital 0,021 22 39,501 0,000 empresa business 0,039 171 38,148 0,000 inversión investment 0,028 63 37,054 0,000 patronal patronal 0,018 10 35,327 0,000 sostenibilidad sustainability 0,037 157 33,945 0,000 medicamento medicine 0,019 17 32,017 0,000 carbono carbon 0,019 17 29,751 0,000 esfuerzo effort 0,020 28 26,401 0,000 productividad productivity 0,018 17 26,303 0,000 internacionalización internationalization 0,018 16 25,801 0,000 red net 0,024 50 25,733 0,000 estrategia strategy 0,026 62 24,983 0,000 turismo tourism 0,027 68 24,126 0,000 banca banking 0,018 24 20,542 0,000 impacto impact 0,020 34 20,242 0,000 gobierno government 0,024 54 19,737 0,000 políticas politics 0,018 24 17,561 0,000 experiencia experience 0,021 39 16,517 0,000 agua water 0,020 37 16,030 0,000 tecnología technology 0,036 170 13,962 0,000 futuro future 0,024 60 13,797 0,000 agricultura farming 0,019 36 12,368 0,000 economía economy 0,021 51 9,053 0,003 España Spain 0,024 74 8,061 0,005 investigación research 0,022 57 6,840 0,009 empleo job 0,020 45 6,606 0,010 universidad university 0,020 48 6,332 0,012 industria industry 0,023 71 3,958 0,047 Note: Coef: cosine coefficient used as the value of the association index. AB: co-occurrence in elementary contexts of those A lemmas, object of analysis (public–private), and their main associated B lemmas that are statistically significant (p 1 there has been an increase in productivity, if MI = 1 it remains the same in the analysed period, and when MI < 1 there has been a drop in productivity. The MI has two components that provide information on the source of the changes that occurred: technical efficiency change (TEC), reflecting improvements in relative efficiency (moving closer to the frontier), and technological change (TC) referring to increases in productivity caused by improvements in technology (a shift in the frontier). In turn, the former may be due to pure technical efficiency change (PTEC), corresponding to the best possible use of the available technology, and/or scale efficiency change (SEC) stemming from an improvement in the volume of inputs/outputs used. The proposed research lies within the EU framework calling for the study of the efficiency of resources allocated to EPAs. A comparative analysis of the private and public sectors is carried out in order to determine whether there is a common pattern at the national level. Due to a lack of information, it is not possible to obtain homogeneous samples: in the corporate sphere, Eurostat provides comprehensive statistics for 25 countries, but at the state level it only does so for 20 countries in the period 2014-2017. It was decided not to homogenize the samples, as this would lead to the elimination of countries as important as Germany and Italy, for which complete series on public sector actions are not available. The variables needed for the application of the DEA technique are defined by two inputs (national expenditure and employment corresponding to EPAs), and two outputs (GHG emissions and output of total EPAs). Eurostat’s classification of economic activities NACE Rev. 2 was used to differentiate between public administration activities and corporate activities. Adjustments were made to the units of measurement of expenditure and output, converting them into units per capita to ensure that the size of the country did not distort the results. In addition, as GHG emissions is an undesirable output, it was inverted (1/GHG) to be able to maximize the outputs with the available resources (Koçak et al., 2021). Table 1 shows the variables used and their units of measurement.

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Table 1. Variables for the DEA technique Variable Unit National expenditure Input Euro per capita Employment Input Full-time equivalent GHG emissions Undesirable output Kg per capita Output* Desirable output Euro per capita Note: * Output consists of products that become available for use outside of the producer unit, any goods and services produced for own final use and goods that remain in the inventories at the end of the period in which they are produced. Source: Own elaboration.

Source: Own elaboration. Figure 2. Classification of EPAs according to Eurostat.

According to the statistics provided by Eurostat, the EPA classification covers all activities and actions aimed at preventing, reducing and eliminating pollution that causes environmental degradation, as well as the restoration of the environment where necessary. Figure 2 details these activities. Table 2 shows the main statistics of the variables for the period 20142017, revealing a marked difference between the sectors analysed.

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Mean SD Max Min

Employment 11,263 14,411 64,073 75

Employment Mean 83,724 SD 96,038 Max 350,301 Min 2,381 Source: Own elaboration.

Public EPAs Expenditure 144 130 530 2 Corporate EPAs Expenditure 326 259 1,156 50

Output 97 131 516 0.420

GHG 0.0325 0.0445 0.2642 0.0061

Output 705 433 1,921 84

GHG 0.0001 0.0001 0.0003 0.0001

Despite the large dispersion in all the inputs/outputs of the two sectors, corporate involvement in terms of employment and expenditure corresponding to EPAs is far greater, with France and Austria, respectively, registering the maximum level in 2017. It should also be borne in mind that the activities carried out by companies are very varied, including agriculture, manufacturing, supply, transport, construction and services, among others. These are activities that provide higher added value and are sometimes more polluting; hence, both output and GHG emissions register higher values as well. To provide an overall picture of what happened during the period analysed, Table 3 shows variation rate of the variables associated with each of the 25 countries analysed between 2014 and 2017; that is, in the inputs and outputs used to calculate the DEA. In the case of GHG emissions, the change in per capita emissions has been calculated so that a negative sign indicates a reduction in emissions. The rate for the other variables has been determined without modifying the units of measurement; thus, a positive sign for expenditure and employment indicates an increase in the resources allocated for this purpose, and for output indicates greater production measured in monetary terms.

Public EPAs Employment Expenditure Belgium -0.03 0.05 Bulgaria 0.31 -0.51 Czechia -0.01 0.60 Denmark -0.03 0.00 Germany* Estonia 0.05 1.44 Ireland 0.04 -0.06 Spain -0.02 0.09 France 0.38 -0.03 Croatia 0.00 0.14 Italy* Latvia -0.26 -0.34 Lithuania 2.22 0.70 Luxembourg* Malta 0.41 -0.04 Netherlands 0.03 0.01 Austria 0.47 0.06 Poland 0.21 0.36 Portugal 1.04 0.00 Romania -0.33 0.42 Slovenia -0.69 -0.31 Finland* Sweden* Switzerland 0.01 0.07 U. Kingdom -0.11 -0.09 Mean 0.18 0.13 Note: * No statistical information available from Eurostat. Source: Own elaboration. Output 0.19 0.32 0.09 -0.05 0.45 0.06 0.00 0.50 0.09 -0.16 -0.34 -0.06 0.14 0.34 0.50 0.85 0.11 0.11 0.08 -0.16 0.15

GHG 0.06 -0.48 -0.12 0.07 -0.38 0.20 0.14 -0.09 0.23 0.19 -0.01 -0.30 -0.11 0.15 -0.04 0.03 0.14 0.14 -0.07 -0.11 -0.02

Employment 0.04 0.35 0.09 0.25 -0.02 -0.11 0.37 0.07 0.04 0.02 0.04 0.06 0.44 0.50 0.19 0.07 0.16 0.18 0.28 -0.09 0.12 0.01 0.06 0.11 0.09 0.13

Corporate EPAs Expenditure 0.07 -0.28 0.07 0.24 0.13 -0.18 -0.19 0.11 0.04 0.27 0.20 0.06 0.03 0.32 0.51 -0.05 0.13 0.23 0.09 0.11 -0.07 0.03 0.15 0.16 0.49 0.11 Output 0.01 0.52 0.16 0.21 0.02 0.04 0.16 0.12 0.02 0.07 0.10 0.16 0.22 0.18 0.17 0.13 0.18 0.25 0.42 -0.05 0.17 0.11 0.05 0.17 -0.01 0.14

Table 3. Variation rate of employment, expenditure, output and GHG emissions, 2014-2017 GHG 0.01 0.07 0.00 0.01 -0.06 -0.02 0.14 0.05 0.00 0.07 0.03 0.06 0.12 0.02 -0.07 -0.01 0.04 0.05 0.13 0.01 0.12 -0.06 -0.04 -0.05 -0.16 0.02

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Detailed examination of the accounting data makes it possible to ascertain EU Member States’ degree of engagement in environmental policies. Altogether, the two sectors have increased their efforts in terms of expenditure and employment corresponding to EPAs, reflecting Member States’ acute awareness of the need to allocate resources to curb climate change. However, although output has increased by around 15%, the public sector alone has managed to reduce its GHG emissions, and only by 2%. There are exceptions, including Slovenia, Bulgaria or Latvia, which have reduced the resources allocated to EPAs, while increasing their emissions. Estonia, Malta, the Netherlands, Switzerland and the United Kingdom are the only countries that have achieved an overall reduction in their emissions during the period analysed, coinciding with the first years of the 7th Environment Action Programme. In short, the public sector demonstrates a notable concern about improving the environmental services provided, as reflected in the output values, which register increases of 85% in the case of Portugal or 50% in Poland and France. However, in terms of cutting emissions, only the public sectors in Bulgaria, Estonia, Malta, Czechia, the Netherlands and the United Kingdom have managed to significantly reduce environmental pollution, by 48%, 38%, 30%, 12%, 11% and 11%, respectively. For its part, the business sector has also shown its commitment to the agreements established by allocating greater resources to these activities. Specifically, the corporate expenditure of Malta, the United Kingdom and Luxembourg stands out, with growth figures of 51%, 49% and 32%, respectively, with similar rises in employment in Luxembourg (50%), Lithuania (44%) and Ireland (37%). The production of these environmental activities displays a similar trend, albeit not as marked, with notable increases in output from Bulgaria (52%), Portugal (42%) and Poland (25%). Nevertheless, in the business sector, only 8 of the 25 countries have managed to reduce their GHG emissions, with cuts ranging from 16% in the United Kingdom to 1% in the Netherlands. In sum, these statistics reveal that the business sector is more focused on boosting the level of production (output) of activities aimed at

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improving the environment than on reducing GHG emissions. These data are consistent with the evaluation of the 7th Environment Action Programme, which reported a lower degree of involvement by the private sector.

RESULTS The study is focused on assessing the efficiency of the EPAs, and therefore only includes activities whose primary objective is the protection of the environment. The analysis thus excludes all those activities that, despite having beneficial effects on the environment, are aimed at meeting technical needs or complying with internal hygiene rules and even safety standards. The time span analysed coincides with the duration of the 7th Environment Action Programme, where all public and private institutions in the EU countries agreed to work together to protect the environment, ensuring an ongoing reduction in their GHG emissions. Through an intertemporal analysis using DEA-bootstrap and the MI, an exhaustive study of EPA performance in the different EU countries has been carried out. Tables 4 (private sector) and 5 (public sector) show the mean efficiency levels achieved in the period 2014-2017 (1st column), the standard deviation (2nd column), the number of times the country has been fully efficient during the four-year period analysed (3rd column), the possible advances in productivity occurring (4th column), and the source of said advances, that is, TC, PTEC and SEC (5th, 6th and 7th columns, respectively). The results are ordered from highest to lowest efficiency to reveal which countries’ EPAs have been the most efficient and which need to change their lines of action to achieve better results. Regarding the business sector, the analysed countries combined achieved an efficiency score of close to 80% (0.795) and a loss of productivity of 2.1%, as shown by the MI (0.979), mainly due to a lack of technological improvements (TC = 0.984). The top places are held by Sweden and Switzerland (0.940 and 0.918, respectively), with the latter being completely efficient in three of the four years analysed. These two

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countries have achieved improvements in scale of 3.4% and 4.5%, respectively; that is, they have been able to better adapt the volume of their resources used to achieve the desired outputs.

Table 4. Efficiency scores of the intertemporal DEA-Bootstrap and MI analysis, corporate EPAs (2014-2017) Country EFF_boot Sweden 0.940 Switzerland 0.918 Luxembourg 0.888 Croatia 0.882 Latvia 0.879 Ireland 0.876 Romania 0.841 Italy 0.838 Finland 0.836 France 0.835 Lithuania 0.835 U. Kingdom 0.824 Denmark 0.824 Portugal 0.823 Malta 0.816 Spain 0.816 Belgium 0.792 Bulgaria 0.744 Slovenia 0.742 Austria 0.703 Czechia 0.681 Netherlands 0.675 Poland 0.665 Estonia 0.654 Germany 0.552 Mean 0.795 Source: Own elaboration.

SD 0.018 0.016 0.025 0.069 0.071 0.028 0.083 0.055 0.113 0.069 0.056 0.060 0.222 0.023 0.069 0.009 0.062 0.096 0.039 0.095 0.172 0.067 0.118 0.139 0.051 0.073

NºEFF 1 3 4 1 2 2 1 1

1 3

1

MI 0.980 1.011 0.934 0.916 0.962 1.057 0.972 0.945 0.846 0.988 0.955 0.907 0.991 0.948 0.946 0.970 0.983 1.067 1.024 1.010 1.039 1.036 0.946 1.076 0.966 0.979

TC 0.950 0.967 0.934 0.946 0.958 1.057 0.972 1.013 0.960 1.040 0.971 1.043 0.944 0.980 0.946 1.011 0.951 0.997 0.938 0.953 1.034 0.982 1.007 0.933 1.126 0.984

PTEC 1.000 1.000 1.000 1.000 1.000 1.000 1.000 0.988 0.930 1.002 0.999 0.951 1.000 1.020 1.000 0.999 0.987 1.044 0.977 1.000 1.007 1.036 1.001 1.062 0.959 0.999

SEC 1.031 1.045 1.000 0.969 1.004 1.000 1.000 0.945 0.947 0.948 0.984 0.914 1.050 0.949 1.000 0.960 1.047 1.026 1.117 1.059 0.999 1.019 0.938 1.086 0.895 0.997

Germany occupies the bottom position, with a fairly low level of efficiency (0.552): the largest expenditure on these activities has failed to increase output and reduce GHG emissions to the levels required by the effort made. This is reflected in the decline in scale efficiency during the

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period 2014-2017, of 10.5% (SEC= 0.895), and a worse use of available technology (PTEC= 0.959). As a result, despite the technological advances introduced by German companies (they occupy the top spot in Europe with an increase of 12.6%), this country’s productivity has fallen by 3.4%. This indicates that innovation focused on the use of novel technology is not sufficient to achieve progress in productivity and high levels of efficiency. More active strategies are required at the business level, such as those implemented in Switzerland, where incentives are provided for innovative and sustainable products. The country takes a proactive attitude, informing the public about sustainable behaviour. In this regard, Vries (2020) attempts to take it further by advising those in charge of communication to take into account the social and psychological processes that could influence sustainable behaviour. This would help improve compliance with environmental policies. Table 5 shows the results obtained in the EPAs developed by the public sector. These results cannot be compared with those of the business sector: they are two different samples that have given rise to different frontiers, meaning that the efficiency levels are not comparable. On average, the public sector registers inefficiency levels of more than 45% (EFF-boot = 0.534), somewhat stagnant productivity (MI = 1.009) and technological improvements of 6.4% which offset the worse use of available technology and scale inefficiency (PTEC = 0.965, SEC = 0.993). The ranking offers a glimpse of the Swiss government’s action on environmental issues (EFF-boot = 0.829), although its progress in productivity (MI = 1.005) is below the European average of 0.9% (MI = 1.009). This progress is solely due to an improvement in the scale efficiency of over 8% (SEC = 1.081). At the other extreme is Spain, whose public action on this issue is totally inefficient, even registering a decline in productivity of 2.9% (MI = 0.971) as a result of worse use of available technology. Moreover, a substantial disparity is observed between the level of efficiency achieved and the change in productivity in the countries analysed. For example, Portugal, which has an EFF-boot of 0.322, has experienced a rise in the MI in this four-year period of 19.3%, due to its

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better use of existing technology (18.3%) and, to a lesser extent, the introduction of new technologies (1.6%). Something similar can be observed in France and Ireland. Table 5. Efficiency scores of the intertemporal DEA-Bootstrap and MI analysis, public EPAs (2014-2017) Country EFF_boot Switzerland 0.829 Estonia 0.818 Malta 0.809 Denmark 0.807 Netherlands 0.778 Latvia 0.737 Slovenia 0.721 Czechia 0.713 Bulgaria 0.690 Croatia 0.600 Lithuania 0.530 Belgium 0.470 Austria 0.404 France 0.370 Romania 0.359 Poland 0.328 Portugal 0.322 Ireland 0.226 U. Kingdom 0.085 Spain 0.077 Mean 0.534 Source: Own elaboration.

SD 0.004 0.063 0.033 0.020 0.058 0.056 0.059 0.104 0.088 0.012 0.132 0.157 0.060 0.072 0.020 0.041 0.088 0.015 0.003 0.007 0.055

NºEFF 2 2 2

3 2 1 1

MI 1.005 0.904 0.952 0.985 1.034 1.072 1.262 0.908 1.224 0.985 0.748 0.987 0.866 1.150 0.932 0.996 1.193 1.027 0.975 0.971 1.009

TC 0.930 0.938 1.116 0.931 0.973 0.974 1.262 1.082 1.224 1.039 0.905 1.371 0.970 1.097 1.025 1.133 1.016 1.280 1.010 1.016 1.064

PTEC 1.000 0.969 1.000 0.998 1.009 1.069 1.000 0.895 1.000 0.950 0.830 1.000 0.873 1.135 0.805 0.771 1.183 1.027 0.897 0.889 0.965

SEC 1.081 0.995 0.853 1.060 1.053 1.029 1.000 0.938 1.000 0.999 0.996 0.720 1.023 0.923 1.130 1.140 0.992 0.782 1.076 1.075 0.993

Figure 3 shows the geographical distribution of corporate and public efficiency values at European country level. This map representation facilitates the analysis and visualization of efficiency levels for both sectors. It should be noted that the administrative boundaries by EuroGeographics© were obtained via the Eurostat open data service with the Eurostat package (Lahti et al., 2017) of statistical software R Core Team (2021). The colour of the country corresponds to the value of the indicator, with the darkest shade indicating the highest value and the lightest shade the lowest value. It can be observed that the values of the

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public efficiency indicator are lower and contain more missing values than the corporate efficiency indicator. The European country with the highest value of corporate efficiency is Sweden, with a value of 0.94, while the country with the lowest value is Germany, with a value of 0.55. With respect to public efficiency, the European country with the highest value is Switzerland, while Spain has the lowest value.

Administrative boundaries: © EuroGeographics for the administrative boundaries. Source: Own elaboration. Figure 3. Corporate and public efficiency levels.

Overall, the results shed light on the need for the authorities in European countries to make a greater commitment to establishing EPAs that encourage the protection of our planet, yielding quantifiable results in terms of cutting emissions and thus improving quality of life for their citizens. Following in the footsteps of Switzerland, incentives should be offered to companies to improve their technology and adjust the scale of their activities in order to maximize the results in terms of protecting the biosphere and putting a stop to the degradation of the planet. Kurylo et al., (2020) point out the crucial need for national and local environmental protection programmes that promote the sustainable development of

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society and the rational replenishment of resources. Lastly, it is worth highlighting that the most recent studies advocate public-private partnerships, with the adoption of specific investment policies and measures for sustainable development (Sikora, 2021; Stephenson et al., 2021).

CONCLUSION Almost all international summits on the environment have been centred around lines of action that seek to curb climate change and regenerate resources. The vast majority of nations have ratified all the agreements adopted, demonstrating their commitment to working in this direction. However, they need to pick up the pace because the problem facing the world’s population is growing exponentially. The empirical analysis carried out in this study provides quantitative information on the achievements made through the EPAs of European countries. A comparative approach is taken, focusing on the efficiency and productivity of these activities developed by private and public entities over a four-year period (2014-2017), with the countries analysed varying notably. The results show that, at company level, the introduction of new technologies is needed to boost the productivity of these activities. In addition, with the exception of Sweden, Switzerland and Luxembourg, it has been shown that the country’s wealth is not a determinant of the efficiency of its EPAs. A case in point is Germany, where the environmental activities carried out by local companies are much less efficient than those in countries such as Croatia or Latvia. European nations’ public sectors have not been able to translate their technological advances into higher levels of efficiency, and there is a marked disparity between countries. Particularly notable is the case of Spain, a country whose results reflect the need to modify its lines of action, intensify its efforts and streamline resources to target them at the environmental objectives established in the European agreements.

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The lack of comprehensive statistics prevents an analysis of all EU member states, while access to more up-to-date information would offer a more current picture of such activities. Future research should seek to explore in more depth the guidelines followed by each country in order to orient decision-making in environments of certainty, correct errors and accelerate the achievement of results. In short, the results of this study enable a comparative analysis of the efficiency of sustainable development policies promoted by the public and private sectors in EU countries in the context of the European Green Deal and the 2030 Agenda. It can be concluded that energy and climate are becoming the most important areas of sustainable economic development in the EU. As such, their ongoing analysis is one of the fundamental duties of the academic scientific community, enabling the adoption of increasingly efficient public-private policies; hence the importance of studies such as this one.

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In: Public-Private Partnerships ISBN: 978-1-68507-184-4 Editors: D. Monferrer Tirado et al. © 2021 Nova Science Publishers, Inc.

Chapter 4

HIERARCHICAL SPICE-MODELS OF PUBLIC-PRIVATE PARTNERSHIPS* Olga I. Gorbaneva1, Guennady A. Ougolnitsky1,† and Anton D. Murzin2 1

I.I. Vorovich Institute of Mathematics, Mechanics and Computer Sciences Southern Federal University, Rostov-on-Don, Russian Federation 2 Faculty of Management, Southern Federal University, Rostov-on-Don, Russian Federation

ABSTRACT The chapter describes hierarchical models of coordination of social and private interests (SPICE-models) with application to the projects of public-private partnerships. In SPICE-models, it is supposed that the agents divide their resources between social and private purposes. Respectively, the payoff functions consist of two summands: an income from the private activity and a share in the social utility. The considered models have a three-level hierarchical structure that includes a center of influence, or Principal (a public partner), an agent of influence (a private *

This work was supported by the Russian Science Foundation, project no. 17-19-01038. Corresponding Author’s Email: [email protected].

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O. I. Gorbaneva, G. A. Ougolnitsky and A. D. Murzin partner), and basic agents (consumers). The center of influence cares for some quality conditions of the project. To provide these conditions, it uses economic and administrative control mechanisms. Game theoretic models of the hierarchical control are built and investigated. The proposed concept and results of model investigation illustrated on the specific example of public-private partnership in the South of Russia.

Keywords: SPICE-models, public-private partnerships, mechanisms, game theoretic models, South of Russia

control

INTRODUCTION Public-Private Partnership (PPP) is an extremely widespread and forward-looking form of attracting private business to solve the tasks of developing economic and social infrastructure. Quite close to PPP is the extensive field of public procurement, which is sometimes also classified to the PPP. The types of PPP, the ways of its organization and financing, the areas of application vary greatly. In more detail, these issues are described in monographs (Yescombe, 2007; Celucci, 2011; Engel et al., 2014; Morley, 2015; Geddes, 2017). The Russian specificity of PPP projects is analyzed in the article (Trotsenko, 2018; Shkred and Murzin, 2020). The key role in the success of PPP projects is played by the coordination of interests of their participants. Therefore, the most natural technique for modeling PPP is provided by the theory of contracts (Iossa and Martimort, 2008; Maskin and Tirole, 2008). For example, Iossa and Martimort (2008) present a basic model of procurement in a multitask environment in which a risk-averse agent chooses unobservable efforts in cost reduction and quality improvement. The authors begin by studying the effect on incentives and risk transfer of bundling building and operation into a single contract, allowing for different assumptions on the contractual framework and the quality of the information held by the government. Then they extend the basic model in several directions. The factors that affect the optimal allocation of demand risk and their implications for the

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use of agents’ charges and the choice of contract length are considered. The relationship between the operator and its financiers, and the impact of private finance are studied. The trade-off between incentives and flexibility in long-term PPP agreements and the dynamics of PPP contracts, including cost overruns is discussed. In addition, the authors consider how the institutional environment, and specifically the risk of regulatory opportunism, affects contract design and incentives. They conclude with some policy implications on the desirability of PPPs. There are many publications dedicated to various specific models of PPP. Thus, Peng et al. (2014) analyze the distribution of costs between participants of a PPP project in the framework of the theory of contracts, considering contracts as “reference points”. Without the assumption of reference point dependence, the optimal allocation of the participants’ investment proportions is determined by the risk they take, the profit of the project, the expectation profit, and the importance of investment. If the government is risk averse, the optimal contract should be flexible, so that the government can choose the investment ratio dynamically to prevent a high risk. On the contrary, if the reference point is taken into consideration, the satisfaction degree of the participants in the PPP project decides whether the total utility of the system can reach the maximum value. The less the satisfaction is, the less the cost the participants will pay. Besides, the risk that the parties are willing to share is affected by many factors. The parties’ utilities from the project are determined not only by the economic benefits, but also by the satisfaction degree of the ownership allocation result. Thus, to avoid discontentment, the parties will adjust not only the cost they pay but also the risks they take, to make up for the psychological loss they may suffer. Thus, the satisfaction of the equity allocation will influence the utility of the participants of PPP projects. Therefore, it is necessary to consider the mental factor in decision-making processes. Osei-Kuei and Chan (2019) proposed a model for predicting the success of PPP infrastructure projects in developing countries and illustrate it in the case of Ghana. The predictive model examines the causal relationship between critical success factors and success criteria for PPP projects. First, a conceptual model for PPP projects success was proposed.

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Second, the theoretical regression model was tested by means of a questionnaire survey with experienced PPP experts. The regression model has shown three best predictors of PPP project success in Ghana, namely: appropriate risk allocation and sharing, sound economic policy and right project identification. Various statistical tests confirmed the validity and goodness of fit for the model. Belenky (2013) analyzed the situation when the state can finance all projects, which it is interested in, and intends to announce tenders for the implementation of each project, for example, within the placement of contracts for the execution of works determined by the plan of public procurement. In this case, the state must determine the starting (reserve) price for each project, proceeding from both its own interests and capabilities, and from the given capabilities of potential performers. The problem is formulated as a three persons game on convex polyhedrons of independent strategies of the players. The author established necessary and sufficient conditions of the existence of Nash equilibrium. The conditions allow for building the equilibrium as a solution of the dual linear programming problems. Lavlinskii et al. (2016) make a comparison of models of planning PPP. In other paper, Lavlinskii et al. (2019) propose a new model of description of the PPP mechanism as a two-level Boolean programming problem. It is p shown that this problem is Σ2 -hard. A stochastic iteration algorithm of its solution is developed. The numerical simulations based on real data about a mineral and raw materials complex illustrating the practical applicability of the approach made. In this paper, PPP is treated in the framework of the theory of sustainable management in active systems (Ougolnitsky, 2011, 2015, 2017; Ougolnitsky et al., 2018). According to the theory, the sustainable development of an active system means satisfaction of two conditions. First, some requirements to the state of the controlled object (viability conditions) must be satisfied. Second, the active agents that are responsible for these conditions should be interested in their satisfaction, or else the requirements will stay only a declaration. Thus, the control objective of sustainable management is to provide an incentive compatible sustainable

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development. If all active agents are initially interested in providing the conditions of viability and do it successfully, then sustainable development is achieved through collaboration. In the overwhelming number of real situations, for ensuring sustainable development a special agent (Principal) is responsible. The Principal can influence on other agents by means of compulsion or impulsion methods. Under compulsion (administrative control mechanisms), the Principal influences on the set of feasible strategies of agents, and under impulsion (economic control mechanisms) - on their payoff functions. A general description of the theory of sustainable management is given in (Ougolnitsky, 2011, 2015), and its application to the territorial management is presented in works (Ougolnitsky, 2017; Ougolnitsky et al., 2018). The approaches and methods used in the theory of sustainable management in active systems are fully consistent with the theory of contracts. As applied to PPP, in this work under the Principal (public partner) the state administration bodies on the federal, regional or municipal level are understood, and the rest of the active agents are business partners. For simplicity and without significant restriction of generality, in the proposed model a single Principal (she) and a single agent (he) are considered. For further specification, it seems natural to use the so-called SPICEmodels, or Social and Private Interests Coordination Engines (Gorbaneva and Ougolnitsky, 2013, 2014, 2015a, 2015b, 2017, 2018, 2020). In the SPICE-models, it is assumed that each agent divides his resource (money, time, etc.) between participation in the production of a public good and in some private activity. Accordingly, the agent’s payoff consists of the income from the private activity and the share in use of the public good jointly produced by all agents. The Principal’s task is the development of administrative and economic control mechanisms that maximize the share of resources, which agents allocate for the production of public good. In other words, the Principal must harmonize the private and public interests of the agents. Static and dynamic settings of SPICE-models for various organizational configurations are possible. A number of analytical results about the type of optimal controls of the Principal is obtained. The application of SPICE-models to the management of territorial

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development is described in (Anopchenko et al., 2019b, 2019c). As applied to PPP, in this work the participation of a business partner in the production of a public good in this PPP project is understood, and private activity means other directions of his business activity. A consideration of SPICEmodels for the analysis of PPP projects, taking into account the requirements for their quality as conditions for sustainable development, is begun in (Anopchenko et al., 2019a). The contribution of this work is as follows. A conceptual model of hierarchical management of PPP projects, taking into account the requirements of sustainable development is proposed. A corresponding mathematical model representing a Stackelberg game is constructed and investigated. Herewith, the Principal’s payoff function takes into account the requirements for the state of the controlled system, which are interpreted as conditions for sustainable development. Numerical experiments with the software realization of this model on real data are carried out, and processing and analysis results of the calculations are received. The rest of the paper is organized as follows. The second section gives a brief overview of the setups and the main results concerning SPICEmodels. The conceptual SPICE-model of PPP project management, taking into account the requirements of sustainable development is described. A corresponding mathematical model is built on its basis. The third section gives the organizational and economic characteristics of PPP projects in the context of the proposed model. The fourth section describes the application of the constructed model to the analysis of a specific PPP project. The fifth section summarizes the results and outlines the perspectives for further research.

SPICE-MODELS The basic model of the coordination of common (public) and private interests (SPICE-model) with one agent has the following form. The agent has a certain amount of resources r, which should be distributed between

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his private interests and the realization of common interests. Quantity of u resources the agent allocates to realization of the common interests, and the remaining quantity r-u is allocated for satisfaction of his private interests. The function p(r-u) reflects the payoff from the realization of the agent’s private interest, and the function c(u) determines the payoff from obtaining the share of s in the realization of common interests. The agent faces with the task of allocation of his funds between private and common interests in such a way that the summary payoff from their implementation be maximal. So, the basic model of the coordination of common and private interests is as follows: 𝑔(𝑢) = 𝑝(𝑟 − 𝑢) + 𝑠𝑐(𝑢) → 𝑚𝑎𝑥, 0 ≤ 𝑢 ≤ 𝑟. Some natural restrictions are superimposed on the functions p and c: they are non-negative, increasing, and concave, p(0) = 0, c(0) = 0. There are several types of hierarchical SPICE-models. Here are two of them. In the first one, there are two participants in the management system: the top-level agent (marked by index 1) and the lower-level agent (index 2). These two participants have a common interest. The upper level has some amount of resources r, the share of which u1 is transferred to the lower-level agent for common purposes, and the rest part left for the realization of her private goals. The lower-level agent receives from the upper-level agent resources in the amount ru1, the share of u2 from which he allocates for common purposes, and the remaining amount of resources he spends on the realization of his private interests. The payoff from the use of resources by the corresponding agent in private interests described by the function pi(x), and the total payoff from the use of resources by the agents for common purposes is expressed by the function c(x). The payoff from the realization of common interests is divided between the two agents fully in shares s and 1-s, respectively. The corresponding model is as follows:

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O. I. Gorbaneva, G. A. Ougolnitsky and A. D. Murzin 𝑔1 (𝑢1 , 𝑢2 ) = 𝑝1 (𝑟(1 − 𝑢1 )) + 𝑠𝑐(𝑢1 𝑢2 𝑟) → 𝑚𝑎𝑥𝑢1 , 𝑔2 (𝑢1 , 𝑢2 ) = 𝑝2 (𝑟𝑢1 (1 − 𝑢2 )) + (1 − 𝑠)𝑐(𝑢1 𝑢2 𝑟) → 𝑚𝑎𝑥𝑢2 , 0 ≤ 𝑢𝑖 ≤ 1, i=1,2.

The functions pi(x) and c(x) are assumed to be non-negative, nondecreasing, and concave in their arguments. The natural properties c(0) = 0, pi(0) = 0 are also satisfied. Another hierarchical SPICE-model implies that the upper level (Principal) influences on the payoff function or the set of feasible strategies of the lower level (agent) so as to maximize the Principal’s payoff function. In the case of the influence of the Principal on the agent’s payoff function, we will say that the Principal applies the mechanism of economic management. In the case of limiting the set of the agent’s admissible strategies by the Principal, we will say that the Principal applies the administrative control mechanism. In particular, if the Principal represents the interests of society then her payoff function can be taken as the utilitarian function of social welfare, representing the sum of the payoffs of all agents included in this society. The agents comprising the members of this society are united by a certain common interest, for the realization of which they are ready to spend a part of their funds. The agents spend the remaining funds on their private interests. Function 𝑔𝑖 (𝑢1 , 𝑢2 , . . . , 𝑢𝑛 ) = 𝑝𝑖 (𝑟𝑖 − 𝑢𝑖 ) + 𝑠𝑖 𝑐(𝑢1 + 𝑢2 +. . . +𝑢𝑛 ) → 𝑚𝑎𝑥 reflects the interests of each of the n agents, where 𝑟𝑖 is the amount of resources available to the agent; 𝑢𝑖 – the amount of resources which agent allocates for common purposes; 𝑟𝑖 − 𝑢𝑖 - the number of resources that the agent spends on private interests. The function 𝑝𝑖 (𝑟𝑖 − 𝑢𝑖 )represents payoffs from the realization of the agent’s private interests. The function 𝑐(𝑢1 + 𝑢2 +. . . +𝑢𝑛 )represents the payoffs from the use of resources in common purposes, the share of si from which the agent receives.

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The strategy of each agent is the amount of resources 𝑢𝑖 , directed to the realization of common interests. This strategy satisfies the constraint 0 ≤ 𝑢𝑖 ≤ 𝑟𝑖 . The functions pi(x) and c(x), as in the previously described models, are assumed to be non-negative, non-decreasing, and concave by their arguments, and c(0)=0, pi(0)=0. The Principal’s payoff function is a social welfare function: 𝑔0 (𝑢1 , 𝑢2 , . . . , 𝑢𝑛 ) = ∑𝑛𝑖=1 𝑝𝑖 (𝑟𝑖 − 𝑢𝑖 ) + 𝑐(𝑢1 + 𝑢2 +. . . +𝑢𝑛 ) → 𝑚𝑎𝑥. In the case of the economic mechanism the Principal’s strategies are values si, i.e., Principal assigns to agents a share of participation in common income with restrictions: 𝑠𝑖 ≥ 0, ∑𝑛𝑗=1 𝑠𝑗 = 1. In the case of administrative mechanism, the Principal chooses the values of qi - the minimal magnitudes of resources, which the agents must spend on common goals. The natural restrictions are 0 ≤ 𝑞𝑖 ≤ 𝑟𝑖 . Then the domain of feasible strategies of an agent narrows from 0 ≤ 𝑢𝑖 ≤ 𝑟𝑖 to 𝑞𝑖 ≤ 𝑢𝑖 ≤ 𝑟𝑖 . In this work we introduce a hierarchical game theoretic model “the center of influence (the state or its representatives) - the agent of influence (a commercial organization that divides resources between realization of this PPP project and other projects) - consumers (society)”. The center of influence (Principal) ensures the requirements of consumers (society) to the quality of the performed project (conditions for sustainable

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development) through administrative and economic control impact on the agent of influence. The conceptual model of PPP in the framework of the theory of sustainable management in active systems is presented in Figure 1.

Public partner Monitoring

Other activities

Incentive mechanisms

Business partner

I ... Conditions of viability

Consumers (society)

Note: Symbol I denotes control impacts inside a PPP project that should provide incentive compatible sustainability. Figure 1. The conceptual model of PPP in the framework of the theory of sustainable management in active systems

The Center of influence (Principal) instructs the Agent (firm, private partner) to develop a public project. For the development of the project, the Agent spends resources in the amount of u units. The utility of the project results is expressed by the function c(u), the share of s from which goes to the Agent, and the remaining share goes to the society. The consumers of this project (members of society) assess the quality of the project by a magnitude xi, which depends on its utility. Consumers’ opinions xi are taken into account by the Principal. Maximization of the opinions of consumers is interpreted as a condition for the sustainable development of the system.

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Besides the given public project, the agent has other private projects that also require investments. That’s why the agent’s task is to distribute funds between public and private projects in such a way as to maximize the total utility from the realization of all projects. The Principal affects the Agent in such a way that he should choose the amount of investment in a public project maximizing the assessment of this project by society. For this purpose, the Principal can apply an economic control mechanism (assign a share s of the utility from the implementation of the project that the Agent receives) or an administrative one (determine a minimum amount of resources q that the Agent is obliged to spend for common purposes). Then a SPICE-model for PPP looks as follows. A payoff function of the Principal has the form 𝑔0 (𝑢) = ∑𝑛𝑖=1 𝑥𝑖 (𝑢) → 𝑚𝑎𝑥,

(1)

where n is the number of consumers. The Agent’s payoff function is 𝑔(𝑢) = 𝑝(𝑟 − 𝑢) + 𝑠𝑐(𝑢) → 𝑚𝑎𝑥, s.t.

(2)

0 ≤ 𝑢 ≤ 𝑟.

(3)

Here i-th consumer does not have a payoff function, but only forms his opinion, which has the form 𝑥𝑖 (𝑢) = 𝑎𝑖 (1 − 𝑠)𝑐(𝑢),

(4)

where r is the amount of resources available to the Agent, p is the function of the Agent’s private interests, ai is a positive parameter characterizing the agent’s level of satisfaction. The bigger is the importance of this parameter, the smaller quality of results execution project is capable to satisfy the consumers. With a small value of ai, the consumer remains

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dissatisfied even with high utility results of the implementation of the project. In the case of economic mechanism, the Principal maximizes its payoff function by means of appointment of the magnitude s, where 0 ≤ 𝑠 ≤ 1.

(5)

In the case of administrative mechanism, the Principal manages the magnitude q, less than which the agent cannot spend resources for common purposes, i.e., in the model is added by the constraint 0 ≤ 𝑞 ≤ 𝑟, and the constraint for the Agent’s strategy 0 ≤ 𝑢 ≤ 𝑟 is replaced by the constraint 𝑞 ≤ 𝑢 ≤ 𝑟. The constructed model is a static hierarchical game with complete information, the solution of which is a Stackelberg equilibrium. In the case of application of the administrative mechanism, such an outcome is the pair (q, u), in the case of application of the economic mechanism - the pair (s, u). The Principal and the Agent know each other’s interests and opportunities, and the opinions of consumers. The Principal makes the first move, choosing the strategy q or s, depending on the applied mechanism of management. Given this strategy the Agent chooses the magnitude u, maximizing his payoff function. Given the Agent’s best response to the choice of her strategy, the Principal selects it so as to maximize her payoff, reflecting the conditions of sustainable development of the system.

INVESTIGATION OF THE MODEL Let us find the Stackelberg equilibrium in the model (1) - (5), in which the Principal uses the economic mechanism of management. Let the functions p and c are power functions with exponent less than one, for example, 𝑝 = 𝑝√𝑟 − 𝑢, c= 𝑐√𝑢. In this case, the payoff function of the Agent has the form 𝑔(𝑢) = 𝑝√𝑟 − 𝑢 + 𝑠𝑐√𝑢.

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The first order condition has the form −

𝑝 √𝑟−𝑢

+

𝑠𝑐 √𝑢

= 0,

from which the optimal Agent’s strategy is 𝑢∗ =

𝑠2 𝑐 2 𝑠2 𝑐 2 +𝑝2

𝑟.

Obviously, it is less than r, i.e., it is not profitable for the Agent to spend all resources only to the public project or only to personal ones. The optimal strategy of the Agent depends on the magnitude s, which is appointed by the Principal. Let us find the magnitude s that is optimal for the Principal. To do this, we substitute the Agent’s optimal strategy in the payoff function of the Principal: 𝑔0 (𝑢) = ∑𝑛𝑖=1 𝑥𝑖 (𝑢) = ∑𝑛𝑖=1 𝑎𝑖 (1 − 𝑠)𝑐(𝑢) = (1 − 𝑠)𝑐√𝑢 ∑𝑛𝑖=1 𝑎𝑖 = =

(1−𝑠)𝑠𝑐√𝑟 √𝑠2 𝑐 2 +𝑝2

∑𝑛𝑖=1 𝑎𝑖 → 𝑚𝑎𝑥.

The first order condition has the form (1−2𝑠)√𝑠2 𝑐 2 +𝑝2 −

(1−𝑠)𝑠2 𝑐2 √𝑠2 𝑐2 +𝑝2

𝑐√𝑟(∑𝑛𝑖=1 𝑎𝑖 )

𝑠2 𝑐 2 +𝑝2

= 0.

After some transformations, we receive the equation (1 − 2𝑠)(𝑠 2 𝑐 2 + 𝑝2 ) − (1 − 𝑠)𝑠 2 𝑐 2 = 0, from which it can be seen that for finding the optimal magnitude s it is necessary to solve the cubic equation 𝑝 2

𝑝 2

𝑠 3 + 2𝑠 ( 𝑐 ) − ( 𝑐 ) = 0.

(6)

O. I. Gorbaneva, G. A. Ougolnitsky and A. D. Murzin

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8

𝑝 6

Using Cardano’s method, we’ll get that the magnitude Q=27 ( 𝑐 ) + 1 𝑝 4 ( ) >0, 4 𝑐

that’s why there is a single real root of this equation, which lies

in the interval (0,1) by the fact that at the ends of the above-mentioned interval the left hand side of (6) has different signs. This root is equal to

3

2

6

4

3

2

6

4

1 𝑝 8 𝑝 1 𝑝 1 𝑝 8 𝑝 1 𝑝 𝑠 = √2 ( 𝑐 ) + √27 ( 𝑐 ) + 4 ( 𝑐 ) + √2 ( 𝑐 ) − √27 ( 𝑐 ) + 4 ( 𝑐 ) ,

that after a transformation is

3

2

3

2

3

2

1 𝑝 32 𝑝 32 𝑝 𝑠 ∗ = √2 ( 𝑐 ) ( √1 + √27 ( 𝑐 ) + 1 − √√27 ( 𝑐 ) + 1 − 1).

Therefore, the higher is the utility from private interests and the smaller is the utility from the project, the greater is the share of s which the Principal should offer to the Agent. Thus, the parameters characterizing the level of satisfaction of the members of society do not affect the choice of the Principal’s action. Thus, for the Principal’s maximization of the public assessment results of the project, the opinions of individual members of the society are not important. It turns out that it is necessary to carry out public projects, but consideration of the opinions of specific members of the society does not effect on a choice of the Principal. Another situation appears for the Principal is she does not maximize the assessment of public opinion, but only provides it at a level not less than a given value, for example, x*. In this case, the Principal selects the magnitude s at which the condition of sustainable development is satisfied: (1−𝑠)𝑠𝑐√𝑟 √𝑠2 𝑐 2 +𝑝2

∑𝑛𝑖=1 𝑎𝑖 > 𝑥 ∗.

(7)

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After transformations, we come to the inequality of fourth degree (1 − 𝑠)2 𝑠 2 𝑐 2 𝑟(∑𝑛𝑖=1 𝑎𝑖 )2 > 𝑥 ∗2 (𝑠 2 𝑐 2 + 𝑝2 ) or 𝑠 4 − 2𝑠 3 + 𝑠 2 (1 −

𝑥 ∗2 2 𝑟(∑𝑛 𝑖=1 𝑎𝑖 )

)−

𝑥 ∗2 𝑝2 2 𝑐 2 𝑟(∑𝑛 𝑖=1 𝑎𝑖 )

> 0.

(8)

The left hand side of the inequality has at least two real roots of the function, since the free term of the polynomial is negative. One or three roots are positive, and one of them is greater than 1 (since the signs of the left hand side of (8) for s = 0 and for s → ∞ are different). It also follows from (8) that the points s = 0 and s = 1 do not satisfy (8), therefore, they do not satisfy the conditions of sustainable development (7). This says that for the Principal it is unprofitable both to leave the Agent completely without his share of utility, and to give him the whole payoff. Let us analyze the first derivative of the left hand side of (8): 3 2

𝑠 2

𝑠 3 − 𝑠 2 + (1 −

𝑥 ∗2 2 𝑟(∑𝑛 𝑖=1 𝑎𝑖 )

).

3

1

One can see that the points 𝑠1 = 0 , 𝑠2 = + √1 + 4 4 3

1

1,𝑠3 4 − 4 √1 +

𝑥 ∗2 2

2𝑟(∑𝑛 𝑖=1 𝑎𝑖 )

𝑥 ∗2 2

2𝑟(∑𝑛 𝑖=1 𝑎𝑖 )

>

are extremum points.

In the case 𝑠3 < 0 the graph of the left hand side of (8) is shown in Figure 2. It is seen that in the domain we are interested in 𝑠 ∈ [0,1] there is no solution of the inequality (8). This case corresponds to the situation 𝑥 ∗ > 4√𝑟 ∑𝑛𝑖=1 𝑎𝑖 . So the smaller is a satisfaction of the members of society and the higher are the requirements for the assessment by the society of the project results, the less are the Principal’s opportunities to provide the conditions of sustainable development.

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Figure 2. The graph of the left hand side of the equation (10) when s 30. First subcase

In the case 𝑠3 > 0 the graph of the left hand side of (8) is shown in Figure 3 and Figure 4. We have 𝑠3 > 0 if 𝑥 ∗ < 4√𝑟 ∑𝑛𝑖=1 𝑎𝑖 . In the case the inequality (8) holds when s=𝑠3, in the domain [0,1] that we consider there is a solution of the inequality (8) (the segment marked with a bold line on the axis Os in Figure 3), and the point 𝑠3 is one of the solutions.

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Notice that in this case, the share of the utility from the project realization that accrues to the Agent cannot exceed half, and it grows with the increase of the aggregate value of parameter of satisfaction of the members of society. In the case if when s=𝑠3 the condition (8) does not hold, in the segment [0,1] interesting to us the equation (8) has no solutions (Figure 4), i.e., in this case the Principal cannot provide the conditions of sustainable development. From the previous reasoning, we can conclude that when the Principal ensures the conditions of sustainable development (7), the parameters of satisfaction of each member of the society, or rather their aggregate value, does matter.

Figure 4. The graph of the left hand side of the equation (8) when s 3>0. Second subcase

APPLICATION TO PUBLIC-PRIVATE PARTNERSHIPS In view of the wide variability of the mechanisms of public-private partnership, we limit ourselves by a conceptual consideration of the projects of interaction between official authorities and business concerning

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the solution of socially significant tasks with the expansion of the organizational model on the public control of the conditions and results of its realization. For indicated purposes, we consider as objective the following interpretation of the conceptual model of public-private partnership (PPP): 1. the initiator and institutional organizer of the partnership is a public side represented by the federal government, regional authorities, local governments, which provides an opportunity and forms the conditions for the realization of the project. In particular, land plots allocated for gratuitous use, developed feasibility study appropriateness of the project at the preparatory stage, provided benefits for individual taxes for private partners for the period realization of the project, special conditions for pricing of services and products are determined, coordination of efforts of the interested participants is ensured; 2. the engaged direct executor and operator of the project is a private business partner - a legal entity or an organized group of business entities which, as a rule, performs on behalf of the public partner the functions of financing, designing and organizing all stages of realization of the project. In particular, a business partner acts as a general contractor for the creation of infrastructure and production facilities and/or their reconstruction, subsequently frequently performs the functions of an operating organization for the period of realization of the project; 3. the consumers of products or services produced in PPP projects are citizens and business entities, including public and environmental organizations, in whose interests these projects are initiated and which have the right to control the results of their realization.

The result of realization of a PPP project is a number of benefits or advantages that are distributed in accordance with the initial interests: the business partner (A1) generates a stream of income from the exploitation of the created investment object and/or possible tax benefits (in the part of federal, regional or local taxes); the public partner (A2) provides an impetus of economic development by creating a pool of jobs, a cluster core of industry, a large infrastructure facility, and society (Principal) receives

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benefits in the form of improving the socio-economic and ecological environment, the use of manufactured products, using of infrastructure facilities (water supply/water treatment, road network). It should be taken into account that the generated benefits for all subjects relations of partnership are of a prolonged nature and do not stop with the achievement of goals or the end of the project. The bail to the successful realization of PPP projects is precisely the partnership, which is expressed in a fair distribution of risks: the private investor (A1) is responsible for the production efficiency and implementation of capital investments, and the public partner (A2) properlyimplements economic regulation of his activity, provides administrative support and takes part in investment. Based on the different orientations of the interests of PPP participants, in practice, achievement of a complete coordination of the interests of all participants in the partnership (the state, business, and society personalized by consumers) is very difficult, but may be represented in theoretical models. In this case, it is expected to achieve a synergistic effect from the realization of PPP projects. Within the framework of integrative interaction, we can talk about a model of partial coincidence of the goals of stakeholders and the achievement of specified goals on the base of the balance of interests of the participants. Finding all the possibilities harmonizing interests between the participants of the partnership will allow to expand boundaries of the achieving synergistic effect. Consequently, it is possible to formulate a list of organizational requirements, which must correspond the models of reconciling the interests of government and business in solution of the socio-economic problems: for the state - the provision of quality services, the distribution of duties and responsibilities between participants of project; for business - a profitable investment of capital, creation of conditions for obtaining income (profit) and guarantees of return on investment, minimization of damage and distribution of risks; for society - a high quality of life, ensuring the transfer ofproperty rights on the created infrastructure facilities.

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A PRACTICAL EXAMPLE As an example of the realization of a large-scale PPP project we can cite the infrastructural project of the joint stock venture (JSC) “Eurasian” in Rostov-on-Don, Russia: “Complex program of the development and reconstruction of the water supply and drainage system in Rostov-on-Don and in the South-West of the Rostov Region”. The structure of this project in the identifiers of the proposed model is presented as follows: the functions of a private partner (A1) are performed by the JSC “Eurasian” as the main investor and executor of the project, and the functions of a state partner (A2) are performed by the Administration of Rostov-on-Don as a state customer and a responsible coordinator. The mentioned PPP project is implemented on the territory of the Rostov region with the involvement of budgetary funds from the federal budget, the budget of the Rostov region, city of Rostov-on-Don, and resources of the Investment Fund of the Russian Federation. The project is designed for the period 2004-2021 and includes three stages: Stage I (2004 - 2013) includes:  Building and commissioning into exploitation of the water treatment facilities running water in the North-Western industrial zone of Rostov-on-Don;  Building, reconstruction and entry into service the water culverts and water mains networks building, reconstruction and commissioning of water supply and sewerage pumping stations in Rostov-on-Don;  Building, reconstruction and entry into service objects of the water treatment facilities waterpipe, increasing the efficiency of production and management system of the water supply and drainage in Rostov-on-Don;  Building, reconstruction and entry into service of sewerage networks in Rostov-on-Don.

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Stage II (2013-2016) includes:  Building of the new water treatment facilities of water preparation and reconstruction of existing water supply and sewerage facilities;  Construction of a sewer collector in Rostov-on-Don. Stage III (2017-2021) includes:  Building of the new water treatment facilities and reconstruction of local water supply and sewerage facilities in settlements in the South-West of the Rostov region;  Construction of a sewer collector in Rostov-on-Don and reconstruction of city sewage treatment facilities of canalization. The realization of the project allows significantly reduce the negative influence on the environment, including the water area of the river Don, the Azov and Black Seas, improve the quality of centralized water supply and drainage for citizens of Rostov-on-Don and the South-West of the Rostov region, reduce operating costs for the maintenance of water supply and drainage networks. The total cost of the project is $530.36 million, the payback period is 20 years from the beginning of realization. Table 1 presents the sources and volumes of finance resources, reflecting the shares of contribution the power and business to the realization of the project. The socio-economic effect from the realization of the I-II stage of the project includes the following. Construction of the infrastructure facilities of water supply and drainage for ensuring housing construction (for 330 thousand inhabitants) and commercial real estate (up to 2 million sq. m.); improving conditions of the quality of life, connecting up to 98% of the city’s population to centralized water supply.

134

O. I. Gorbaneva, G. A. Ougolnitsky and A. D. Murzin Table 1. Sources and amounts of project financing, $ million13

Total 20042021 Estimated cost 530,36 Sources of financing for a complex investment project: Investor’s own funds 282,09 Investor’s borrowed funds 68,51 Regional budget funds 61,13 Municipal budget funds 23,48 Federal Investment Fund 95,15

Stage I 20042013 248,27

Stage II 20132016 109,73

Stage III 20172021 172,36

– 68,51 61,13 23,48 95,15

109,73 – – – –

172,36 – – – –

Improving the quality of water supply: conformity of 98% total number of drinking water sampling with the requirements of sanitary rules and regulations; reduction of technological, environmental and terrorist risks, ensuring environmental safety of the river Don as a source of water supply, reduction of dumping rinsing water; increasing the efficiency of water preparation and reducing energy consumption, increasing the reliability of water supply strategic facilities (Table 2). Provision of drainage from areas of mass housing development (for 350 thousand inhabitants), prevention of sewage pollution of the territory of the city of Rostov-on-Don and the river Don; connection of up to 80% of the population to centralized water disposal services, compliance of 75% of wastewater samples with regulatory requirements (Table 2). Stable guaranteed round-the-clock provision of water supply services, reducing the operating costs of water supply, reducing the time of permissible emergency shutdown on 25% (Table 3).

Order of the Government of the Russian Federation от 30.11.2006 N 1708-р (as amended on 14.04.2014) 13

Voroshilovsky Zheleznodorozhnyy Kirovsky Leninsky Oktyabrsky Pervomaisky Proletarsky Sovetsky Total

Administrative district of the city w/s 1313,8 411,9 1385,4 93,0 65,9 778,7 1962,6 1711,1 7712,7

total d 1259,1 393,2 1290,9 102,9 65,1 765,3 1628,2 1482,1 6977,0

2013 w/s d 107,7 110,8 36,9 36,2 34,8 35,6 5,6 5,8 10,9 10,0 51,3 48,8 21,7 20,6 7,2 6,6 276,3 274,6

Load, cubic meters/hour 2014 2015 w/s d w/s d 269,3 267,8 410,3 356,1 86,4 92,1 100,9 95,6 208,4 203,5 497,7 496,3 12,5 12,5 33,7 43,8 14,6 13,6 18,6 21,7 129,8 125,6 229,6 223,1 157,0 155,7 640,4 642,5 110,6 121,9 485,2 409,1 988,7 992,8 2416,6 2288,4 w/s 526,5 187,6 644,4 41,2 21,7 367,9 1143,5 1108,1 4031,1

2016 d 524,3 169,2 555,4 40,9 19,7 367,7 809,4 944,4 3421,1

Table 2. The dynamics of the load on water supply (w/s) and drainage (d) in the City of Rostov-on-Don

kWh/m3

unit/km hour/day % kWh/m3

Unit of measure

0,16

w/s 4,83 23,973 41,24 0,01 0,24

2013 d 13,25 24,000 0,51 0,16

w/s 4,78 23,974 41,24 0,01 0,24

2014 d 13,21 24,000 0,51 0,16

w/s 4,72 23,975 41,00 0,01 0,24

2015 d 13,16 24,000 0,51 0,15

w/s 4,67 23,975 40,39 0,01

0,24

2016 d 13,10 24,000 0,50

14

Decision of the Rostov-on-Don City Duma of 23.11.2010 N 26 (as amended on 23.10.2012)

Accident rate Service delivery time Rate of loss Water and wastewater treatment Transportation of water and wastewater

Indicator name

Table 3. Dynamics of the realization of the investment program of the development of the water supply (w/s) and drainage (d) in Rostov-on-Don14

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137

The organizational chart of the project is represented in Figure 5.

Investment Сontract

Administration of Rostov-on-Don

Lease Сontract Private partner JSC "Water of Rostov"

Management Сontract

Consumers

JSC "PO Vodokanal"

Service Agreement

Figure 5. The structure of organizational relations in the considered PPP project

The scope of property rights of participants in a complex investment project distributed as follows: 



Rights of the municipality stands at 100 percent of the rights to objects, the creation of which is financed by the Investment Fund of the Russian Federation, the budget of the Rostov region and the municipal budget; Rights of the JSC “PO Vodokanal of the City of Rostov-on-Don” to objects, creation of which is financed by of society, are determined in accordance with the investment agreement.

Consider the first two stages of realization of the project, since the results of the third stage are not yet accessible. Notice that, starting from the second stage, the project is realized exclusively at the expense of the investor, therefore to it can be applied the results of the study of model (1) - (5) proposed in Section 3. Following the results of the first stage of the project, 28 objects enshrined the private investor completed within the standard time frame:

O. I. Gorbaneva, G. A. Ougolnitsky and A. D. Murzin

138      

More than 40 km main water duct were built. 4 largest pumping stations were reconstructed. Block of treatment facilities of drinking water at the Aleksandrovsky contractions is reconstructed. A complex for ultraviolet disinfection of drinking water at the Aleksandrovsky treatment contractions is launched. Workshops for the production of sodium hypochlorite at the Central and Alexandrovsky treatment facilities are put into exploitation. Design and budget documentation for the construction of seven large facilities was completed and handed over to municipal customer.

As a result of the realization of the first stage of the investment project, significant problems of the city’s water supply and drainage infrastructure are eliminated. Objects of reconstruction and new building, carried out using modern materials, equipment and technologies, made it possible to improve the quality of provided services, to ensure epidemiological, industrial and environmental safety at all constructions treatment drinking water. The operating experience of the constructed and reconstructed facilities allows us to draw the following conclusions about the results of the realization of the 1st stage of the Project, which are in the area of responsibility of the JSC “PO Vodokanal”: 1. All the expected results of increasing the operational reliability and sustainability functioning infrastructure of the water supply are fully achieved, the accident rate at main water pipelines and the largest pumping stations has been sharply reduced, the productivity and quality of drinking water purification are improved, an advanced water disinfection technology is introduced, which made it possible to decommission a warehouse of the liquid chlorine. 2. The main infrastructure problems that could have a negative impact on water supply and drainage in urban areas are eliminated.

Hierarchical SPICE-Models of Public-Private Partnerships

139

3. A positive experience in implementation of automatization of the processes of increasing the energetic and management efficiency of the functioning of engineering systems is obtained. 4. A positive experience of using modern technologies and materials at the objects of repair, reconstruction and building of networks and structures is obtained. 5. All other tasks of the project adequately reflect the needs of improvement of the operational reliability, efficiency, operational activity, and development water supply system of the city. From the financial statements of PO “Vodokanal” and the documentation of the regional budget of the Rostov region as well as from the documentation on the results of the project the parameters of the model are determined. Table 4. Funding and development, $ million Indicator Investment fund RF Budget Rostov region Budget Rostov on Don Investorfunds TOTAL

Disbursed 4,14 22,15 3,29 11,64 41,22

Mastered 5,87 2,44 2,59 13,01 23,91

Table 5. The fulfillment of the obligations of financing, $ mln. Participants of the Project Investment fund RF Administration of Rostov region Administration of the City of Rostov JSC “PO Vodokanal” SUB-TOTAL

Plan 95,15 61,13 23,48 68,51 248,27

Fact 95,15 43,90 10,95 65,73 215,73

Deviation 0,00 17,23 12,53 2,79 32,54

Fulfilment,% 100,00 71,82 46,65 95,93 86,89

The financial indicators of realization of the I stage of the project are given in Tables 4-5. The second and third stages are financed fully from the investor’s funds and include work on the development and improvement of the

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reliability of water supply to the left-bank part of Rostov-on-Don and the satellite town of Bataysk, switching in Rostov-on-Don the Dachny water conduit from technical water-to-water potable quality. One of the largest facilities of the second stage is a complex of constructions of the reuse of water of filter washing at the Aleksandrovsky wastewater treatment plant, worth over $ 14 million. Let A1 be the private side of the partnership in the person of PO “Vodokanal”, and A2 - the state side of the partnership in the person ofthe Administration of the Rostov region and the Administration of the City Rostov-on-Don, r1 - the financial resources which has PO “Vodokanal”, r2 - budgetary funds, allocated by participants A2 for municipal economy. These magnitudes are estimated from the above documentation as r1= $1884,84 mln, r2= $712347,85 mln. Ratios of production activity: p1 = 1,3286, while p2 = 1, с=1,α = 0,9999. From the project documentation, u1 = $68,51mln, u2 = 95,15 + 61,13 + 23,48 = $179,76 mln. The income is divided between the participants in a proportional relationship (from Figure 2 and indicated in the documentation of project the property rights to the project results), i.e., s1 = 68,51/248,27 = 0,276, s2 = 1–s1 = 0,724. The parameters of the model correspond to the case when the functions of private activity are linear, and the function of general activity is powerlaw with an exponent less than one. With the found parameters, the income of the participants are: income from the realization of the project itself $248,09 mln, income of the PO “Vodokanal” $2481,68 mln, aggregate income of budgetary organizations $712347,73 mln, total income of participants $714829,40 mln. Let us use the results of the investigation of SPICE-models in (Gorbaneva and Ougolnitsky 2018,2020), in accordance to which the optimal strategy for the entire system is determined by the expression

Hierarchical SPICE-Models of Public-Private Partnerships

u

iM

i

max

   rj ,    jM 1  c ,  pmin

r jM

1

c

 1

j

c pmin



141

,

pmin

r. jM

j

So, u1max+u2max=$0,005 mln, and since p2 = 145 years old) and rural female respondents were presented to have moderate attitudes towards SWM. Similarly, in Japan, Rahardyan et al., (2004) found that respondents aged between 40s and 50s welcomed activities in the field of SWM, particularly the implementation of new facilities, more than younger ones. This was true for landfills and incinerators, yet all age groups accepted the implementation of recycling facilities. Conversely, in Malaysia, 60% of the respondents (university students) had positive attitudes towards the implementation of SWM facilities (Desa et al., 2012). When correlating between age and awareness of problems induced by the landfilling process, Al-Yaqout et al., (2002) concluded that older people were more aware of the such problems; perhaps because they might have a greater practical experience of the emerging health and environmental impacts. Freshman students in Malaysian universities still need to raise their awareness level and attitudes towards SWM facilities

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(Desa et al., 2012). In Hebron district of Palestine, the age of the respondents had a significant statistical effect on opposing a landfill or a recycling facility (but not an incinerator) implementation (Al-Khatib et al., 2014). The scarcity of SWM facilities in Palestine as well as the minimal provision of information have negative effects on public opinion since people are unfamiliar of the potential impacts of such facilities on their health and the environment (Al-Khatib et al., 2014). Furthermore, the statistical significance of the different personal attributes at the confidence level of 95% and the alpha-level of 5% was investigated. The results were really interesting and showed how personal attributes contribute to the behavior and attitude of the person. As for the age variable, there is a statistically significant difference among the responses according to this variable for the implementation of the incinerator and landfill facilities, but not the recycling facilities. As for the gender variable, there is a statistically significant difference among the responses according to this variable for the implementation of the landfill and recycling facilities, but not the incinerator facilities. As for the locality type variable, there is a statistically significant difference among the responses according to this variable for the implementation of the incinerator and recycling facilities, but not the landfill facilities. Having noted the perceived fairness levels for the respondents from various locality types, the authors requested them to rate certain statements related to the implementation of SWM facilities. The scores ranged from 0; 0 which stands for “not worried at all,” to 3 which stands for “very worried.” To secure the stability of the outcomes, the “not sure” replies were excluded during the raw data processing. The statements belonged to four major categories for the SWM facilities as indicated hereafter: 1. Reliability: status and effectiveness of the SWM facility, information disclosure on operation/management, reliability of technology, financial stability of the facility owner, clarified mechanisms and procedures in the facility, initial cost, operation and maintenance cost and post closure property value, 2. Nuisance: decrease of property value, deterioration of living environment, influence on farm products, stench and noise of collection vehicles, stench and noise of landfill, traffic congestions caused

Assessing People’s Concerns and Attitudes towards Solid Waste … 203 by collection vehicles and the spread of pests including flies, insects, rodents and crows, 3. Natural diversity: effects on plants, animals and forests and 4. Pollution: soil, water and air pollution. As presented in Figure 2, the reliability category of the SWM facility had the highest concern rating of 2.14 (average score was taken for each category). Based on the average score of respondents regardless of their locality type, the second-rank category was the pollution (2.02), then the nuisance (1.84) and finally the natural diversity category (1.72). The range of scores per statement did not present a great difference since it was from 0.05 to 0.5 points. This is an indication that locals have similar concern levels regardless of their locality types.

Figure 2. Rating of concerns according to the locality type (urban, rural or refugee camp) from 0 “not worried at all” to 3 “very worried.”

Rahardyan et al., (2004) found that the pollution category of the SWM facilities had the highest rating, followed by the categories of reliability and then the natural diversity. Ishizaka and Tanaka (2003), however, pointed out that the Japanese residents were concerned of environmental pollution occurring from solid waste as well as the noise and odor resulting from waste transportation vehicles. Similarly, the Kuwaiti residents were concerned for environmental pollution (50%), air pollution (42%), health hazards (40%) and bad odors (22%) of SWM facilities (Al-Yaqout et al., 2002). Considering all responses, as shown in Figure 2, the status and

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effectiveness of the SWM facility was the parameter of the highest concern to the Palestinian respondents, whereas the forest harm was the parameter of the lowest concern to them. Table 2. Association of concerning statements from different categories and attitudes towards SWM facilities Category Statements

Pollution

Air Pollution Water Pollution Soil Pollution Natural Forest Harm diversity Plant and Animal Harm Nuisance Flies, rodents, crows Traffic accidents caused by collection vehicles Traffic congestions caused by collection vehicle Stench and noise of landfill Stench and noise of collection vehicle Influence on farm products Deterioration of living environment Decrease of property value Reliability The status and effectiveness of the facility Information disclosure on operation/management Reliability of technology Financial Stability of facility owner Clarify the mechanism and the procedures in the facility Initial Cost

Incinerator GK coef. -0.27 -0.29 -0.3 -0.3 -0.34 -0.48 0.04

Chi2 sig. 0.1 0.08 0.05* 0.04* 0.03* 0.004** 0.77

-0.07 0.36

Landfill GK coef. -0.39 -0.43 -0.46 -0.42 -0.42 -0.74 0.05

Chi2 sig. 0.008** 0.004** 0.001** 0.002** 0.004** 0.000** 0.72

Recycling facility GK Chi2 coef. sig. -0.19 0.14 -0.29 0.02* -0.3 0.013* -0.2 0.08 -0.28 0.02* -0.41 0.001** 0.16 0.15

-0.10

0.17

-0.07 0.25

-0.67 0.000** -0.65 -0.61 0.000** -0.60

0.000** -0.49 0.000** 0.000** -0.55 0.000**

-0.02 0.9 0.03 0.88

0.96 0.88

0.06 -0.02

0.19 0.21

0.1 0.1

0.16 0.02* 0.13 -0.53 0.000** -0.50

0.07 0.15 0.02* 0.000** -0.51 0.000**

-0.56 0.000** -0.51

0.000** -0.51 0.000**

-0.70 0.000** -0.70 -0.31 0.04* -0.59

0.000** -0.61 0.000** 0.000** -0.52 0.000**

-0.18 0.18

-0.21

0.09

0.03

0.97 0.006 0.23 0.12 0.04 0.77

0.84

-0.05 0.68 0.19

0.11

Operation and maintenance cost 0.33 0.05* 0.39 0.001** Post closure property value 0.09 0.53 0.21 0.07 Chi2: Chi–square test; GK: Goodman-Kruskal Gamma. ** Significant at the 1% level, * significant at the 5% level, no stars at all: not significant.

Assessing People’s Concerns and Attitudes towards Solid Waste … 205 The rural respondents presented the highest ratings in most statements of the reliability category of the SWM facilities. This could be an evidence that the rural community had little trust in the information disseminated by the private sector regarding the SWM facilities. Nevertheless, the respondents from refugee camps had the lower ratings in almost all statements except the “deterioration of living environment.” This might show the high environmental pressure to sustain the minimum living conditions exist in the refugee camps. Having the ranking of their concerns, the respondents were requested to state their attitudes towards the implementation of specific types of SWM facilities, namely landfills, incinerators or recycling facilities in each locality type. Unsurprisingly, the respondents were not concerned about the implementation of such SWM facilities. This demonstrates the limited dissemination of environmental information to the local community confirmed by Al-Khatib et al., (2007). In effect, people with no obvious attitudes towards SWM facilities are those with no concerns about pollution, natural diversity, nuisance and reliability. The same results were depicted in the Japanese study of Rahardyan et al., (2004). To assess the concern-attitude relation, Good-Kruskal (GK) Gamma was applied. The strength of association of the cross tabulated data with GK coefficient values ranging from -1 to 1. The GK coefficient values vary between -1 for opposing attitudes and 1 for supportive attitudes (Rahadyan et al., 2004). Table 2 shows the association of concerning statements from the different categories and the respondents’ attitudes towards the different types of SWM facilities. To assess the influence of concerns on the respondents’ attitudes towards SWM facilities, discriminant analysis was applied (Figure 4). This time the listed concerns were directly linked to the overall management of the SWM facility but not to its specific type. This means that parameters of the pollution, nuisance and natural diversity categories were the only ones taken into consideration. To safeguard the outcomes, “not sure” replies were excluded.

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Figure 3. (Continued)

Assessing People’s Concerns and Attitudes towards Solid Waste … 207

Figure 3. Rating of concerns by different attitude group to the implementation of incinerators, landfills and recycling facilities.

Figure 4. Standardized discriminant function coefficients.

The major concerns regarding the given statements per SWM facility, as depicted in Figure 4, were: influence on farm product (for incinerators), traffic congestions caused by collection vehicles (for landfills) and forest harm (for recycling facilities). These concerns play the most significant role into the opposing position to the implementation of SWM facilities.

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On the contrary, statements such as traffic accidents caused by collection vehicles, traffic congestions caused by collection vehicles, influence on farm products, decrease of property value, initial cost, operation and maintenance cost, post closure property value and deterioration of living environment did not play a major role into the acceptance of any SWM facility. Overall, the assessed percentage of acceptance was formatted to be 77% for incinerators, 78% for landfills and 74% for recycling facilities. Inconsistency had been noted since potential environmental harm (being a negative statement) did not reflect negative but positive population perceptions. That was for the case of landfill where negative statements such as water pollution, deterioration of living environment, etc. did not constitute reasons for population’s concerns (since positive values were noted). Similar inconsistency was tracked in the Japanese population (Rahardyan et al., 2004). This, in both cases, is justified by the lack of environmental culture and the limited environmental awareness. Appropriate dissemination of information on SWM is after all essential for the understanding of environmental balances as well as the pursuing of sustainable roadmaps in this field.

CONCLUSION AND RECOMMENDATIONS In order to study people’s concerns and attitudes towards solid waste management (SWM) facilities, a questionnaire was structured and distributed in the West Bank of Palestine in the frame of an extended field research. Almost 381 households were targeted in each of two Palestinian districts: Nablus and Jenin. The raw data were scientifically processed and statistically analyzed. Although there was no solid waste segregation, almost 38% of the respondents were concerned about the local recycling practices in the Palestinian community. About 65% of the respondents felt pessimistic about the future of the SWM system in Palestine because of the limited ability of the governing authorities to address the emerging issues and challenges. The concern levels about the unfair implementation

Assessing People’s Concerns and Attitudes towards Solid Waste … 209 of a new SWM facility in neighboring areas were the highest for the rural community and the lowest for respondents from refugee camps. While the young male rural respondents perceived an unfair implementation of a new SWM facility in their proximity, older female rural respondents did not think so. In general, considering all locality types, the opposition levels for the implementation of a nearby SWM facility were 69% for incinerators, 70% for landfills and 65% for recycling facilities. The stated denial to any kind of SWM facilities, as well as the high levels of “not concerned” people describe the lack of environmental culture and the limited dissemination of environmental information. This is an open invitation for all stakeholders of the SWM system to develop education programs that raise awareness and understanding of the Palestinian community to tackle its environmental challenges for the sake of a better future for the new generations. The discriminant analysis was applied in order to assess the influence of concerns on the respondents’ attitudes towards a SWM facility. After all the inconsistencies identified in the discriminant analysis proved that negative statements (such as environmental pollution) did not constitute a significant parameter that negatively influenced the respondents’ opinions on SWM. Having the experience of visiting a SWM facility significantly altered the respondents’ attitudes towards SWM facilities in a positive way. Overall, public awareness in Palestine needs to be enhanced; the governing authorities in collaboration with the private sector should undertake initiatives towards the SWM field. Particularly young population should develop positive environmental culture and comprehend the importance of implementing SWM facilities. Besides all the young scientists are expected to set the local priorities and motivate the application of new technologies. Public consultation and participation in the decision-making process starting from the planning period are a prerequisite to increase the trust level and ultimately run successful SWM programs in the local community. The proper management of solid waste services is an essential element for maintaining the safety and health of the

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society members. It is absolutely conceived that solid waste services should be managed smartly after the onset of the novel coronavirus pandemic in a developing country with limited physical, technical and financial resources such as Palestine. Public-private partnership is a must for a successful SWM system that can provide the service of a higher quality at a lower cost.

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developing countries: A review. International Journal of Advanced Science and Research, 1(10), 22-29. Sukholthaman, P., & Shirahada, K. (2015). Technological challenges for effective development towards sustainable waste management in developing countries: Case study of Bangkok, Thailand. Technology in Society, 43, 231-239. Thompson, S. K. (2012). Sampling, 3rd Edition. John Wiley and Sons, NJ, USA. Thoni, V., & Matar, S. (2019). Solid Waste Management in the Occupied Palestinian Territory: West Bank Including East Jerusalem and Gaza Strip. CESVI Overview Report, Bergamo (Italy). UNDP (2014). The 2014 Palestine Human Development Report: Development for Empowerment. United Nations Development Programme, Jerusalem (Palestine). UNEP (2020). State of Environment and Outlook Report for the Occupied Palestinian Territory 2020. United Nations Environment Programme, Nairobi (Kenya). Wang, Z., Dong, X., & Yin, J. (2018). Antecedents of urban residents’ separate collection intentions for household solid waste and their willingness to pay: Evidence from China. Journal of Cleaner Production, 173, 256-264. Xu, L., Ling, M., Lu, Y., & Shen, M. (2017). External influences on forming residents’ waste separation behaviour: Evidence from households in Hangzhou, China. Habitat International, 63, 21-33. Zhang, L., & Klenosky, D. B. (2016). Residents’ perceptions and attitudes toward waste treatment facility sites and their possible conversion: A literature review. Urban Forestry & Urban Greening, 20, 32-42.

In: Public-Private Partnerships ISBN: 978-1-68507-184-4 Editors: D. Monferrer Tirado et al. © 2021 Nova Science Publishers, Inc.

Chapter 7

DEVELOPING A SUSTAINABLE MANAGEMENT MODEL FOR HEALTHCARE SOLID WASTE: NABLUS HOSPITALS AS A CASE STUDY Issam A. Al-Khatib1,2, PhD, Yasmeen Shanaa1 and Abdelhaleem I. Khader3,*, PhD 1

Institute of Environmental and Water Studies, Birzeit University, Birzeit, West Bank, Palestine 2 Universal Institute of Applied and Health research, Nablus, Palestine 3 Civil Engineering Department, An-Najah National University, Nablus, Palestine

ABSTRACT Medical waste in Palestine continues to pose a threat to public health and the environment, although there has been some improvement in its management. However, this improvement has not reached the required level. Medical waste is collected mixed with municipal waste in most communities in the West Bank, Palestine. There is a treatment for *

Corresponding Author’s Email: [email protected].

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I. A. Al-Khatib, Y. Shanaa and A. I. Khader infectious medical waste in some hospitals through sterilization or by uncontrolled incineration in incinerators that do not meet the specifications required for burning waste. Management of medical waste in the city of Nablus needs further study and analysis, particularly the sustainable management of solid waste in the city’s hospitals. The aim of this chapter is to identify sustainable development opportunities in managing medical solid waste in Nablus hospitals, and create sustainable management model for managing hospitals healthcare waste. It utilized a qualitative investigation to collect data for the study that was carried out in two hospitals in Nablus city (a governmental hospital: Rafidia hospital, and a charitable hospital: St. Luke’s hospital). Qualitative methods were used to evaluate and understand the medical waste management process and the healthcare waste management (HCWM) in the selected hospitals. Furthermore, Interviews were conducted with key persons related to healthcare waste management in the Ministry of Health (MOH), Nablus Municipality (NM) and Environmental Quality Authority (EQA) for identification of strength points which lead to switching to a sustainable waste management system, and to design a system that deals with the healthcare waste generated from the studied facilities. Healthcare solid waste is dangerous and affects human health and the environment. Hence, development of appropriate management system is necessary. In the selected hospitals in the study area there was no budget for medical waste management system, which means shortage of tools and equipment for the sustainable medical waste management system. There are no training plans as well as medical waste learning materials. There is no medical waste management department or committee, even on the governmental level, despite the Palestinian Cabinet's decision No. 10 of 2012 on the medical waste management. It was found that the targeted hospitals in the research do not segregate all the medical wastes or treat the hazardous wastes. They suffer from absence of treatment and disposal ways. Analytical hierarchy process (AHP) was used to develop model for sustainable management for medical waste solid waste. AHP as Multi Criteria Decision Making (MCDM) process was used to develop sustainable management model for healthcare solid waste in Nablus city hospitals. The sustainable model using AHP shows that waste treatment before disposal has the highest priority among main criteria (42.3%), followed by social and environmental aspects (27%) and waste management cost with (16.1%). In sub criteria, in waste handling procedure, waste segregation had the highest priority (70%); in waste management cost, recycling cost had the highest priority (46%), and in waste treatment the sub criteria with the highest priority is treatment before disposal (50%). Lastly, in terms of overall ranking of sub-criteria with respect to goal, treatment before disposal had the highest priority (21.1%), followed by social and environmental aspects (27%), and waste segregation (10.9%) are the top

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three sub-criteria. Using AHP, the model found that Plasma Pyrolysis is the best method to treat medical wastes.

Keywords: medical solid waste, qualitative investigation, sustainable management model, AHP, Nablus hospitals

INTRODUCTION Risks related to healthcare waste and management of it has become more important in recent years. The need for appropriate healthcare waste management has been gaining more attention due to the disease burdens associated with poor practices. Despite the magnitude of this problem, practices, capacities and policies in many countries in managing or dealing with healthcare waste disposal, especially developing nations, are inadequate and require intensification (Ananth et al., 2010; Su and Chen, 2018). Since healthcare solid waste is a major public health hazard, it is important to protect public health and well-being through the appropriate control and management of medical wastes generated from all healthcare facilities. It is important to grasp the scope of the current status of quantity, sources, storage, transport, and disposal of waste resulting from primary, secondary, and all other healthcare activities (Al-Khatib and Sato, 2009). So, there is a need for healthcare centers to reduce the quantities of generated waste, their carbon footprints, financial costs and adverse environmental impacts (Mukonoweshuro and Nichols, 2016).

LITERATURE REVIEW Between 75% and 90% of the waste produced by healthcare centers are “general” healthcare waste (HCW), comparable to domestic/household waste. It comes mostly from the administrative and housekeeping functions of healthcare establishments and may also include waste

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generated during maintenance of healthcare premises. The remaining 10– 25% of healthcare waste is regarded as hazardous and may create a variety of health risks (WHO, 1999). WHO has advocated that hospital wastes must be treated as special wastes (Rushbrook et al., 2000; Bdour et al., 2007). Handling and managing medical waste is more difficult if it is not properly sorted. For the waste to be infectious, it must contain pathogens with sufficient virulence and quantity so that exposure to the waste by a susceptible host could result in an infectious disease (Blackman, 1996; Bdour et al., 2007). Medical waste is one of most important hazardous waste in Palestine, because of its bad effect on workers of healthcare centers, community and public health and its ability to transmit many diseases if not properly managed (Al Khatib, 2003). Organizational practices in relation to sustainable methods of HCW management, including waste segregation and waste recycling are often poorly examined and documented in some parts of the world despite the health risks posed by improper handling of HCW (Abah and Ohimain, 2011). The faced problems in hospital waste management were inappropriate segregation of infectious wastes from noninfectious wastes into colored and coded bags and deficiency in plastic bags supply and bag holders (Abd El-Salam, 2010). Segregated wastes (normal waste and hazardous waste) are mixed by domestic workers as they collect wastes for external storage, or mixed by municipal workers who mix the different types of wastes together during collection (Bdour et al., 2007).

Environmental Impact Untreated HCW disposal in landfills if landfills are not properly constructed can lead to the contamination of drinking water. WHO states that

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“The treatment of healthcare wastes with chemical disinfectants can result in the release of chemical substances into the environment if those substances are not handled, stored and disposed in an environmentally sound manner. Incineration of waste has been widely carried out, but inadequate incineration or the incineration of unsuitable materials results in the release of pollutants into the air and in the generation of ash residue. Incinerated materials containing or treated with chlorine can generate dioxins and furans, which are human carcinogens and have been associated with a range of adverse health effects. Incineration of heavy metals or materials with high metal content (in particular lead, mercury and cadmium) can lead to the spread of toxic metals in the environment. Only modern incinerators operating at 850-1100°C and fitted with special gas-cleaning equipment are able to comply with the international emission standards for dioxins and furans. Alternatives to incineration such as autoclaving, microwaving, steam treatment integrated with internal mixing, which minimize the formation and release of chemicals or hazardous emissions should be given consideration in settings where there are sufficient resources to operate and maintain such systems and dispose of the treated waste.” (WHO, 2018)

Abd El-Salam (2010) found that incineration is the most frequently used treatment practice for solid medical waste. But a variety of harmful pollutants may be emitted by incinerators if they are not operated and maintained correctly and if gas cleaning equipment is not fitted. “These pollutants include particulate matter, acid gases, toxic metals, and toxic organic compounds products of incomplete combustion, e.g., dioxins, furans, etc.” (WHO, 1999).

Characteristics and Classification of Healthcare Solid Waste The first step to any successful waste management policy is the characterization of the waste in order to estimate potential materials recovery, identify sources of component generation, facilitate design of processing equipment, estimate physical, chemical, and thermal properties of the wastes, and maintain compliance with regulations (Adeniran et al., 2007). WHO classified waste and by-products from hospitals as the following:

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I. A. Al-Khatib, Y. Shanaa and A. I. Khader “Infectious waste: waste contaminated with blood and other bodily fluids (e.g., from discarded diagnostic samples), cultures and stocks of infectious agents from laboratory work (e.g., waste from autopsies and infected animals from laboratories), or waste from patients with infections (e.g., swabs, bandages and disposable medical devices), Pathological waste: human tissues, organs or fluids, body parts and contaminated animal carcasses, Sharps waste: syringes, needles, disposable scalpels and blades, etc., Chemical waste: for example solvents and reagents used for laboratory preparations, disinfectants, and heavy metals contained in medical devices (e.g., mercury in broken thermometers) and batteries, pharmaceutical waste: expired, unused and contaminated drugs and vaccines, cytotoxic waste: waste containing substances with genotoxic properties (i.e., highly hazardous substances that are, mutagenic, or carcinogenic), such as cytotoxic drugs used in cancer treatment and their metabolites, Radioactive waste: such as products contaminated by radionuclides including radioactive diagnostic material or radio therapeutic materials, and Non-hazardous or general waste: waste that does not pose any particular biological, chemical, radioactive or physical hazard.” (WHO, 2018)

Healthcare Solid Waste Management The first global and comprehensive guidance document for safe management of wastes from healthcare centers was developed by WHO in 1999. The guidance document is targeting managers of hospitals and other healthcare centers, policy makers, public health professionals and managers involved in waste management, as part of monitoring sustainable development. The guide contains aspects such as regulatory framework, planning issues, waste minimization and recycling, handling, storage and transportation, treatment and disposal options, and training (WHO, 2018). Hospitals waste management system is affected by many factors such as, number of beds, number of employees, level of service, population, birth rate, and fertility rate. As a result, this management system requires a deep analysis to determine the role of each factor and its effect on the whole system. It is profoundly essential to recognize the kinds of infectious and non-infectious waste and to segregate, collect, and dispose or treat them in an acceptable manner (Al-Khatib et al., 2016).

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Medical waste ought to be transported by wheeled trolleys, containers or carts that aren’t used for other purpose. The trolleys ought to be cleaned daily. Offsite transportation vehicle ought to be marked with the name and address of carrier. Biohazard sign ought to be painted and appropriate system for securing the load throughout transport ought to be ensured. Such a vehicle ought to be simply washer-friendly with rounded corners (Abor, 2013). There have been viable approaches for effective disposal of HCW such as, burning, land filling, recycling or utilizing. Burning has been the foremost outstanding methodology adopted in most of the developing countries (Alvim-Ferraz and Afonso, 2005; Rogers and Brent, 2006; Chauhan and Singh, 2016; Dhakal et al., 2016). Land filling is a popular approach of waste disposal because of its low price of operation. However, land filling is also important because anatomical waste, hazardous waste (radioactive and heavy metals) and infectious waste produce dangerous atmospheric emissions. The closing ash content is supposed to be landfilled carefully after incineration. The recycling or reusing has been described as the third possible method of disposal of the waste generated at some point of healthcare activities (Lee et al., 2002; Chauhan and Singh, 2016). The basic treatment goals of Bio-Medical Waste consist of quantity reduction, disinfections, neutralization or other trade-off composition to lessen hazards to health and environment. After such remedy the residues may be dealt with safely, transported, stored and disposed of (Yadav, 2001).

Sustainable Healthcare Solid Waste Management Prevention and reduction of HCW is fundamental for any hospital to begin or continue its environmental sustainability journey. This can lead to substantial fee savings and discounts in environmental and health impacts. The part of the waste diverted from disposal via recycling and other methods varies, depending on medical institution size and location,

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management techniques, and the availability of nearby markets (American Hospital Association, 2018). Energy savings in hospitals can be made through the reduction in carbon emissions – in many cases energy bills can be reduced by 15% with the implementation and monitoring of A/C modules, therefore turning into more cost efficient (Oberlin, 2016). Measures to prevent and manage health center wastes include enforcing environmentally top-rated purchasing guidelines and programs, imposing more green ordering protocols, the usage of control efficiency techniques to reduce wasteful practices and operations, donating materials that are no longer needed but are nevertheless useful, recycling nontraditional waste streams, and investing in local companies to stimulate the recycling market (Plisko et al., 2015).

Analytical Hierarchy Process (AHP) The Analytic Hierarchy Process (AHP) is a theory of measurement through pairwise comparisons and relies on the judgements of experts to derive priority scales. It is these scales that measure intangibles in relative terms. The comparisons are made using a scale of absolute judgements that represents, how much more, one element dominates another with respect to a given attribute. Because of hierarchical structures, it lets in choice makers to understand, organize, and analyses the decisive situations in a manner that becomes favorable for them. Following are the steps of AHP (Saaty, 2008). AHP can simplify a complex question and remedy it hierarchically with distinct perspective. Also, by its quantitative judgment and comprehensive assessment via its context, it provides choice makers with sufficient records to make suitable selection as nicely as lessen the danger of making wrongful decisions. In the selection-making methodology of more than one goals and guidance, AHP is a simple and possible method. This technique entails a complex analysis of the situation problem’s model regarding its criteria, feasible sub-criteria and alternatives, for that

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reason enabling the choice makers to perform a concrete prioritization and selection (Hyun et al., 2015). The AHP has been implemented unevenly in healthcare studies. A minority of studies defined all the relevant aspects. Thus, the statements in this review can be biased, as they are limited to the facts to be had in the papers. Hence, further research is required to find out who need to be interviewed and how, how inconsistent answers have to be dealt with, and how the final results and balance of the results should be presented. In addition, we need new insights to determine which target group can satisfactory handle the challenges of the AHP (Schmidt et al., 2015).

METHODOLOGY Study Area The city of Nablus was founded by the Roman Emperor; Vespasian in seventy two CE as Flavia Neapolis, the town has been ruled by way of many empires over the course of its almost 2,000-year-long history. Nablus is considered one of the most important business and cultural centers in Palestine, and the main commercial enterprise and population center of the northern part of the West Bank, Palestine (An-Najah National University, 2018).

Location, Population and Land Use Nablus city is located about 60 kilometers north of Jerusalem. Located in a strategic valley between Mount Ebal and Mount Gerizim, Nablus city is placed at an altitude of 465-539m above sea level (Applied Research Institute- Jerusalem, ARIJ, 2014).

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Nablus Governorate is bordered by Jenin and Tubas Governorates to the north, Tubas and Jericho Governorates to the east, Salfit, Qalqilya and Tulkarm Governorates to the west and Ramallah & Al Bireh Governorate to the south. The total area of Nablus Governorate is about 605 km2 (ARIJ – GIS Unit, 2013), with about 400 thousand inhabitants as estimated in 2019 (Palestinian Central Bureau of Statistics, PCBS, 2019). The total area of Nablus city is approximately 33 km2.

Figure 1. Location of Nablus district within the West Bank.

Research Design and Approach Field work and data collection of this study were carried out in two hospitals in Nablus City (a governmental hospital: Rafidia hospital, and a charitable hospital: St. Luke’s hospital). Interviews with key participants

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(Head of Nurses, Officer of Hygiene workers, Managing Director, Chief Doctors, Laboratory Officer, and Radiology Image Officer) in each of the hospitals were conducted with the purpose of gaining a greater understanding of awareness around sustainability, waste management practice and to identify opportunities in relation to potential sustainable waste management interventions within Nablus hospitals. Furthermore, interviews were conducted with key persons related to management in the Ministry of Health (MOH), Nablus Municipality (NM) and Environmental Quality Authority (EQA) for identification of strength points which lead to switching to a sustainable waste management system, and to design a system that deals with the HCW generated from the studied facilities.

Site Selection In this study two hospitals were selected, Rafidia hospital and St. Luke’s hospital. Rafidia hospital (established in 1976, 200 beds) was chosen because it is a public hospital which is crowded most of the time. St. Luke’s hospital (established in 1900, 48 beds) is a hospital with high quality service and not always crowded. The staff distribution in the two selected hospitals is shown in Table 1. Table 1. Staff distribution in selected hospitals Hospital

Specialist Resident doctor doctor

Professional Medical pharmacist assistant

Nurse

Administrative Daily staff member worker

Rafidia hospitals

51

107

8

78

237

93

54

St. Luke’s Hospital

10

15

3

9

38

10

25

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Data Collection The data collection for this research was based on a qualitative method (interviews), in addition to data from literature. The interviews were conducted during the field visits. Field visits were conducted during the period from February, 2019 until April, 2019, where personal experience was used and observations were made. At the beginning of the interviews, the purpose of the interview was explained to participants. The interviewed respondent distribution in the two selected hospitals is shown in Table 2. Table 2. Respondent distribution in the two selected hospitals Doctors

2/a chief of doctors and a doctor.

Nurses

2/a head of nurses and a nurse.

Service (domestic) worker

2/an officer of service (domestic) worker and a domestic worker.

Administration

Managing director.

Labs

Lab scientist.

Radiology

Radiology image officer.

The questionnaire for hospitals include questions such questions about the routine process when wastes generate, how to deal with generated waste, knowledge about rules, policies, solid medical waste management system and sustainability, sustainable management system for medical solid waste and future plans. The questionnaire for the Ministry of Health, Nablus Municipality, and Environmental Quality Authority was about regulations, rules, responsibilities, budget, knowledge about sustainable management system for medical solid, sustainability and future plans. Field notes and interviews were recorded then typewritten in an electronic format and analyzed using logical qualitative analysis, the interview data was then sorted and explained.

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Development of Sustainable Management Model Using Analytical Hierarchy Process (AHP) Using AHP to develop model for sustainable management for medical solid waste. AHP briefly involves the following three steps.

Identification of Criteria and Sub Criteria The main criteria and sub criteria were identified, depending on literature. The main goal which is hospital solid waste management is divided into four main criteria and each main criterion is further divided into their associated sub criteria. Table 3 shows the selected main criteria, sub criteria, and description of sub criteria. According to this criteria and sub criteria the model of AHP is created. Solving a problem using the AHP starts with preparing the hierarchical structure of the system, this means identifying the main elements of the system and grouping these elements according to a hierarchy. All the elements located on a higher hierarchical level act on the elements in the lower level (Cabała, 2010). The chart in Figure 2 shows the hierarchy of the model, it shows the main criteria, sub criteria, and the alternative for waste treatment.

Figure 2. Hierarchy for model.

Waste handling procedure

Main criteria Waste management cost

Waste transportation Frequency per day

Waste segregation

Recycling and remanufacturing cost Disposal and treatment cost Waste collection

Transportation cost

Storage cost

Sub-criteria Waste handling cost

Cost of disposal differ depends on the way of treatment way chosen by the hospital, each treatment way have different cost. Collect waste bags label it after it closed tightly are part of the collection stage. The domestic (service) worker collects the HCW in the system’s container, which is then transfer by the vehicle to empty in central containers. Segregation process is the separation of generated wastes according to used classification (infectious, special, and non-risk (common, general waste, similar to household waste)). Flow of wastes from the generation points towards treatment station and finally to disposal. How many time wastes are collected and disposed per day.

Description Expenses appear in waste bins, trolleys, coloured bags, personal protective equipment, and persons to collect and handle waste. Cost of an area inside hospital or in hospital boarder (empty area) designated for waste storage before its transportation by municipality's car or before it treated if there is a treatment policy. It includes operational cost, utility requirement, and may be overheads. Expenses for waste transportation from healthcare facility to disposal side including waste collection vehicles, bins, and freight charges. Recycling cost includes cost of recycling process by outsourced contract with recycle agency.

Table 3. Main and sub-criteria for hospital waste management

Treatment before disposal

Sub-criteria Recycling/Reuse

Description Recycling is defined as process of collecting, sorting, decontaminating and returning of waste substances to commerce as commodities for use once more or exchange Reuse is can be describe of anything that can use again The ways used to treat wastes before final disposal it to inactivate the risk and danger associated to that waste and to minimize its harmful nature. 1-Autoclaves. 2-Microwave. 3-Chemical disinfections. 4-Controlled and healthy landfills. 5-Plasma Pyrolysis. 6-Incineration.

Disposal methods Hospitals treatment systems depending on the characteristics of generated wastes. Social aspect Taking into consideration any effect on human representing in human health. Interviews for data collection were designed to identify main criteria and their associated sub criteria to meet the objective of the research and to implement AHP successfully.

Main criteria Waste treatment

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Comparison of the Determined Criteria/Pairwise Comparison In this step, the priority scale determined, and paired comparisons are made on the comparison matrix for each stage (Ly et al., 2018). The AHP process compares criteria, or alternatives with respect to a criterion, in a natural, pairwise mode. In AHP, multiple pairwise comparisons are based on a standardized comparison scale of nine levels (Kambiz et al., 2012). Table 4 shows the standardized comparison scale of nine levels. Table 4. Comparison scale for different criteria (Hyun et al., 2015; Saaty, 2008) Significance level 1 3 5 7 9 2, 4, 6, 8

Definition Equal significance. Slightly higher significance. Strong significance. Very strong significance. Extreme significance. Values with intermediate significance.

In this step, individual elements are evaluated and the consistency of the evaluation is checked. The evaluation works by comparing all pairs of elements at a given level from the point of view of every element placed a level better inside the previously constructed hierarchical structure. The end result of the comparisons is a set of matrices which, after normalization and examination of consistency, form the basis for the very last evaluation of the system (Cabała, 2010).

Evaluation of Criterion Weights and Consistency In this step, the percentage distributions indicating the importance stages of the criteria over each other are calculated using equation (1) to determine the weights within the complicated structure by use of the eigenvector: 1

𝑎𝑖𝑗

𝑊𝑖 = 𝑛 ∑𝑛𝑗=1 ∑𝑛

𝑗=1 𝑎𝑖𝑗

(1)

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𝑎𝑖𝑗 is actual judgment, the significant of the item with respect to other items compared with. n is (the matrix size) number (items) of criteria or sub criteria compared in the matrix. A is the comparison matrix. Where the column vector (𝐴𝑊) is the product of the comparison matrix 𝑎𝑖𝑗and the priority matrix W. 𝜆𝑚𝑎𝑥 is the principal or maximum eigen value of positive real values in judgment matrix, maximum eigen value 𝜆𝑚𝑎𝑥 of the pairwise comparison matrix is the final expression of the preferences between the investigated elements.𝑊𝑗 is the weight of 𝑗 𝑡ℎ factor, and 𝑊𝑖 is the weight of 𝑖 𝑡ℎ factor. Saaty (1990) recommended that the maximum eigen value,𝜆𝑚𝑎𝑥 , can be determined as: 𝜆𝑚𝑎𝑥 =

1 𝑛 (𝐴𝑊)𝐼 ∑ 𝑛 𝑖=1 𝑊𝑖

(2)

Saaty (1990) recommended the use of consistency index (CI) and consistency ration (CR) to check for the consistency related to the comparison matrix (Kambiz et al., 2012). Saaty proved that for steady reciprocal matrix, the biggest Eigen fee is equal to the variety of comparisons, then he gave a degree of consistency, known as Consistency Index as deviation of consistency using the following formula 𝐶𝐼 =

𝜆𝑚𝑎𝑥 −𝑛 𝑛−1

(3)

Consistency Ratio, which is a comparison between Consistency Index and Random Consistency Index, in equation (4): 𝐶𝐼

𝐶𝑅 = 𝑅𝐼

(4)

where RI represents average consistency index over a number of random entries of same order exchanged matrixes, the random index (RI) varies

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with the magnitude of the matrix (n), and the possible values are shown in Table 5 below (Gnanavelbabu and Arunagiri, 2018). Table 5. Random indexes for different comparison matrices (Gnanavelbabu and Arunagiri, 2018) N RI

2 0

3 0.58

4 0.9

5 1.12

6 1.24

7 1.32

8 1.41

9 1.49

CR is acceptable, if it is not greater than 0.10. If it is greater than 0.10, the judgment matrix will be considered inconsistent (Kambiz et al., 2012). The acceptability of the consequences derived from AHP criterion comparisons highly depends at the consistency of the decision-making experts’ comparisons. There is a high opportunity for those comparisons to be inconsistent. A consistency ratio of 0% is indicative of complete consistency for a matrix. However, a whole consistency isn't very probably in practice. Therefore, comparisons are deemed consistent provided the consistency ratio is underneath 10%. In cases where in the consistency ratio exceeds this value, comparisons ought to be repeated except a consistent matrix is obtained (Saaty, 2008; Hyun et al., 2015). The problem of defining the alternatives for medical waste has a hierarchical nature, for that reason enabling the usage of MCDM methods with its multi-criteria-based totally structure. AHP became used for calculation of the scores of this research.

Limitation of Study The permission to conduct interviews with the employees in the governmental hospital and to take pictures within the hospital was a major challenge. But it was very easy and flexible in the other hospital. Obtaining data about medical solid waste and the process of managing that waste is often challenging because hospitals avoid sharing any of its solid waste management record.

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The majority of interviewed participants were very discreet while answering the questions, but they lacked knowledge about sustainable management for medical solid waste.

RESULTS AND DISCUSSION Comparison between the Two Selected Hospitals Table 6 compares between the two hospitals in the study, explains the difference between them in all targeted fields and shows findings in each hospital according to the interviews. Table 6. Comparison between two selected hospitals Understanding and knowledge

Segregation

Rafidia Hospital  Domestic workers have limited knowledge and understanding of the danger of hazardous medical wastes, but medical staff knowledge is intermediate.  Understand how to deal with medical solid wastes according hospital policies.  Lack of knowledge about sustainable management system for solid waste.  Unawareness of how to act in case of accident injuries by sharp waste, or leakage of wastes.  Limited knowledge about policies and regulations.

St. Luke’s Hospital  Limited knowledge and understanding of the danger of hazardous medical wastes.  Understand how to deal with medical solid wastes according to hospital policies.  Lack of knowledge about sustainable management system for solid waste.  Awareness of how to act in case of accident injuries by sharp waste, or leakage of wastes.  Limited knowledge about policies and regulations.

 Irregularities and lack of commitment (example, carton box in medical waste container and needle in normal wastes bin).

 Few Irregularities (one bags of normal waste found in central container of hazardous waste). The packaging carton box segregated sometime alone in special container but with lack commitment.

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Collection

Transfer

Treatment

Storage

Rafidia Hospital  Collection done in two stages first by domestic worker from generation points.  Second stage waste collected by municipality from central container, wrong location between cars in hospital yard, not easy to reach by municipality collecting vehicles, nonexistent of safety considerations (workers just wear gloves). Sometimes they use manual way to collect waste. Transfer done in two stages first one transfer from generation points to central container using cart, same cart used to transfer all medical wastes. The second stage done by municipality by waste transfer vehicles, used vehicles not specially designed or prepared to transfer hazardous dangerous waste. The same vehicle used to transfer household wastes. There is not any type of treatment of hazardous waste before disposal. There is no storage inside hospital because this storage needed if there is treatment before disposal, but there is storage in central container outside hospital building, storage period not exceeding 48 hours. Wastes found in the ground, in the same place of the two central containers. The container itself is old open, and suffers from holes and rust.

St. Luke’s Hospital  Collection done in two stages first by domestic worker from generation points it done in the right way with limited safety consideration.  Second stage waste collected by municipality from central container, suitable location in hospital backyard easy to reach by municipality collecting vehicles, nonexistent of safety considerations (workers just wear gloves). Sometimes they use manual way to collect waste. Transfer done in two stages first one transfer from generation points to central container using cart, different cart used to transfer medical wastes and others used for ordinary wastes. The second stage done by municipality by waste transfer vehicles, used vehicles not specially designs or prepared to transfer hazardous dangerous waste. The same vehicle used to transfer household wastes. There is not any type of treatment of hazardous waste before disposal. There is no storage inside hospital because this storage needed if there is treatment before disposal, there is storage in central container outside hospital building, storage period not exceeding 48 hours. Area around the two central containers is clean. Container of hazardous waste is old, it has cover with lock, and there is rust and small hole.

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Pharmaceutical product

Recycle/Reuse

Rafidia Hospital There are no clear policies to deal with residual pharmaceutical products, or expired medicine. They only disposed of with other medical waste.

The concept is not used and there in no plan to be adopted, and limited knowledge about recycle and reuse. Not used system, they lack knowledge about the system.

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St. Luke’s Hospital There are no clear policies to deal with residual pharmaceutical products, or expired medicine. They only disposed of with other medical waste. But they are looking for way to find plan to deal with that products in the right ways. The concept is not used and there in no plan to be adopted, and limited knowledge about recycle and reuse.

Sustainable Not used system, they lack management knowledge about the system. system Pictures in Annex 1 show the current situation in the selected hospitals.

Nablus Municipality The following result from interview with the solid waste department manager in Nablus municipality.

Policies and Regulations The environmental engineer in Nablus Municipality said that there are policies and regulations to dispose of medical waste through special medical containers for each medical center where dangerous medical waste is separated from the normal wastes. Legalized laws by the Ministry of Health concerning the disposal of solid medical waste through the creation of special containers for the collection and segregation of waste from other solid waste. About the budget, he answered that there is no separate budget for solid medical waste disposal but it is within the solid waste disposal budget. The cost of disposing of HCW is within the total cost of solid waste disposal, approximately $4.6M per year. The needed budget for sustainable management system for healthcare solid waste is about $8.6M per year. Saving money can be achieved by generating energy from waste

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incineration, in this way the cost is reduced by reducing cost of separation and landfilling. He explained safety rules and personal protection from wastes by providing special tools, uniform and vaccinating staff with annual periodic vaccinations. The wastes collection car’s driver and waste collection workers are not trained to collect medical waste. When asked about medical waste collection, he answered that the waste of healthcare centers is collected with special containers which are distinguished from other municipal containers and are assigned a particular color to distinguish them from solid waste collection vehicles. Medical waste is not mixed with normal waste during the collection of waste, unless it already mixed by hospitals staff, the collection depends on waste weight each time.

Main Responsibility About main responsibility he said that Nablus Municipality and the joint council covers waste collection and transfer service from Nablus City to the Zahrat Al Finjan landfill by collecting it at Al-Serafi transfer station east of the city, sorting some plastic, cardboard, nylon and scrap at the site, and then a private contractor departs it to Zahrat Al Finjan landfill. Healthcare centers waste is disposed of by sending it to the landfill. Hazardous medical waste is collected separately from normal waste but is disposed of in one location, Al-Serafi transfer station. Sustainable Management Model for Solid Medical Waste The understanding of sustainability and sustainable medical solid management is limited only in recycling of waste, but there is clear understanding to the meaning of recycling of wastes and what it need to be done. There is a lack of knowledge of a sustainable waste management system, but there is belief that a sustainable medical waste management system reduces costs, and reduces pollution. Adherence to segregation processes plays an important role in achieving this, as segregation processes reduce pollution and thus reduce the subsequent costs of eliminating such pollution.

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He was aware of the meaning of climate change, the reasons that cause it and how the waste and the disposed of ways effect the climate. If policies and laws are available from the relevant authorities such as municipalities, governorates and Environmental Quality Authority, a sustainable system can be implemented in compliance with the crews and administration in hospitals. He explained that a successful waste management system can be applied by awareness-raising between citizens, applying policies and laws and fine violators, providing stations for separating and sorting wastes and modern mechanisms. The most important point to achieve success in solid waste management either HCW or normal solid waste in the municipality point of view is changing people attitudes and raising awareness about the importance of waste segregation before disposing. Time needed to commitment from all society is about 6 to 12 months, to implement the solid waste management system, perhaps there are barriers such as resistance to change. The main obstacle that may face recycling and reuse according to environment engineer in Nablus Municipality is citizens' lack of awareness of the importance of pre-sorting waste. There are no facilities for remanufacturing operations and High costs that can affect the sale of materials produced.

Environmental Quality Authority Laws and Regulations According to the responsible person in Environmental Quality Authority the policies and laws imposed by the Environmental Quality Authority are the Environment Amendment Act No. 7 of 1999, Council of Ministers Decree No. 10 of 2012 on the medical waste management and circulation System, The executive regulations on medical waste and Council of Ministers resolution No. 3 of 2019 on the regulation of medical waste management.

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He said that the role of the Environmental Quality Authority is to monitor and supervise all matters related to solid medical waste management. The future plan for solid medical waste management through the allocation of solid medical waste cells within the landfill, the establishment of solid medical waste treatment and disposal sites, the expected constraints related to the quantity of medical waste which is a big quantity and the lack of available capabilities in medical centers for the treatment of waste before disposal.

Main Responsibility He explained that the main responsibility of Environmental Quality Authority is to keep the forms of wastes transfer after it is signed by the healthcare center, transporter, ministry of health, treatment station and the landfill, to get report about transport plans for all waste collecting cars and about the case of leakage or any other problems during transfer the waste to landfill, coordination with Ministry of Health to determine the specifications of the waste treatment unit, designate the site where the unit can be created and issue approval for the establishment of this plant, coordination with the Ministry of Health to inspect the operation of solid medical waste management inside and outside the health centers. Inspectors by ministry of health with help from environmental Quality Authority, monitoring process and ensure that the processed flow in done. Environmental Quality Authority issue approvals in the case of the transfer of wastes outside Palestine. About amount of waste in hospitals he explained that there is no exact number that accurately limits the general generated solid medical waste, and there is no exact number that accurately limits the general solid medical waste. But the amount of medical waste is estimated according to some studies about 0.59-0.95 kg/bed/day (Average medical waste production in hospitals).

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Ministry of Health Laws and Regulations The responsible person in ministry of health said about laws and regulations that laws imposed by ministry of health are Council of Ministers Decree No. 10 of 2012 concerning the regulation of the management and circulation of medical wastes, The Environment Act No. 7 of 1999, in particular article 12. In addition to the executive regulation on medical waste, and council of Ministers resolution No. 3 of 2019 on the regulation of medical waste management. Generated Healthcare Solid Wastes According to ministry of health the amount of generated healthcare solid wastes from all Nablus hospitals is approximately 850-900 Ton /year. The issue of medical waste management is one of the Ministry's priorities for its importance and its risk to public health and the environment. Main Responsibility About the responsibility, he said solid waste inside the healthcare centers is the responsibility of the healthcare center and ministry of health. Coordination with Environmental Quality Authority to determine the specifications of the waste treatment unit, designate the site where the unit can be created and issue approval for the establishment of this plant, coordination with Environmental Quality Authority to inspect the operation of solid medical waste management inside and outside the health centers. Inspectors by ministry of health with help from environmental Quality Authority, monitoring process and ensure that the processed flow in done. The actions taken by the Ministry to train all staff in the hospitals of the Ministry of Health in the management of medical waste inside hospitals with separation bags and sharps tools boxes. Give vaccine to all staff members in hospitals.

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Model Results First step was to identify the main criteria and their associated sub criteria that are essential and needed for hospital waste management. All criteria and sub criteria were defined previously in Table 3.  Four main criteria and thirteen sub criteria were considered.  All the criteria and associated sub-criteria were validated and ranked using pairwise comparison.  AHP was applied to rank and priorities given to the identified main criteria and their associated sub criteria for sustainable hospital waste management.

Pairwise Comparison between the Main Four Criteria Table 7 shows the pairwise comparison between the main four criteria in the model, and the level of importance for each one. Table 7. Pairwise comparison between main four criteria Criteria

Waste management cost Waste treatment Waste handling procedure Social and environment aspects Sum

Waste management cost 1 4 1 1 7

Waste treatment 0.25 1 0.33 1 2.58

Waste handling procedure 1 3 1 2 7

Social and environment aspects 1 1 0.5 1 3.5

Appling the Pairwise Comparison Method to All Sub Criteria After pairwise comparison for the main criteria, each sub criteria were compared with each other with respect to the main criteria belonged to.

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Pairwise comparison of waste management cost

Table 8 shows the pairwise comparison method for sub criteria that belong to first main criteria waste management cost. Table 8. Pairwise method for waste management cost Criteria

Waste handling cost Storage cost Transportation cost Recycling/ reuse /cost Disposal cost Sum



Waste handling cost 1 1 2 5 4 13

Storage cost

Transportation cost

Recycling cost

Disposal cost

1 1 0.5 5 5 12.5

0.5 2 1 4 5 12.5

0.2 0.2 0.25 1 0.33 1.98

0.25 0.2 0.2 3 1 4.65

Pairwise comparison of waste handling procedure sub-criteria

Table 9 shows the pairwise comparison method for sub criteria that belong to second main criteria Waste handling procedure. Table 9. Pairwise method for waste handling procedure Criteria Waste collection Waste segregation Waste transportation Frequency/day Sum



Waste collection 1 8 1

Waste segregation 0.13 1 0.14

Waste transportation 1 7 1

Frequency/ day 3 8 3

0.33 10.3

0.13 1.39

0.33 9.33

1 15

Pairwise comparison of waste treatment sub-criteria.

Table 10 shows the pairwise comparison method for sub criteria that belong to third main criteria waste treatment.

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Criteria Recycling/reuse Treatment before disposal Disposal method Sum

Recycling 1 5

Treatment before disposal 0.5 1

Disposal method 3 2

0.5 6.5

0.33 1.83

1 6

Evaluation of All Criteria Table 11 includes the main aimed result and summarizes the main criteria importance weights (priority) and their associated sub criteria local and weights (priority). It also shows the consistency ratio of each sub criterion. Table 11. Evaluation of all criteria Main criteria

Weight

Sub-criteria

Waste management cost

0.1608

Waste treatment

0.4234

Waste Handling procedure

0.1453

Social and environment aspects

0.2701

Waste handling cost Storage cost Transportation cost Recycling and reuse cost Disposal cost Sum Recycling/Reuse Treatment before disposal Disposal method Sum Waste collection Waste segregation Waste transportation Frequency/day Sum Social and environment aspects Sum

Subcriteria local weight 0.071 0.089 0.081 0.462 0.298 1 0.211 0.500 0.190 1 0.119 0.704 0.124 0.053 1 1

Subcriteria global weight 0.011 0.014 0.013 0.074 0.048 0.161 0.089 0.212 0.080 0.381 0.017 0.102 0.018 0.008 0.145 0.271 0.9581

Consistency ratio

0.0756

0.0634

0.058

0.029

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The results show that waste treatment before disposal (42.3%) has highest weight, then social and environmental aspects (27%) and waste management cost with (17.08%), that criteria are most important main criteria for hospital sustainable solid waste management system. Similarly, in waste handling procedure, waste segregation (70%) waste collection and waste transportation (12%). Recycling cost (46%)most important sub criteria in waste management cost, the next one is disposal cost (29.7%), and in waste treatment the top sub-criteria is treatment before disposal (50%), recycling (22%) and disposal method (19%). Lastly, in terms of overall ranking of sub-criteria with respect to goal, treatment before disposal (21.1%), social and environmental aspects (27%), and waste segregation (10.9%) are the top three sub-criteria.

AHP for Waste Treatment The system of hazardous medical waste treatment is the most important point with highest priority. Hazardous medical waste treatment needs appropriate physical, chemical, biological or thermal processes or combination of more than one treatment way, in order to decrease wastes volume and eliminate or reduce the hazardous characteristics. The evaluation was based on four main criteria, environmental, economic, technical and social criteria. Some of the most common treatment and disposal methods used in infectious medical waste management include:      

Autoclaves (Azmal et al., 2014). Microwave Disinfection Systems (Azmal et al., 2014) Chemical disinfections (Azmal et al., 2014). Controlled and healthy landfills (Azmal et al., 2014). Plasma Pyrolysis (Ghasemi and Yusuff, 2016). Incineration (Ghasemi and Yusuff, 2016).

Advantages

Disadvantages

Autoclave  Environmentally sound.  Adopted for many years.  No hazardous emissions.  Low cost.  Technology is easy to apply.  No pre or post treatment required.

 Need drying mechanism.  Foul odors.  Not suitable for all types of wastes.  Need a shredder to reduce the volume.

Incineration

 Accept the greatest variety of waste.  Treated waste is unrecognizable as ash.  Significant volume reduction.  Energy recovery.  Waste totally sterilized.

 Very expensive.  Acid gases in air emissions.  Heavy metals in  Ash residues.  Convert biological problem into potential air quality emission problems.  Major source of dioxin and furan emissions

Technology is easy. Reduce volume by 80%. Environmentally sound. No liquid effluents. The emissions are minimal.

 Cost is very high.  Not suitable for all types of wastes.  The shredder used is noisy.  Offensive odors.

    

Treatment Technologies Microwave

 Requires highly skilled operators.  Cost is very expensive.

 Suitable for all types of wastes.  Consumes less space.  Environmentally sound.  Does not require a chimney.  Less Toxic residuals  Does not require segregation.  Energy recovery.  Reduce volume more than 99%.

Plasma Pyrolysis

 Requires access to sanitary landfill.  Cause soil pollution and water contamination.

 Low cost.  Easy operation.

Landfilling

Table 12. Comparison of treatment technologies (Ghasemi and Yusuff, 2016)

Infectious Yes Yes Yes Yes Yes

Type of Treatment

Incineration

Autoclaving

Microwaving

Plasma pyrolysis

Landfilling

Yes

Yes

Yes

Yes

Yes

Sharps

No

Yes

No

No

Yes

Pathological

No

Yes

No

No

Yes

Pharmaceutics

No

Yes

No

No

Yes

Genotoxic

No

Yes

No

No

No

Radioactive

Table 13. Suitability of treatment procedures for each type of clinical waste (Ghasemi and Yusuff, 2016)

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Chemical disinfectants are used in a variety of applications. Disinfection is based on unique residences of the chemical agent to disable the pathological organisms. A form of chemicals may be used to acquire chemical disinfection, a number of these chemical substances encompass alcohols, acids, alkalis, phenols, halogens, heavy steel compounds, detergents (such as quaternary ammonium compounds) anti-metabolites and peroxide. Sodium hypochlorite (commonly called bleach) is one of the most common solutions used for disinfection. However, due to the adverse health effects of chlorine, and because it has been shown that chlorine is a precursor for the formation of dioxins in combustion, non-chlorine based disinfectants are used. Sterilization can also be achieved by the use of several chemicals in gaseous form. These compounds, together with formaldehyde and ethylene oxide, are exceptionally toxic (Diaz et al., 2005). Table 12 shows the advantages and disadvantages of suggested treatment methods to help to choose the most suitable alternative to treat waste in selected hospitals in the study. Table 13 shows the suitability of these treatment methods for each type of waste.

Pairwise Comparison between the Main Four Criteria Table 14 shows main criteria pairwise comparison and the importance level for each criterion. Table 14. Main criteria pairwise comparison for AHP to choose treatment way Criteria Environmental Economic Technical Social Sum

Environmental 1 1 0.5 0.5 3

Economic 1 1 0.5 1 3.5

Technical 2 2 1 2 7

Social 2 1 0.5 1 4.5

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Evaluation of Treatment Alternatives Local and Global Priority/Weight Table 15 below summarizes the main criteria importance weights and the treatment alternatives local and global priority. It also shows the consistency ratio of each criterion, alternative local weight, and alternative global weight for each alternative with respect to main criteria. Table 15. Evaluation main criteria of treatment alternatives local and global priority Main criteria

Weight

Alternative

Environmental

0.337

Autoclave Microwave Chemical disinfections Controlled and healthy landfill Plasma Pyrolysis Incineration Sum Autoclave Microwave Chemical disinfections Controlled and healthy landfill Plasma Pyrolysis Incineration Sum Autoclave Microwave Chemical disinfections Controlled and healthy landfill Plasma Pyrolysis Incineration Sum Autoclave Microwave Chemical disinfections Controlled and healthy landfill Plasma Pyrolysis Incineration Sum

Economic

Technical

Social

0.282

0.141

0.241

Alternative local weight 0.257 0.188 0.078 0.028

Alternative global weight 0.087 0.064 0.026 0.010

Consistency ratio 0.078

0.405 0.043 1 0.313 0.196 0.125 0.299

0.137 0.015 0.323 0.088 0.055 0.035 0.084

0.066

0.035 0.075 1 0.179 0.261 0.148 0.020

0.010 0.021 0.294 0.025 0.037 0.021 0.003

0.078

0.026 0.087 1 0.322 0.189 0.116 0.044

0.086 0.012 0.184 0.077 0.045 0.028 0.011

0.083

0.268 0.062 1

0.064 0.015 0.748

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Autoclave

Microwave

0.267

0.201

Chemical disinfections 0.120

Controlled and healthy landfill 0.097

Plasma Pyrolysis 0.306

Incineration 0.063

Table 16 shows the final scores to choose waste treatment technology to treat the medical waste and deal with it. The results from analytical hierarchy process to choose the best way for waste treatment, that Plasma Pyrolysis with highest score 30.62%, then with 26.72 achieved by Autoclave. Notice that both choices have disadvantage and advantage. Plasma Pyrolysis is the most environmentally friendly choice and it is suitable for all medical waste but it is expensive and need high skill for operating. Autoclave method is not suitable for all kinds of clinical wastes and large amounts of hazardous waste. It is easy to operate and need low cost to be operated. Sometime waste need more than one procedure to be treated, for example it may need to be treated by autoclave and then disposed of to landfill. Plasma pyrolysis is the best choice for waste treatment that was selected by model, although it is more expensive than others but it is a sustainable system to manage healthcare solid waste. It is better for the environment and human health, decrease diseases, decrease emissions and greenhouse gases release from burning the medical waste, and decrease soil and water pollution.

CONCLUSION AND RECOMMENDATIONS Conclusion Targeted hospitals in the study do not segregate all the medical wastes or treat the hazardous wastes. Healthcare centers suffer from absence of treatment and disposal ways and the governmental hospital don’t have

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strategic plans to treat the hazardous wastes before disposal, or for sustainable management of medical solid waste. The disposal of hazardous medical waste with household waste in Zahrat Al Finjan landfill is wrong and unsafe way to dispose, because of chemical reactions that may accrue resulting in harmful contaminants to the soil, groundwater, and air quality. The Disposal of medical wastes without treatment is a major cause of disease. And if the normal wastes mixed with untreated hazardous medical waste in any stage, all wastes become hazardous. Random disposal of healthcare solid wastes not only affect the environment, but also human health. When hazardous medical wastes dumped in open areas other than the landfill the releasing liquid from that wastes consist of heavy metals and poisonous elements, which leak into soil, plants, grass, ground water, and animals which ate the contaminated grass. The Ministry of Health is responsible for enforcing the laws and regulations regarding medical waste. It coordinates with Environment Quality Authority to monitor healthcare centers. The Municipality is responsible for transferring the segregated wastes from hospitals to the landfill. Zahrat Al-Finjan landfill is responsible for disposal. Finally, Environmental Quality Authority’s responsibility is to inspect the managing process with coordination with the Ministry of Health, and monitoring the transfer process from healthcare centers to treatment or final disposal. In the end all wastes end up mixed with each other, hazardous medical wastes and household wastes. Proper waste management can provide a healthy and safe environment in hospitals. In selected Nablus hospitals there is a lack of regulations, rules and policies of effective and efficient hospital waste management. There were no administrative procedures or policies like labelling or recording wastes or archiving. Lack of vehicles for hazardous waste, means of transport, and internal containers for waste before treatment, internal storage in hospitals for waste, and used warning signs in hospital’s corridors, room and places where waste bins and vehicles exist are not enough.

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There is no specialized committee or department or even specialized employee in hospital’s organizational structure, to be responsible for monitoring the management of medical waste, only Anti-infection Committee is following up on some matters of the system. So, one of most important challenges facing implementing sustainable management solid waste system in hospitals is shortage of qualified staff and expert in sustainable solid waste management. And Medical staff had no knowledge about regulations and laws related to management of medical wastes. In spite of all these problems, there are no training plans as well as medical waste learning materials, and there is no control or monitor over medical waste where there is no special staff member or special medical waste control committee. The sustainable model using AHP shows that waste treatment before disposal has the highest priority among main criteria (42.3%), followed by social and environmental aspects (27%) and waste management cost with (16.1%). In sub criteria, in waste handling procedure, waste segregation had the highest priority (70%); in waste management cost, recycling cost had the highest priority (46%), and in waste treatment the sub criteria with the highest priority is treatment before disposal (50%). Lastly, in terms of overall ranking of sub-criteria with respect to goal, treatment before disposal had the highest priority (21.1%), followed by social and environmental aspects (27%), and waste segregation (10.9%) are the top three sub-criteria. Using AHP, the model found that Plasma Pyrolysis is the best method to treat medical wastes.

Recommendations 



Create system of standard work procedures, policies and regulations, to provide procedures that can be followed to ensure the sustainable, proper, and right disposal of medical waste. Policy and guideline must be developed by government to make sure that HCW is effectively managed in compliance with international best practice.

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



 

251

Budget allocation by hospitals and by government for managing medical solid waste in sustainable way. Training programs for all staff, services, technicians, doctors, nurses and pharmacists on sustainable management system for managing solid wastes and related procedures. Training on the basic concepts and risks of medical waste and how to manage it. Providing well trained staff, bins, vehicles, containers, and transport cars designed for transfer medical and hazardous waste and driven by drivers and trained crews. Proper storage of medical solid waste inside hospital building, in suitable isolated area prepared previously to this aim, in coordination and accreditation by the Ministry of Health Adopting projects for recycling, reusing and remanufacturing of medical waste, or contracting with recycling plant. All medical waste should be treated before final disposal, since disposal without changing the nature of its biological composition causes the spread of infectious wastes.

ANNEX 1: RELEVANT PHOTOGRAPHS

Figure A1. Yellow bag (hazardous waste) in hospital yard.

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Figure A2. Yellow bag (hazardous waste) in ordinary waste container.

Figure A3. Hazardous wastes central container.

Figure A4. Ordinary wastes central container.

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Figure A5. Hazardous wastes central container.

Figure A6. Ordinary wastes central container.

Figure A7. All waste in the same central container.

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Figure A8. Unclear signs.

Figure A9. Normal waste bin/hazardous waste bin and sharp box (Notice that there are no signs).

Figure A10. Trolley used to transfer wastes from hospital departments to central container (charity hospital).

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Figure A11. Waste pins in random area governmental hospital.

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In: Public-Private Partnerships ISBN: 978-1-68507-184-4 Editors: D. Monferrer Tirado et al. © 2021 Nova Science Publishers, Inc.

Chapter 8

QUALITATIVE AND QUANTITATIVE ANALYSIS OF GENERATED DENTAL WASTE IN NORTHERN WEST BANK, PALESTINE CLINICS Sameer M. Al-Qorom1, Issam A. Al-Khatib2,*, PhD, Majed I. Al-Sari’1,3, Stamatia Kontogianni4, PhD and Fathi M. Anayah5, PhD 1

Universal Institute of Applied and Health Research, Nablus, Palestine 2 Institute of Environmental and Water Studies, Birzeit University, West Bank, Palestine 3 The Joint Service Council for Solid Waste Management for Hebron and Bethlehem Governorates, Hebron, Palestine 4 Laboratory of Heat Transfer and Environmental Engineering, Dpt. of Mechanical Engineering, Aristotle University of Thessaloniki, Thessaloniki, Greece 5 Faculty of Engineering and Technology, Palestine Technical University – Kadoorie, Tulkarm, West Bank, Palestine

* Corresponding Author’s Email: [email protected].

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ABSTRACT This study focuses on dental solid waste (DSW) management in central and northern Palestine, in particular Nablus and Salfit governorates. Qualitative and quantitative data was retrieved to serve the overall investigation through structured questionnaires and on-site sampling. The overall results showed that dentists’ attitude towards sustainable DSW management is positive. In particular 71% are willing to participate in future waste separation and recycling programs. However, 60% of the dentists’ do not own the appropriate equipment to perform waste separation, recovery and recycling. Age, gender, location of the clinic, and level of education, are significantly affecting dentists’ waste management behavior. The DSW generation rate is 57.2 g/patient/day. Infectious/potentially infectious waste represents 68.3% of total fraction, whereas non-infectious 4.8% and domestic-type waste 26.9% (by weight). The infectious and potentially infectious waste fraction is composed mainly by: sharps (13.1%), amalgam (0.8%), blood soaked dressings (43.3%), Paper (11.3%), plastic and rubber (0.3%) and extracted teeth (31.3%).

Keywords: dental waste management, characterization, generation rate, developing countries

INTRODUCTION Health care provision institutions besides their great contribution to public health elevation are responsible for the generation of infectious waste whose mis-management introduces hazard to local population, although 80% of the total waste stream generated by health care facilities is non-hazardous (World Health Organization – WHO, 2017; Minoglou and Komilis, 2018). Medical waste is regulated by most government agencies internationally. On the contrary, dental solid waste (DSW) is a field that still needs to be further highlighted as per its sustainable management which highly contributes to the preservation of people’s health and quality of life (Ozbek and Sanin, 2004; Al-Widyan et al., 2010) and also to the enhancement of work quality performed in dental offices for both professionals and patients (Fan and McGill, 1989(.

Qualitative and Qualitative Analysis of Generated Dental Waste … 263 As in all waste fractions, the quantity and composition of DSW vary, depending on factors such as location, season, lifestyle, food habits, and living standards. The local level of development, in the field of sustainable waste management, has also a direct impact on the rate and type of solid waste generated (Kurt et al., 2001; Ebrahimzadeh et al., 2018). Direct hazards and cross-infectious risks have been recorded and have resulted mainly from the mismanaged dental and also healthcare waste (Vieira et al., 2011; Mandalidis et al., 2018) to the following involved personnel categories: dentists, paramedical staff, labors in health institutions and clinics, patients, visitors, labors dealing with waste handling, collection, treatment and transportation, etc. Even children playing in the proximity of health institutions or waste containers are vulnerable to similar risks occurring from mismanaged healthcare waste (e.g., mixing with municipal waste). The occurrence of injuries and infections due to the diversity of the pathogen in medical waste are multiple, especially in developing countries, where healthcare waste management is mostly unorganized, there is lack of sustainable management know-how and lack of available facilities for final treatment (WHO, 1999).

BACKGROUND Dental Waste Fraction Dental clinics generate infectious solid waste ranging from 10 to 25% of the total generated waste (Michael et al., 2010). DSW categorization is found to be a profounding issue as some dental consumables belong to more than one waste category due to internal professional practices; e.g., impression materials may contain chemical substances, amalgam may contain heavy metals, etc., but overall their contact to biological liquids categorizes them as infectious materials (Kontogianni et al., 2008). The hazardous waste generated by dental clinics originates from the following sources:

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

 





X-ray tiles, containing lead and silver (Kontogianni et al., 2008), X-ray fixer containing silver, X-ray film: The more the darker the areas are, the more the silver content (Mackey et al., 2014). Sharp items bearing body fluids such as blood/saliva (Kontogianni et al., 2008). Amalgam composed of 50% mercury (when disposed to the environment forms methyl mercury that is a toxic agent) (Kontogianni et al., 2008). Infectious waste (similar to healthcare waste) such as dressing swabs soaked in blood, other clinical waste, and general healthcare waste. Chemicals from sources like cleaners for developer systems and cleaners that contain chromium (Mn TAP, 1995).

Overall, DSW similar to healthcare waste consists of three main categories: infectious waste, non-infectious waste and domestic-type waste (Kizlary et al., 2005; Vieira et al., 2009). But dentistry involves a material that healthcare waste does not. Dental amalgam is an approximately 1:1 mixture of metallic mercury and a powdered alloy consisting of Ag, Sn, Cu, Zn and probably other metals as well (Farmer et al., 1997; Balarak et al., 2017). Although mercury is a naturally occurring metal, 50% of its amount in environment is released by human activities; 13% of it comes from general industry and general activities. The major player in generating this metal is burning fuels for energy generation. The remaining 34% originates from waste burning processes. Dentistry’s input does not exceed 1% (Johnson, 2000). DSW as a whole fraction may be mixed and managed with other healthcare waste, usually through incineration. But if amalgam is present, the contented mercury is evaporated and released into the air (Guay, 2007; Kontogianni et al., 2008; Muhamedagic et al., 2009, Maamari et al., 2015). Besides its known effects on health, mercury creates an important environmental impact that should be dealt with (Al-Khatib and Darwish, 2004).

Qualitative and Qualitative Analysis of Generated Dental Waste … 265 Consumption of mercury for one tooth-filling amounts in average 350 mg (based on information retrieved from nine major product manufacturers) and about 700 kg of mercury is annually used for 2 million fillings, which sooner or later will be released to the environment, unless it is recycled/ recovered. Kontogianni et al., 2008 found that 5 g of solid amalgam waste are disposed daily from a typical private dental office, while the rate of amalgam over resin-use in restorative procedures is onethird. On the other hand, the mean amount of mercury released from Lebanese dental clinics was estimated to be 13.42 g per week (2.6 g/d) per clinic since only half of the clinics in Lebanon still use amalgam (Daou et al., 2015). Amalgam high content of mercury has created a long-term debate regarding its use until nowadays. Currently the main objective of policies in relation to management of mercury is to reduce the environmental impacts from its use in dentistry and to reduce its contribution to the overall environmental problems (Mudgal et al., 2012). In the meantime, the environmental regulations that deal with DSW management as well as the introduction of alternative materials for teeth filling (such as resins) have already reduced the risk, minimizing the negative effects in dental clinics and enhancing the environmental profile of dental care professionals (Kontogianni et al., 2008). Effective DSW management is significant to minimize all mentioned introduced risks. Studies results in both developed and developing countries (Kontogianni et al., 2008; Vieira et al., 2009) show that most of the generated waste that is considered as biomedical is misclassified, consequently making the infectious waste amount appear much larger. Several developed countries have established a comprehensive system for the management of dental health care wastes (Darwish and Al-Khatib, 2006; Gusca et al., 2015). Currently in Greece regulations (CMD, 2012) on management of healthcare waste require Greek dentists to sign a contract with relevant companies, for proper management of their waste. The very opposite is the current status in most developing countries which suffer from unsustainable DSW disposal, lack of financial resources, insufficient awareness of potential health hazards and limited availability

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of data on such waste generation and disposal paths (Viragi et al., 2013). Besides the limited number of field studies conduction on recording and auditing of DSW management processes, official guidelines/regulations do not exist. In particular in Jordan almost all of the DSW produced in private clinics and a large proportion of that produced in larger central dental care facilities are mixed with the domestic waste stream and end up in the landfills with the potentially grave environmental and health consequences (Al-Widyan et al., 2010). The same practice takes place in Lebanon where infrastructure for management of non-infectious hazardous waste is limited. Based on a recommendation by the Ministry of Environment of Brazil, such waste was stored and exported under the Basel Convention until a solution is available on national level (Daou et al., 2015). In Brazil it is estimated that 76% of the cities dispose domestic and medical waste together in municipal dumpsites (Vieira et al., 2009) despite medical waste been regulated under medical waste control laws.

Dental Waste Management in Palestine In 1994 the Palestinian National Authority, responsible for the health sector in the West Bank and Gaza, took measures to increase local population access to health services resulting to the general population health elevation. Since then there was no planning on sustainable medical and DSW management and no available infrastructure (vehicles, treatment plants, etc.), thus the increased generated waste quantity posed a serious problem. In most areas of the West Bank of Palestine, healthcare and DSW are collected together with municipal waste and disposed (dumped) in uncontrolled landfills, introducing serious environmental hazard (AlKhatib and Darwish, 2004). In the study area, the only measure that was undertaken was the construction of a customized landfill site for the sole disposal of healthcare (including dental) waste located in Salfit and Nablus governorate. Healthcare providers are instructed to transfer the waste generated in their clinic on their own means for safe disposal. Additionally, in southern West Bank and in particular Hebron and Bethlehem

Qualitative and Qualitative Analysis of Generated Dental Waste … 267 governorates, the Joint Service Council for Solid Waste Management for Hebron and Bethlehem governorates (JSC-H&B) is operating a medical waste treatment facility where the medical waste is collected separately from hospitals, medical laboratories and some private and dental clinics only (JSC-H&B, 2019). The waste is treated at treatment facility, which utilizes microwave technology, then transferred for disposal at the local sanitary landfill. The overall objective of this study is to quantify and characterize DSW generated at dental clinics in Nablus and Salfit, and assess the dentists’ perception and behavior in DSW management setting the foundations for efficient DSW management roadmap.

METHODOLOGY Salfit and Nablus districts lay on the central and northern parts of Palestinian territory, respectively. The total population of both districts is approximately 442,099 in accordance with the Palestinian Central Bureau of Statistics (PCBS, 2014b), and is the second densely populated area in the West Bank of Palestine. The conducted study applied two methods for data collection: data collection via structured questionnaires and face-to-face interview with the responsible dentist as well as sampling of DSW from several dental clinics.

Questionnaire Field Research The questionnaire was structured based on the findings of an extended literature research (Adegbembo et al., 2002; Al-Khatib and Darwish, 2004; Michael et al., 2010). Part I included information regarding the dental clinic location, the responsible dentist graduation date, the gender of dentist, the level of education (Bachelor or higher degree), the type of clinic (private, governmental, etc.), the operational duration of the clinic and the involved staff number. Part II of the questionnaire aimed at

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recording the characteristics of waste produced by each dental clinic on a daily basis in addition to questions concerning the type of amalgam applied, the waste disposal methods practiced and the applied occupational health and safety measures. Researchers formed interviewer teams which were trained on the research scope and performed mock interviews to ensure full understanding of the questionnaire and be able to assist respondents. Afterwards the questionnaires were piloted on a small sample of population to ensure that the required data can be collected by the correspondent questions. During the study period filled questionnaires were delivered to researchers daily and random quality controls were implemented to 20% of the respondents through telephone calls. Questionnaires that bared mistakes, mismatches or were half-filled were discarded. The population surveyed had been assumed to be normally distributed with a confidence level of 95%. The population sample had been randomly selected, and sample size had been estimated as per Eq. (1), p(1−p)

n = (SE÷t)+[p(1−p)÷N]

(1)

where n =sample size, N = total number of dental clinics (sample frame), Z = standardized value corresponding to the 95% confidence level (Z =1.96), p = proportion of success (assumed to be 50%) and SE = allowable margin of error (assumed to be 5%). Based on the number of dental clinics (181: 32 in Salfit and 149 in Nablus) registered according to the Palestinian Central Bureau of Statistics (PCBS) (PCBS, 2014c), the sample size was estimated to be 123 dental clinics.

Waste Sampling The sampling procedure aimed at quantifying and characterizing DSW, while the questionnaire aimed to collect information regarding the currently applied practices for DSW management. Totally 20 clinics (10

Qualitative and Qualitative Analysis of Generated Dental Waste … 269 from Salfit and 10 from Nablus) were selected for the application of waste sampling process. The selection was performed based on geographical criteria (location of the clinic in the investigated area), demographic criteria (population size reflects the total potential patients), type of area (cities, villages and refugee camp) and operation criteria (type of clinic, staffing requirements). The overall number of clinics participating in the research is a sufficient random statistical sample, appropriate to reflect the research outcomes into the total local dentistry population. The sampling process involved primarily the characterization, considering the three main categories of DSW classifications: Infectious and potentially infectious waste, Non- infectious waste and Domestic-type waste as per (Tiejen, 2003). The daily generated waste was separated into two parts. The first part contained mainly used ampoules, sharps, such as needles, extracted teeth, syringes, broken glass, dental tools, etc., which were collected in yellow, thick wall plastic container of 5.4 liters capacity and were labeled properly. The second part contained non-sharp items used in dental practice, such as blood contaminated cotton, plastic gloves, plastic glasses, paper, paper towels, gypsum, wax, etc., which were collected in yellow plastic sacks labeled properly and were numbered to maintain the anonymity of the sample origin. All of the samples were collected at the end of each working day, transported to the lab where they were handled separately and manually segregated into several categories: infectious metal waste, non-infectious waste, domestic, amalgam, blood soaked dressings, paper, extracted teeth, plastic and rubber in accordance with Singh et al., (2012). The waste sampling lasted five consecutive days starting from Sunday up to Thursday in order to have a representative sample considering the variation in the number of patients throughout the one week period. The total number of patients during the sampling days was 398 and 498 in Nablus and Salfit areas, respectively.

Analysis of Retrieved Raw Data The analysis of the data was then conducted using Microsoft Excel and Statistical Package for Social Science (SPSS) version 20. Waste

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quantification and characterization analysis was conducted through Microsoft Excel software, while qualitative data was conducted using SPSS software. Descriptive statistics were then utilized; frequencies and correlation tests presented researchers with the necessary information to identify the potential relationship between several set dependent and independent variables. Hereafter, correlation coefficients values and P-values were reported for the identified variables of significant relationships. In order to find which factors mostly affect dentists’ behavior in application of in-situ (clinic) waste management practices, age, gender, level of education, location of the clinic, duration of dentist’s work experience clinics’ were assessed. Overall 5 hypotheses were applied (as listed below) and they were accepted if the P-value ≤ 0.05:     

Hypothesis 01: Dentist’s behavior in DSW management is significantly affected by age. Hypothesis 02: Dentist’s behavior in DSW management is significantly affected by gender. Hypothesis 03: Dentist’s behavior in DSW management is significantly affected by level of education. Hypothesis 04: Dentist’s behavior in DSW management is significantly affected by the location of the clinic. Hypothesis 05: Dentist’s behavior in DSW management is significantly affected by the duration of dentist’s work experience.

RESULTS AND DISCUSSION Since the study focused on DSW management, quantification and characterization, the analysis of the data collected through questionnaires, represented the waste management perspective in terms of attitude and behavior towards sustainable DSW management. The composition and generation rate results were obtained through samplings collection, segregation and weighting. The overall study sample consisted of 100

Qualitative and Qualitative Analysis of Generated Dental Waste … 271 dental clinics, officially registered to the Ministry of Health (MoH). The responsible dentists sample comprised of 79% males and 21% females with the following characteristics: 42% aged less or equal 40 years, 91% of them with experience of 20 years or less, 80% were general practitioners and 70% owned clinics of 50 m2 or less.

Current Management Practices in Dental Clinics/Offices The dentists’ attitude towards DSW management was assessed based on the willingness of them to follow guidelines and practice in-site effective waste separation and temporal storage processes. Overall the results showed positive attitudes since 71% of the dentists are willing to practice waste sorting and temporal storage based on a health and safety plan specifically compiled for dental offices; 11% of them are unwilling to participate and 18% of them believe that they can only partly follow the given instructions, claiming reasons of time and space availability. Having the necessary knowledge is not enough when it comes to day- to- day practice; lack of training or lack of strict laws in this particular field, lead to a loose target in achieving efficient and responsible DWM. The willingness to create environmental profiles comes in contrast with the fact that 60% of them are not in possession of any equipment (bins, bags, amalgam separator), appropriate to practice waste separation in the clinics. The aforementioned reveals the gaps in the environmental education of these professionals that can be partly minimized by the development of an official local/national DSW management plan. Nabizadeh (2012) found in Hamdan, Iran that 70% of the dentists are practicing separation. Daou et al., (2015) found that 96% of the surveyed dental clinics were not practicing waste recycling. On the other hand 62.0% of surveyed dentists were found to recycle precious metals in a study conducted in Thessaloniki, Greece (Kontogianni et al., 2008). In Lebanon 27% of the surveyed clinics had direct instructions and an approved plan for mercury phase-out (Daou et al., 2015). A study on amalgam use and DSW

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management in Pakistan conducted by Mumtaz et al., (2010) found that only 5.9% of the dentists have an amalgam separator in their clinics.

Assessment of Awareness Level The results showed that 46.0% of the interviewed dentists believe that there should be an official roadmap concerning overall medical waste disposal and 35.0% of them think that generated waste should be incinerated in appropriate facilities. Al-Widyan et al., (2010) proved that more than 80% of DSW is made of combustible materials e.g., approximately 60% have paper origin and the rest is made of plastic, providing a promising potential for energy recovery. A low but significant percentage of dentists (19.0%) supports the continuation of current practices (disposal with other domestic wastes) despite their unsustainability. An interesting fact showcasing lack of communication among authorities (MoH, Environmental Quality Authority (EQA), Dental Association, related non-governmental organizations (NGO)) and healthcare providers is that 19.0% of the latter did not acknowledge the healthcare waste disposal landfill in Salfit and Nablus governorate existence. This finding matches to that of a research performed in Lebanon, where the majority of dentists (90%) acknowledged a lack of written procedures for waste management (Daou et al., 2015). The data analysis showed that 97.0% of the dentists perceive the serious health risks occurring from DSW mismanagement; 74.0% perceive the serious health risks introduced by amalgam bearing materials, but only half of them (59.0%) know that chromium is contained in medical films photography development products. The chromium-containing liquid, generated during film development, is disposed-off directly into the sewage according to 55.0% of the dentists. It is worth mentioning that 35% of dentists have X-ray unit in their clinic but only 65% of them develop the films inside clinic (22% in total). The latter is mainly attributed to the introduction of digital medical photography technology. Last but not least,

Qualitative and Qualitative Analysis of Generated Dental Waste … 273 about 62% of the dentists believe that clinics do not produce radioactive waste that spontaneously emits ionizing radiation. In Pakistan, Mumtaz et al., (2010) found that 90.4% of the dentists perceived amalgam to be a health risk for both dentists’ personnel and patients alike.

Assessing Dentists’ Behavior in Application of In-Situ (Clinic) Waste Management Practices A set of independent variables, including age, gender, experience, location of the clinic (being located in Nablus or Salfit), and level of education (being general practitioner, MSc degree holder or PhD degree holder), were selected to assess their effect on professional dentists’ behavior with regard to DSW management. As the data is qualitative, a Spearman’s Correlation test was conducted to identify the variable of significant relationship, the magnitude of effect (how much the dependent variable can be predicted by the independent variable), and the direction of the relationship between both dependent and independent variables. The sign of the correlation coefficient (+/-) indicates the direction of the relationship, while the coefficient value indicates the magnitude, which normally ranges between (-1) and (1). The larger the positive value (closer to +1), the stronger the relationship in ascending order, and larger the negative value (closer to -1), the stronger the relationship in descending order. If the correlation coefficient value is zero, there is no relationship. The results in Table 1 show the variables of relationships at levels (P = 0.01 and P = 0.05). The findings showed that dentist’s behavior in DSW management is significantly affected by age, gender, level of education, and the location of the clinic, while the duration of dentist’s work experience was found non-significant. The correlation analysis showed in particular that: 

Age: dentists with lower ages apply DSW recycling practices (P = 0.007, correlation coefficient = -0.269), and also practice in-site

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







amalgam separate collection (P = 0.039, correlation coefficient = -0.207), and thus Hypotheses 01 is accepted; Gender: female dentists practice DSW separation (P = 0.005, correlation coefficient = -0.279), as well as DSW recycling (P = 0.006, correlation coefficient = -0.271) in-site, and thus Hypotheses 02 is accepted; Level of education: dentists with higher education degree practice DSW separation (P = 0.013, correlation coefficient = 0.249), and own a silver recovery unit (P = 0.03, correlation coefficient = 0.219), and thus Hypotheses 03 is accepted; Location of the clinic: dental clinics located in Nablus city practice DSW separation (P = 0.011, correlation coefficient = 0.254), and sustainable DSW disposal (P = 0.011, correlation coefficient = 0.254), and thus Hypotheses 04 is accepted. It is worth mentioning that there was to statistically significant relationship (P > 0.05) between dentists’ behavior and duration of dentist’s work experience, and thus Hypotheses 05 is rejected.

Qualitative and Quantitative Analysis of Generated Dental Wastes Around 60% of the total dental clinics generation is characterized as infectious waste and it is mainly consisted of cotton contaminated with blood or saliva. It was also observed, that 91% of the clinics produce sharp medical waste (such as needles, syringes, lancets, etc.) which are disposed with domestic waste. Moreover, clinics produce pharmaceutical waste, used in the treatment (59%) and are considered dangerous when mismanaged as the contained chemicals have serious impacts to both humans and the environment. 58% of the clinics produces pathological waste comprised (in 78% of the cases) by liquid waste such as blood and saliva and other human fluids. Liquid waste includes scrap amalgam, vapors, and silver (the latter is generated

Qualitative and Qualitative Analysis of Generated Dental Waste … 275 by the solution used in processing of dental radiographs). Overall the qualitative and quantitative field research results are illustrated in Table 2. Table 1. Correlation between dentists’ behavior and affecting factors Variables Age / Existence of DSW recycling program Age / Existence of amalgam recycling program Gender / Existence of DSW separation program Gender / Existence of DSW recycling program Level of education / Existence of DSW separation program Level of education / existence of silver recovery unit Location / Existence of DSW disposal program Location / Existence of DSW separation program

Correlation coefficient -0.269** -0.207* -0.279** -0.271** 0.249*

P-Value

0.219* 0.254* 0.254*

0.030 0.011 0.011

0.007 0.039 0.005 0.006 0.013

* Correlation is significant at the 0.05 level (2-tailed). ** Correlation is significant at the 0.01 level (2-tailed).

Table 2. Sources and generation of dental waste Dental waste categories Infectious Sharp Pharmaceutical Pathological Liquid Heavy metals Heavy radioactive X-rays Waste X-rays X-ray films development activity Waste liquid for X-rays development

Percentage of the investigated clinics Always Sometimes Never 16% 68% 18% 91% 7% 2% 5% 59% 36% 20% 58% 22% 78% 15% 7% 35% 52% 13% 10% 28% 62% Yes No 35% 65% 65% 35% Trash Drain No need (digital films) 55% 36% 9%

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The results showed that 52% of the clinics produce waste bearing heavy metals, such as mercury. The large percentages of infectious, sharps, pharmaceutical wastes produced, confirm the need for a comprehensive management system to deal with these hazardous end-of-use products. This system should include handling, collection, and disposal but to ensure all of them, the establishment of environmental awareness should precede. Overall DSW generation analysis showed that the average daily production is 57.2 g/patient/day (67.2 g/patient/day in Salfit and 44.7 g/patient/day in Nablus). In European countries, Kizlary et al., (2015) found that the generation rate in Xanthi (Greece) was 513 g/patient/day, Kontogianni et al., (2008) found that the generation rate is 433 g/patient/day in Thessaloniki (Greece). In addition, the waste characterization by weight showed that infectious and potentially infectious waste accounts for 68.3%, non-infectious waste accounts for 4.8%, domestic waste accounts for 26.9% as per Table 3. Table 3. Average waste fraction in g/patient/day Governorate Salfit g/patient/d % Nablus g/patient/d % Total g/patient/d %

Infectious waste 44.2 65.8 32.6 73.0 39.0 68.3

Non-infectious waste 2.1 3.2 3.5 7.9 2.7 4.8

Domestic 20.9 31.0 8.6 19.2 15.4 26.9

Total 67.2 100.0 44.7 100.0 57.2 100.0

In other countries, Kizlary et al., (2015) found that DSW generation in Xanthi (Greece), represented infectious and potentially infectious waste (94.7) and non-infectious waste (2.0%) while domestic-type waste accounted for (3.3%). In Brazil the DSW categories represented: infectious and potentially infectious waste (24.3%), non-infectious waste (48.1%), and domestic-type waste (27.8%) of the total generated DSW stream (Vieira et al., 2009).

Qualitative and Qualitative Analysis of Generated Dental Waste … 277 Table 4. Average infectious waste in g/practice/day according to district Infectious waste fraction Sharps Amalgam Blood soaked dressings Paper Extracted teeth Plastic and rubber Total

Salfit g/patient/day %

Nablus g/patient/day %

Total (Average) g/patient/day %

4.5 0.4 18.3

10.2 0.9 41.4

6.0 0.2 15.1

18.3 0.6 46.2

5.1 0.3 16.9

13.1 0.8 43.3

5.1 0.1

11.5 0.2

3.6 0.2

11.0 0.6

4.4 0.1

11.3 0.3

15.8

35.7

7.6

23.2

12.2

31.3

44.2

100.0 32.7

100.0 39.0

100.0

Further analysis was conducted for infectious waste and the analysis showed that sharps accounts for (5.1 g/p/d), amalgam (0.3 g/p/d), blood soaked dressing (16.9 g/p/d), paper (4.4 g/p/d), extracted teeth (0.1 g/p/d), plastics and rubber (12.2 g/p/d) as also shown in Table 4. Kizlary et al., (2015) found that amalgam waste generation in Xanthi (Greece) was (0.33%). A study of the DSW produced in a school of dentistry in Turkey, showed that rubber waste generation was (35.0%) and paper waste generation was (30.0%) of the total DSW stream (Ozbek and Sanin, 2003). In Iran, Balarak et al., (2017) reported that sharps represents (9.8%) of the total DSW generated in north-west Iran (6.93 g/p/d).

CONCLUSION AND RECOMMENDATIONS Environmental culture and attitude towards sustainable DSW management is measured based on the willingness of the dentists to participate in sustainable waste separation and disposal. The results of the field study in Palestine proved the willingness of most professional dentists

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(~71%) in it, despite the highlighted lack of communication among healthcare providers and authorities. To follow the instructions of the existing local plan, dentists’ need to practice source separation and purchase the appropriate equipment particularly for amalgam, which only 40% of them own at the moment. Factors affecting dentists’ behavior in DSW management was studied in depth and was found that age, gender, level of education, and location of the clinic are the dominant factors affecting the dentist behavior in uptaking of DSW management initiatives. DSW generation and characterization showed that the average generation rate at both governorates, Nablus and Salfit, is 57.2 g/patient/day. The waste is characterized by infectious and potentially infectious fractions that both account for 68.3%, non-infectious that accounts for 4.8%, and domestic-type waste that accounts for 26.9% by weight. The infectious and potentially infectious waste fraction consists of six individual fractions; sharps (13.1%), amalgam (0.8%), blood soaked dressings (43.3%), Paper (11.3%), plastic and rubber (0.3%) and extracted teeth (31.3%). Since DSW is a proportion of medical waste, it is highly recommended to establish and largely communicate a comprehensive medical waste management plan on national level (supported by national law), involving source separation, proper packaging, and recycling and metal recovery procedures in dental offices. Collaboration among MoH, EQA, related NGO’s, and local dental associations, in terms of promoting the sustainability principles, compiling a legislative framework, organizing training/communication activities is highly significant. Undertaking effective measures to protect dentists’/citizens’ health and promote environmental welfare is a principal outcome of a roadmap that needs to be followed shortly. Prevention and mitigation measures should be proposed and applied in the total process, starting from the storage area requirements in the dental clinic continuing over sustainable collection, transportation, treatment and final disposal processes and resulting into environmental sustainability assurance.

Qualitative and Qualitative Analysis of Generated Dental Waste … 279

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Darwish, R., & Al-Khatib, I. A. (2006). Evaluation of dental waste management in two cities in Palestine. Eastern Mediterranean Health Journal, 12(2), 12. Ebrahimzadeh, G. R., Norzaee, S., Djahed, B., Enayat, E., Fakhri, Y., & Taghavi, M. (2018). Quantitative and qualitative analysis of dental clinics waste in Zabol city, Iran. Data in Brief, 19, 1865-1870. Fan, P. L., & McGill, S. L. (1989). How much waste do dentists generate? J. Calif Dent Assoc., 17(12), 39-40. Farmer, G., M., Stankiewicz, N., Michael, B., Wojcik, A., Lim, Y., & Ivkovic, D. (1997). Audit of waste collected over one week from ten dental practices. A pilot study. Aust Dent J, 42(2), 114-117. Guay A. H. (2007). The role dentists can play in mass casualty and disaster events. Dent Cin North Am., 51(4), 767-778. Gusca, J., Kalnins, S. N., Blumberga, D., Bozhko, L., Khabdullina, Z., & Khabdullin, A. (2015). Assessment method of health care waste generation in Latvia and Kazakhstan. Energy Procedia, 72, 175-179. Hamdi, S. (2003). Environmental Management: Principles and Practices. Arab Organization for Development Management. Cairo, Egypt (in Arabic). Johnson, B. (2000). Mercury amalgam treatment technologies for dental offices, EIP Associates. Journal of California Dental Association, 17, 39-41. Joint Service Council for Solid Waste Management for Hebron and Bethlehem governorates (JSC-H&B) (2019). Monthly billing data. Bethlehem, Palestine. King, J. K., Harmon, S. M., Fu, T. T., & Gladden, J. B. (2002). Methyl mercury formation and sulfate-reducing bacteria profiles in wet land microcosms. Chemosphere, 46(6), 859-870. Kiyak, H. A., Beach, B. H., Worthington, P., Taylor, T., Bolender, C., & Evans, J. (1990). The psychological impact of Osseo integrated dental implants. International Journal of Oral and Maxillofacial Implants, 5, 61-69. Kizlary, E., Losifidis, N., voudrias, E., & Panagiotakopoulos, D. (2005). Composition and production rate of dental solid waste in Xanthi,

Qualitative and Qualitative Analysis of Generated Dental Waste … 281 Greece: variability among dentist groups. Waste Management, 25, 582-591. Kontogianni, S., Xirogiannopoulou, A., & Karagiannidis, A. (2008). Investigating solid waste production and associated management practices in private dental units. Waste Management, 28, 1441-1448. Kurt, D., Tong, W., & Yuping, W. (2001). Municipal solid waste management in China using commercial management to solve a growing problem. Waste Management, 31, 2376-2389. Maamari, O., Brandam, C., Lteif, R., & Salameh, D. (2015). Health care waste generation rates and patterns: The case of Lebanon. Waste Management, 43, 550-554. Mackey, K., Contreras, J. T., & Liang, B. A. (2014). The Minamata convention on mercury: Attempting to address the global controversy of dental amalgam use and mercury waste disposal. Science of the Total Environment, 472, 125-129. Mandalidis, A., Topalidis, A., Voudrias, E. A., & Iosifidis, N. (2018). Composition, production rate and characterization of Greek dental solid waste. Waste Management, 75, 124-130. Maxon, P. (2007). Mercury in Dental Use: Environmental Implications for the European Union. Concorde East/West Sprl, 2-34. Minnesota Technical Assistance Program (Mn TAP) (1995). Managing waste generated by dental clinics. Minnesota Office of Environmental Assistance to the University of Minnesota, School of Public Health. Minoglou, M., & Komilis, D. (2018). Describing health care waste generation rates using regression modelling and principal component analysis. Waste Management, 78, 811-818. Mudgal, S., Vanlong, L., Mitsios, A., Phal, S., Detoni, A., & Hylander, L. (2012). Study on the potential for reducing mercury pollution from dental amalgam and batteries (final report), European commission DGENV. Muhamedagic, B, Muhamedagic, L., & Masic I. (2009) Dental Office Waste – Public Health and Ecological Risk. Materia socio medica, 21(1), 35-38.

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Mumtaz, R., Ali Khan, A., Noor, N., & Humayun, S. (2010). Amalgam use and waste management by Pakistani dentists: an environmental perspective. Eastern Mediterranean Health Journal, 16(3), 334-339. Mutter, J. (2011). Is dental amalgam safe for humans? The opinion of the scientific committee of the European Commission, Journal of Occupational Medicine and Toxicology, 6, 2. Nabizadeh, R., Koolivand, A., Jafari, A., Yunesian, M., & Omrani, G. (2012). Composition and production rate of dental solid waste and associated management practices in Hamadan, Iran. Waste Management & Research, 30(6), 619-624. Ozbek, M., & Sanin, F. D. (2003). A study of the dental solid waste produced in a school of dentistry in Turkey. Waste Management, 24(4), 339-345. Palestinian Central Bureau of Statistics (PCBS) (2014a). Localities in Salfit Governorate by Type of Locality and Population Estimates, 2007-2016, Ramallah, Palestine. Palestinian Central Bureau of Statistics (PCBS) (2014b). Localities in Nablus Governorate by Type of Locality and Population Estimates, 2007-2016. Ramallah, Palestine. Palestinian Central Bureau of Statistics (PCBS) (2014c). Establishment’s census 2012. Ramallah, Palestine. Sawair, F., Hass Oneh, Y., Jamleh, A., & Al-Rabah, M. (2010). Observance of proper mercury hygiene practices by Jordanian general dental practionors. International Journal of Occupational Medicine and Environmental Health, 23(1), 47-54. Singh, B., Khan, S., Agrawal, N., Siddharth, R., & Kumar, L. (2012). Current biomedical waste management practices and cross-infection control procedures of dentists in India. International Dental Journal, 62, 111-116. Tiejen, L. B. (2003) Infection prevention guidelines for healthcare facilities with limited resources publisher, “JHPIEGO”; Baltimore, USA. Vieira, C. D., Carvalho, M. A. R. D, Cussiol, N. A. M., Alvarez-Leite, M. E. A., Santos, S. G. D., & Gomes, R. M. D. F. (2009) Composition

Qualitative and Qualitative Analysis of Generated Dental Waste … 283 analysis of dental solid waste in Brazil. Waste Management, 29, 13881391. Vieira, C. D., de Carvalho, M. A. R., & Cussiol, N. A. M. (2011). Count, identification and antimicrobial susceptibility of bacteria recovered from dental solid waste in Brazil. Waste Management, 31(6), 13271332. Viragi, P. S., Ankola, A. V., & Hebbal, M. (2013). Occupational hazards in dentistry – Knowledge attitudes and practices of dental practitioners in Belgaum city. Journal of Pierre Fauchard Academy (India Section), 27(3), 90-94. World Health Organization (WHO) (1999). Safe management of wastes from health-care activities. Geneva. World Health Organization (WHO) (2017). Media Center. Health-care Waste. www.who.int/mediacentre/factsheets/fs253/en/ (accessed September 9, 2018).

In: Public-Private Partnerships ISBN: 978-1-68507-184-4 Editors: D. Monferrer Tirado et al. © 2021 Nova Science Publishers, Inc.

Chapter 9

MEDICAL LABORATORIES GENERATED WASTE MANAGEMENT IN WEST BANK, PALESTINE Rami A. Banishamseh1, Issam A. Al-Khatib2,*, PhD, Majed I. Al-Sari3, Stamatia Kontogianni4, PhD and Fathi M. Anayah5, PhD 1

Faculty of Graduate Studies, Birzeit University, Birzeit, Palestine 2 Institute of Environmental and Water Studies, Birzeit University, Birzeit, Palestine 3 Universal Institute of Applied and Health Research, Nablus, Palestine; The Joint Service Council for Solid Waste Management for Hebron and Bethlehem Governorates Hebron, Palestine 4 Laboratory of Heat Transfer and Environmental Engineering, School of Mechanical Engineering, Aristotle University of Thessaloniki, Thessaloniki, Greece 5 Faculty of Engineering and Technology, Palestine Technical University – Kadoorie, Tulkarm, West Bank, Palestine

*

Corresponding Author’s Email: [email protected]; [email protected].

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ABSTRACT This field research focuses on the evaluation of healthcare waste (HCW) management practices applied in Medical Laboratories (MLs) in Nablus and Ramallah governorates, Palestine. Totally 100 MLs were selected representing a variety of legal statuses (governmental, private and Non-Governmental Organization’s). Eight out of 100 MLs were further selected to participate into a HCW sampling research that measured and characterized the generated waste fraction. Overall results showed that less than half of the MLs present an excellent environmental performance (as per a predetermined set of indicators) and approximately two thirds of them pre-treat HCW prior to final disposal. MLs HCW comprises of household-like wastes (45.50%), waste mixed with infectious waste (21.07%), tissues and pathological waste (18.48), plastic waste resulting from medical processes (7.18%), sharps (4.88%) and absorbent waste (2.89%). Following that and having identified that two parameters, namely the number of (i) samples taken from the patients and (ii) the number of tests performed, largely affect the overall HCW generation, a HCW generation pattern was developed for the study area.

Keywords: healthcare waste, laboratories, pathological waste, sharps, infectious waste

INTRODUCTION Healthcare waste (HCW) management constitutes any solid waste generated in the diagnosis, treatment or immunization of human beings and animals (Makajic-Nikolic et al., 2016; Su and Chen, 2018). This includes the wastes generated from all types of healthcare facilities, e.g., hospitals, clinics, doctor’s offices (dental and veterinary) and Medical Laboratories (MLs) (WHO, 1999, 2005; Idowu et al., 2013; Chauhan and Singh, 2016; Hong et al., 2018).The rapid growth of population and increase of healthcare and treatment demands in communities have resulted into the increase of the number of healthcare service providers e.g., hospitals, clinics and public/private laboratories (Pruss et al., 1999;Tchobanoglous and Theisen, 2003; Le et al., 2006; Amouei et al., 2012; Komilis et al., 2012; Bokhoree et al., 2014; Windfeld and Brooks, 2015). Also the high

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diversity of conducted activities (in diagnosing microbial pathogens in blood, urine and feces) lead into the generation of a great variety of hazardous wastes by MLs. These particular waste properties vary (infectious, toxic, dangerous chemicals like carcinogens and sharps as well as non-infectious (household-like) wastes) (Amouei, 2002; Taghipour and Mosaferi, 2009). Some of MLs waste contains metals, dioxins, lixiviated phthalates from plastics such as vinyl chloride and other chemicals that are not biodegradable in the environment and are potentially harmful to human health (Komilis et al., 2009). It worth mentioning that in the United States, infectious wastes generated in MLs contaminate the surface and underground water and contribute to seven million yearly cases of microbiological infections (Pedrozo and Philipi, 2005). According to ISWA sustainable and efficient management of HCW starts at the source, at the generation point where the risks in processes such as generation and initial segregation are considered to be the highest of all. Accordingly, the highest training demands exist at this level (ISWA, 2014). Nevertheless, sustainable management of HCW is either not applied or commitment to guidelines’ practices is not existent by involved staff (e.g., waste producers, transporters and operators of treatment plants and disposal facilities). In terms of generation patterns 85% of the generated HCW is considered as household-like waste, while infectious waste represents only 15%of it and is comprised by pathological waste, sharps, chemical and pharmaceutical waste and toxic waste (radioactive, pressurized bottles, broken thermometers and batteries, etc.) (Pruss et al., 1999; Al-Khatib, 2007). The percentages of those particular waste streams depend highly on the institution type and the provided services. However, infectious waste can pose significant public health problems (Pruss et al., 1999; Yong et al., 2009; Oroei et al., 2014). Mis-management of HCW exposes medical staff, waste-handling workers and surrounding communities to infectious diseases, toxic effects and injuries, posing serious health problems in most developing and developed countries of the world (Johannessen, 2000; Marinkovic et al., 2008; Shiferaw et al., 2012; Idowu et al., 2013). Mismanagement of HCW is found to be the reason for many injuries (by sharp

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instruments), leading to infectious diseases such as hepatitis B virus, hepatitis C virus, human immunodeficiency virus and respiratory, enteric and soft tissue infections (Jang et al., 2006; Blenkharn, 2007; Marinkovic et al., 2008; Yong et al., 2009; Ferreira and Teixeira, 2010; Garikos et al., 2010; Dursun et al., 2011; Oroei et al., 2014; Maamari et al., 2015). Askariyan et al. (2004) research on the quality and quantity of the generated HCW in Shiraz, Iran resulted that the generated waste per capita was 4.45 kg a day, out of which the general waste, infectious waste and sharps comprised 71.44%, 27.80% and 0.76%, respectively. Amouei et al. (2012) found that in hospitals of Babol University (Iran) the amount of total healthcare solid waste per capita was 2.99 kg/bed-day and mean generating rate of general wastes, infectious wastes, sharps and hazardous chemical wastes as kg per day were 1.97, 0.89, 0.1 and 0.05 respectively. Recent studies have reported that the estimated HCW generation in Nigeria varies from 0.562 to 0.670 kg/bed/day (Idowu et al., 2013). A research by Komilis et al. (2009) on dental laboratories’ wastes in Xanthi, Greece showed that the medical infectious, chemical and household-like wastes daily average generated quantity per capita in each laboratory were 290, 5.3 and 831 g, respectively. In a study by Garikos et al. (2010) in Greek MLs, the amounts of infectious, hazardous chemical and general wastes generated for each patient treatment are 48±6.4, 10±9.8 and 6.1±3.2 g/day respectively (Taghipour and Mosaferi, 2009). In Jordan, Bdour et al. (2007) found that the HCW generated by MLs with governmental legal status is (0.053 – 0.065) kg/test and (0.035 – 0.102) kg/test for privately owned MLs. In accordance with the environmental survey conducted on 2009by the Palestinian Central Bureau of Statistics (PCBS 2016), the estimated HCW generation in Palestine (West Bank and Gaza Strip) is as shown in Table 1. Palestine is a developing country sharing the same financial and infrastructural constraints in waste management sector. Recent assessment studies on HCW management have revealed several problems in-site in various management stages: segregation, handling and temporary storage are not conducted according to sustainable methods described in

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international regulations and good practices (Askarian et al., 2004; Phengxay et al., 2005; Marinkovic et al., 2008; Moreira and Günther, 2013). Inefficient management in waste generation points (of healthcare services provision) has high negative impact on overall management; application of treatment and final disposal sustainable options. The Palestinian Environment Quality Authority (EQA) has become increasingly concerned about solid waste management including HCW. The fifth strategic objective of the National Strategy for Solid Waste Management in the Palestinian Territory 2010 – 2014, includes “principles and mechanisms suitable for managing healthcare, hazardous and special wastes”. Several targets are described, e.g., (i) creating appropriate inventory and tracking systems for hazardous waste, (ii) treating HCW before its final disposal according to the “polluter pays” principle to limit its negative health and environmental impacts and (iii) minimizing the negative health and environmental impacts of special waste (EQA, 2010). Following that, the Palestinian National Authority (PNA) introduced the HCW management system bylaw, under the cabinet decision no. (10) of 2012 (PNA, 2012). Together with that, PNA coordinated an external fund, which provided the Joint Services Council for Solid Waste Management of Hebron and Bethlehem Governorates (southern West Bank) with a HCW treatment plant. Internationally the stages of HCW management involve source separation, collection to temporary storage in-site, transfer for pretreatment (autoclave and shredding), final disposal (incineration, landfilling and recycling where it is appropriate). In Palestine, not all stages of HCW management are applied and on the other hand, application of specific stages is considered moderate (Khalaf and Al-Khatib, 2011). To this direction and for the purpose of long-term planning and design of HCW management system, it is important to have background data on HCW generation rate and composition as well as to support the capacity of sustainable management practices application by healthcare providers and HCW handlers. Even though overall HCW management system in some Palestinian cities has been studied, HCW originating from MLs has never been separately audited thoroughly. The main objective of the

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research presented in this paper is to characterize the HCW generated by MLs and build a mathematical model to determine the generation rate pattern as well as to evaluate the current management practices applied in local MLs of Nablus and Ramallah governorates. Table 1. Estimated quantity of healthcare waste generated by healthcare centers in Palestine for the year 2009 (PCBS, 2016) Estimated monthly quantity generated (ton) for (2008) West Bank Gaza Strip Total Secondary healthcare centers1 307.4 254.4 561.8 Primary healthcare centers2 169.1 213.8 382.9 Other activities related to human health3 39.8 6.0 45.8 Total 516.3 474.2 990.5 Estimated monthly quantity generated (ton) for (PCBS, 2016) Location of healthcare center West Bank Gaza Strip Total North 120.4 n/a Middle 178.2 n/a South 173.8 n/a Total 472.4 729.5 1674.3 1 Secondary Healthcare refers to a second tier of health system, in which patients from primary health care are referred to specialists in higher hospitals for treatment. 2 Primary healthcare denotes the first level of contact between individuals and families with the health system. 3 Clinics, doctor’s offices, urgent care centers, serve as first point of contact with a health professional and provide outpatient medical, nursing, dental, and other types of care services. Type of healthcare center

MATERIALS AND METHODS Study Area Currently HCW is co-disposed with municipal solid waste in all governorates except to Hebron and Bethlehem governorates. In those two governorates a sanitary landfill has been constructed on 2014. Thus all HCW generated by public and private hospitals is autoclaved and shredded

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in-site prior to its final disposal at HCW Al-Minya sanitary landfill (The World Bank, 2019).

Figure 1. Location of Palestine and of Nablus and Ramallah and Al Bireh governorates in which the field research took place (PCBS, 2019).

Table 2. Distribution of medical labs in the study area Category of Medical laboratories Private NGOs and charities’ Health Directorate (governmental) Hosted in governmental hospitals Hosted in NGOs’ and private hospitals

Nablus governorate 36 15 9 2 4

Ramallah and AlBireh governorate 30 8 26 1 6

Total 66 23 35 3 10

The study area involves (i) Nablus governorate and (ii) Ramallah and Al-Bireh governorates that represent approximately 25.5% of the total

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population of the West Bank (PCBS, 2016) and are two out of the 11 governorates in Palestine. Figure 1 provides oversight of the study area. In Nablus governorate there is a sustainable management system available for HCW whereas Ramallah there is not. The distribution of Medical Laboratories in the study area is presented in Table 2.

Field Research Means The field research presented in this paper focuses on the qualitative and quantitative evaluation of the HCW generation in MLs as well as the evaluation of the applied practices regarding HCW stream management. To achieve the aforementioned research purpose, researchers implemented the research in two phases. The first involved interviews with the MLs responsible personnel or representatives and the second one involved the generated HCW sampling. The questionnaire particular aim was to evaluate the efficiency of the applied management practices to the generated HCW stream in MLs. It was developed in cooperation with representatives of both the Ministry of Health and the Center of Health Information and it covers all stages of HCW management: (i) collection, (ii) sorting, (iii) storage, (iv) pre-treatment, (v) final disposal, as well as (vi) occupational health and safety guidelines. Sustainable HCW practices (described in HCW management related international and Palestinian regulations) also inspired the development of the qualitative evaluation statements. Towards the evaluation of the MLs HCW management practices efficiency a three-point scale was applied; ExcellentSatisfactory- Unacceptable corresponding to Always-Sometimes-Never potential replies of the respondents. The second field research phase aimed at the quantitative analysis of the generated HCW from MLs. Trained (in HCW handling researchers) were involved in sampling procedure which lasted 5 weeks. Samples were collected from the generated waste during a four consecutive days period (Monday to Thursday) and it was conducted in a HCW cumulative process after the official working hours (8:00 am - 3:00 pm) to ensure the reception

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of representative daily samples. The four consecutive days were selected in order to check the fluctuation in the rate of HCW generation and audit potential changes during each week. Totally 20 HCW samples per ML were collected throughout the research period resulting from 4samplings per research week (5 totally). The total HCW volume was transported to an appropriate university facility (bearing HCW temporary storage characteristics, e.g., refrigerated room, limitation of access, leak-proof, etc.) were they were classified into categories as per the following (WHO, 2004): 1. Absorbent waste: Cotton, pads, bandages, disposal diapers or bedding saturated or stained with human or animal blood, pus, discharge or secretion. 2. Sharp items: Discarded sharps, hypodermic needles, syringe surgical blades and blood lancets. 3. Tissue and pathological waste: tissues of human, organs, blood, pus, body parts and fluids that are removed during infectious agents from test or examination, culture dishes and discarded blood fluids and containers. 4. Medical plastic waste: urine and stool sampling bucket, bag, blood bag or waste taken from blood dialysis, other plastic (does not include syringes). 5. Household-like waste mixed with infectious waste: turning and mixing tools, plastic and paper test slides and sampling and transfer tools. 6. Household waste: food and beverage waste usually discarded (household-like waste).

Research Population The MLs in the research area have various legal statuses; governmental, private or NGO. Each of them provides healthcare services to different local population groups having various life statuses. To this direction, the research sample of MLs population was based mainly on the

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legal status in order to represent the existing strata of local population. The overall ML population in the research area numbers 137 MLs. Out of them 28 are governmental, 71 are private and 28 are NGO. The research sample involved 73% of them that is 100 local MLs. Their legal status is as follows: 19 Governmental (2 of them are hosted in public hospital facilities), 55 private (7 of them are hosted in private hospital facilities) and 26 NGO. The representatives of those 100 MLs participated in the interviews conducted via the structured questionnaire developed for this purpose (phase 1). Due to the sampling procedure demanding nature and the potential hazards involved for researchers, the second phase of the field research was implemented to a sub-sample of the phase 1 research. This involved eight of the 100 MLs initially involved, for on-site HCW sampling, measurement and characterization activities. All involved MLs representatives provided their written consent to the research prior to its implementation and they are presented in Table 3 together with the corresponding ML legal status. In addition, (i) the number of testing samples taken from the patients and (ii) the number of medical tests performed by each ML during the study period were recorded and obtained directly from the corresponding ML archive. Table 3. Selected Medical Laboratories of the quantitative study (phase II) No. 1 2 3 4 5 6 7 8

Medical Laboratory name Palestinian red crescent (hosted in hospital) Al-Wosta Az-Zakah committee Baita medical center Midi-care lab-Al-Farah Mid-lab Midi-care lab (Al-Irsal) Rafidia hospital laboratory

Legal status NGO

Location (City/governorate) Al-Bireh/Ramallah and Al-Bireh

Government NGO Government Private Private Private Government

Al-Makhfyyah/Nablus Baita/Nablus Baita/Nablus Ramallah/Ramallah and Al-Bireh Ramallah/Ramallah and Al- Bireh Ramallah/Ramallah and Al-Bireh Nablus/Nablus

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Data Processing The analysis of all obtained data was carried out using the Statistical Package for Social Sciences software (SPSS Inc., Chicago, IL, USA), version2.0. Furthermore, Microsoft Excel 2010 was also used for data interpretation. Following that, two regression models were developed to quantify the HCW generated by MLs and to assess the appropriate variable for the development of a HCW generation estimation pattern for MLs.

RESULTS AND DISCUSSION Waste Characterization The generated HCW waste quantity by MLs and its characteristics highly depend on data such as the number of served patients’, the number of medical tests performed and the number of samples. The quantity was determined via the HCW sampling process whereas the data was retrieved by the MLs’ archives. Table 4 presents the raw data regarding the quantity of generated waste by MLs as well as the number of patients served during the research period. The average number of tests performed per sample was 2.2. An increased rate is noticed to Midi-care (Al-Farah) private MLs which depend mainly on the implementation of multiple tests as an effect of patients’ annual blood checks. This is not the case in the governmental or NGO MLs where two or three tests are performed per sample due to the doctor order as appointments are usually intended for a specific health condition. Particularly for governmental and NGOs MLs the tests per sample are low (1.8-1.9) but in private MLs the rate is higher (3.1). Test per sample ration together with employees’ number and patients number influence HCW generation in MLs.

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Table 4. Healthcare waste quantities as a relation to the number of samples and number of medical tests performed in the study medical laboratories during the indicative period of four consecutive days

Laboratory name/Ownership type Palestinian Red Crescent Hospital/NGO Al-Wosta/Governmental Az-Zakah Committee/NGO Baita medical center/Governmental Midi-care-Al-Farah/Private Midi-care (Al-Irsal)/Private Mid-lab/Private Rafidia Hospital/Governmental Total

Average HCW generation (kg/4days)

Samples no.

Tests no.

Tests/Samples ratio

13.06

184

456

2.5

22.90 6.91 9.25 24.78 13.74 6.50 242.20 339.34

354 186 244 210 141 51 1829 3199

504 243 487 1103 285 111 3949 7138

1.4 1.3 2.0 5.3 2.0 2.2 2.2 2.2

Overall, the number of employees in MLs affects the number of served patients increasingly. To this direction, the high number of patients leads to an increased number of samples per ML. At this point researchers noticed that the test per sample ratio plays a significant role in ML HCW generation; if the ML is private, the ratio is high leading to limited liquid HCW generation from private MLs yet an increased solid HCW generation (as a consequence of increased plastic test tubes usage). If the ML is governmental or NGOs the opposite is noticed. This is depicted also in Table 5 where the quantities of the generated HCW per category are presented. Private MLs present the higher total HCW generation compared with other legal status MLs. It must be explained that the total HCW generation from the governmental Rafidia hospital ML is due to the large number of patients (visiting and hospitalized). The large scale of this particular health facility compared to the other governmental ML (AlWosta) that is not hosted in a hospital, is highly influencing the HCW generation. Furthermore, the high HCW quantity generated at the governmental Rafidia Hospital ML (132.42 g/sample) and is attributed to the following parameters:

Average

Rafidia Hospital Lab/Governmental

Mid-lab/private

Midi-care lab (Al-Irsal)/private

Midi-care lab -AlFarah/Private

Az-Zakah Committee lab/NGO Baita medical center/Governmental

Al-Wosta lab/Governmental

Palestinian Red Crescent Hospital Lab/NGO

Laboratory name/Ownership type

Absorbent waste 7.39 2.98 1.15 0.81 2.74 2.10 0.59 0.29 4.48 0.85 4.11 2.04 5.41 2.49 3.05 1.41 3.06 1.37

Unit g/sample g/test g/sample g/test g/sample g/test g/sample g/test g/sample g/test g/sample g/test g/sample g/test g/sample g/test g/sample g/test

1.67 5.70 2.64 4.05 2.02

1.90 0.77 8.79 6.17 1.37 1.05 3.29 1.65 5.24 1.00 2.34 1.16 3.63

Sharp items

9.28 31.97 14.81 8.70 3.97

Tissue and pathological waste 4.29 1.73 0.00 0.00 3.72 2.85 0.00 0.00 5.84 1.11 3.62 1.79 20.20 1.98 6.87 3.18 7.85 4.03

9.95 4.01 9.75 6.85 8.92 6.83 9.20 4.61 6.70 1.27 7.06 3.49 4.31

Medical plastic

14.41 29.37 13.60 16.87 7.76

Waste mixed with infectious HCW 14.84 5.99 13.73 9.64 5.27 4.03 6.02 3.02 18.61 3.54 15.82 7.82 31.37 28.74 55.47 17.84 44.69 18.63

32.61 13.16 31.29 21.97 15.11 11.56 18.82 9.43 77.14 14.69 64.50 31.91 62.55

Household like waste

Table 5. HCW generation as per sample and test number in the investigated MLs

58.57 132.42 61.33 86.00 39.01

70.98 28.64 64.69 45.44 37.13 28.42 37.91 19.00 118.01 22.47 97.45 48.21 127.47

Total

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298 





The laboratory includes a blood donation unit visited by 50 persons on a daily basis who undergo required medical tests prior to blood donation; In case patient blood sample is not tested as per its appropriateness (HIV free, Hepatitis free, level of Fe, etc.) prior to blood donation the donation cannot be included in the local blood bank and therefore blood and blood bag is disposed as waste; and Some visitors (elderly or families with babies) spend more than half an hour in the ML until they are ready to leave and accordingly this practice increases the generation of general (household-like) waste (e.g., juice bottles, papers and food waste) to 55.47 g/sample.

The largest quantity generated per sample was found at Rafidia Hospital ML in Nablus city (132.42 g/sample). However, the smallest quantity generated was found at Az-Zakah committee ML (37.13 g/sample). The largest waste quantity generated per test performed was found also at Rafidia Hospital ML (61.33 g per test), while the smallest quantity was at Baita medical center (19 g/test). Τhe HCW generated by the MLs in the study area is found to be in the range of:   

(37.13 – 70.98) g/sample or else (28.42 – 28.64) g/test for the NGOs MLs. (97.45 – 127.47) g/sample or else (22.47 – 58.57) g/test for the private sector MLs. And (37.13 – 132.42) g/sample or else (19.0 – 61.33) g/test for the governmental MLs.

It is considered rather alarming that the private ML named Mid-lab and the governmental ML named Rafidia hospital generate high quantity of waste mixed with infectious waste compared to other MLs regardless of their legal status. This fraction of HCW typically presents an increased volume when limited HCW source separation practices are applied in-site; certain quantities of household-like waste is mixed with infectious ones resulting into a high volume waste stream that needs to be treated as

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infectious after all. Comparing PRC to Az-Zakah committee MLs, while almost the same number of samples was taken from patients, in PRC ML the number of tests is double, leading to a double HCW generation. Financial status increase tends to augment HCW generation in all cases of healthcare provision. Given that the financial status of the patients visiting Az-Zakah Committee ML is significantly lower to the patients’ of PRC ML, less tests are implemented in this ML as opposed to the Palestinian Red Crescent Hospital lab and more HCW is generated. Comparing these results with those of nearby countries, Bdour et al. (2007) found that MLs in the north of Jordan HCW generation is in the range of 53 – 65 g/test for governmental MLs and 34 – 102 g/test for private MLs. However, the average HCW generated per sample by the study laboratories constitutes of 3.06 g absorbent waste, 4.05g sharps, 8.7g tissues and pathological waste, 16.78 g waste mixed with infectious waste, 7.85g discarded medical plastics and 44.69g household-like waste. In terms of medical tests performed, the average HCW generated constitutes of 1.37 g absorbent waste, 2.02 g sharps, 3.97 g tissues and pathological waste, 7.76 g waste mixed with infectious waste, 4.03 g discarded medical plastics and 18.63 g household-like waste. Characterization of HCW generated by MLs is shown in Figure 2. The largest fraction is the household-like waste (45.5%), while the smallest fraction was found to be the absorbent waste (2.89%). The sharps fraction represents (4.88%), which is in line with Amouei et al. (2012) study resulted that the amount of household-like waste is (38.67%), infectious waste is (51.92%), chemical waste is (4.64%) and sharps is (4.77%). In comparison with the composition of hazardous HCW generated by healthcare facilities in Jenin governorate (Palestine), Abu Khalaf (2009) found that absorbent waste (15.4%), sharps (7.3%), tissues and pathological waste (30.0%), discarded medical plastics (21.4%) and waste mixed with infectious waste (25.8%). Taghipour and Masaferi (2009) found that household-like waste, infectious waste and sharps generated by healthcare centers were 70.11, 29.44 and 0.45%, respectively in Tabriz, Iran. In Sistan and Baluchistan province, Iran, Bazrafshan and Mostafapour (2010) found that infectious

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waste, household-like waste and sharps constituted 51.6, 47.2 and 1.2% of the hazardous HCW stream, respectively. Askariyan et al. (2004) found that the HCW generated in Shiraz, Iran, was (71.44%) household-like waste, (27.8%) infectious waste and (0.76%) sharps. Furthermore, in a study conducted by Al-Khatib et al. (2016) in Nablus city public, private and NGO hospitals’, it was found that the annual average amount of infectious waste generated yearly was higher in public facilities, accounting for 39.64%. Most importantly in NGOs hospitals’ infectious waste generation was 16.8% of total HCW generated. The HCW average generation in Lebanon hospitals follows the WHO pattern as it comprises of approximately 80% household-like waste and 20% hazardous or risk waste (Chaker 1999).

Figure 2. Composition of the healthcare waste generated by Medical Laboratories’.

EFFICIENCY OF APPLIED HCW PRACTICES (PERFORMANCE EVALUATION) The evaluation of HCW management by the involved MLs is based on the following performance indicators regarding HCW: (i) collection, (ii) sorting, (iii) storage, (iv) pre-treatment, (v) final disposal and (vi)

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occupational health and safety guidelines in the ML. The outcomes on the HCW collection and sorting are presented in Figure 3.

Figure 3. Healthcare waste source separation and disposal processes by Medical Laboratories.

The availability of separation boxes and bins scored 74% being an excellent performance indicator. Application of practices regarding pretreatment of generated HCW in-site (e.g., autoclave or disinfection practices) was not identified in solid HCW. Nevertheless, liquid waste is pre-treated (before its disposal through the sewer system) in some cases. This parameter scored 43% which constitutes an unacceptable performance indicator. Similarly, Kihampa and Kihampa (2015) study pinpointed that only 7.7% of liquid waste generated by MLs in Dar Es Salaam (Tanzania) is treated before its disposal, also presenting an unacceptable performance indicator. The survey also investigated the disposal means available for the generated HCW of each ML and the outcomes are presented in Figure 3. Unfortunately, the majority of the MLs’ (59% of them) are disposing HCW directly to the municipal waste bin or the personnel is mixing them with municipal waste prior to disposal. In only 28% of the MLs HCW are disposed in separate containers to be treated with HCW from other regional generation sources.

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Figure 4. Healthcare waste disposal means and practices from the Medical laboratories’ personnel.

Figure 5. Healthcare waste in-site temporary storage and disposal.

The average set of performance indicators regarding waste in-site temporary storage and disposal is shown in Figure 4. Based on the replies received and calculations implemented 49% of the MLs are presenting excellent performance, compared to 24 and 26% of them whose performance is either satisfactory or unacceptable, respectively. The highest excellent performance indicator scored 71% and is related to HCW temporary storage on a daily basis. However, the highest unacceptable performance indicator (scored 51%) and is mostly related to low level of

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health and safety measures (e.g., unskilled personnel employment to be responsible of HCW handling) based on the retrieved raw data. In addition, the waste disposal frequency (from temporal storage to final disposal) was assessed as shown in Figure 5. It is ascertained that the collection frequency is low as HCW should be collected daily, according to WHO. Regarding the occupational health and safety field performance the results are shown in Figure 6.

Figure 6. Frequency of waste collection in MLs.

In this significant field in terms of human health, in 46% of laboratories perform excellent compared to 15% and 39% that present a satisfactory or an unacceptable performance, respectively. The results showed that 88% of the MLs are vaccinating personnel against hepatitis (presenting an excellent performance indicator). This is in contradiction with El-Gilany et al. (2017) study results where it was found that only 20% of the MLs personnel were vaccinated against hepatitis B. On the other hand, when it comes to the application of an expanded program of immunization, 76% of the Palestinian MLs perform unacceptable. Such a program application controls diseases and enhances the health status of MLs personnel who is exposed to multiple viruses, Hepatitis B included (El-Gilany et al., 2017).

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From the occupational health and safety point of view, trained personnel having the necessary know-how to handle HCW, is considered a laboratory asset and contributes to the reduction of risks associated with HCW. The results (Table 6) show a significant relationship (p