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REPORT OF THE AUDITOR-GENERAL ON A SUSTAINABLE DEVELOPMENT AUDIT OF

MEDICAL WASTE AT THE NATIONAL DISTRICT HOSPITAL, DEPARTMENT OF


HEALTH, FREE STATE PROVINCE FOR THE 2002-2003 FINANCIAL YEAR
1. PURPOSE AND CONTENT OF THE REPORT
1.1 The purpose of this report is to bring the findings of the audit regarding the handling,
storage and transportation of medical waste at the National District Hospital,
Department of Health, Free State Province to the attention of the Free State
egislature. The content of the report is based mainl! on the re"uirements of
sections # and $ of the %uditor&'eneral %ct, 1(($ )%ct No. 1* of 1(($+ )%ct+.
1.* ,wing to time constraints an all&encompassing investigation was not conducted, nor
would it be practicable. However, sufficient auditing was done to provide sufficient
audit evidence for the findings contained in this report. The findings contained in this
report point out e-amples of the conse"uences of deficient management measures
as well as non&adherence to the applicable laws, regulations and procedures and
should not be regarded as comprehensive.
1.# .t is hoped that this report will give rise to corrective steps, which will contribute
constructivel! to the establishment and implementation of proper management
measures as well as adherence to the applicable laws, regulations and procedures in
the interests of the environment.
2. AUDITING CONCEPTS AND APPROACH
*.1 The primar! ob/ective of a sustainable development audit is to focus on activities that
ma! have an impact on the environment )air, water, soil, natural resources, fauna,
flora+ and humans.
*.* The audit focused mainl! on management and s!stem controls relating to waste
management. Section # of the 0nvironmental 1onservation %ct, 1(2( )%ct No. 3# of
1(2(+ refers to re"uirements to establish whether environmental polic! is being
complied with.
*.# The 0nvironment 1onservation %ct, 1(2( )%ct No. 3# of 1(2(+ mandates the 4inister
of 0nvironmental %ffairs and Tourism in terms of section *)1+ to determine the general
polic! to be applied with a view to5
)a+ the protection of ecological processes, natural s!stems and the natural beaut!
as well as the prevention of loss of biological diversit! in the natural
environment6
)b+ the promotion of sustainable utilisation of species and ecos!stems and the
effective application and re&use of natural resources6
)c+ the protection of the environment against disturbance, deterioration,
defacement, poisoning, pollution or destruction as a result of man&made
structures, installations, processes or products or human activities6 and
)d+ the establishment and maintenance of acceptable living environmental needs
of communities.
*.7 The 1onstitution determines in section *7 that, amongst others, ever!one has the
right&
8to an environment that is not harmful to their health or well&being6 and to have the
environment protected, for the benefit of present and future generations, through
reasonable legislative and other measures that&
)a+ prevent pollution and ecological degradation6
)b+ promote conservation6 and
)c+ secure ecologicall! sustainable development and use of natural resources
while promoting /ustifiable economic and social development.9
*.$ The 'reen Paper on a New 0nvironmental Polic! for South %frica was released for
comment during ,ctober 1((:. %ccording to the green paper, there was no
overarching environmental polic! that reflected the view of the new democratic
government. %s a result environmental concerns were not ade"uatel! ta;en into
account in man! important areas of polic! and government administration. .t also
states that government is accountable for the implementation of all aspects of
environmental polic!.
*.: The <hite Paper on 0nvironmental 4anagement Polic! for South %frica )white
paper+ was published on *2 =ul! 1((3. .t contains, amongst others, the following
provisions, which are particularl! relevant to the financial reporting aspects of
environmental auditing5
*.:.1 8Full cost accounting5 Decisions must be based on an assessment of the full social
and environmental costs and benefits of policies, plans, programs, pro/ects and
activities that impact on the environment.9
*.:.* 8Polluter pa!s5 Those responsible for environmental damage must pa! the repair
costs both to the environment and human health, and the costs of preventative
measures to reduce or prevent further pollution and environmental damage.9
*.:.# 8To report periodicall! on the state of the South %frican environment5
)a+ To provide accurate, timel! and accessible information about the condition and
prospects of the South %frican environment.
)b+ To increase public understanding of these issues.
)c+ To report on the effectiveness of policies and programs designed to respond to
environmental change, including progress towards achieving environmental
standards and targets.9
*.3 .t is not the %uditor&'eneral>s function to "uestion polic!. .t is, however, his
responsibilit! to investigate the effect of polic! and the management measures that
lead to polic! decisions.
3. SCOPE
#.1 The audit carried out at the department focused on s!stems and processes to
establish if reasonable measures were put in place )refer to section *2 of the
National 0nvironmental 4anagement %ct, 1((2 )%ct No.1?3 of 1((2++ regarding
medical waste @ handling, transportation and disposal. The following was specificall!
covered5
)a+ Documentation review5 0valuating the management process in terms of the
e-istence of policies, standard wor;ing procedures, and resources, monitoring
and control6
)b+ Ph!sical inspection5 To establish the e-tent of compliance with the applicable
legislation6
)c+ Disposal of e-pired medicine5 To focus on the procurement process and
disposal thereof6
)d+ Process and control measures5 Should be put in place to mitigate an! impact
on or harm to the environment andAor humans.
#.* 0nvironmental law is a vast group of legal norms put together and forms an integral
part of the management process. %n! legal principle, which relates to environmental
management, whether directl! or indirectl!, or which has an actual or potential impact
on the environment, should fall within the purview of environmental law. The most
appropriate legislation relating to the aspects and impacts identified during planning
and e-ecution of the audit was considered. egislation and other legal provisions
considered, include5
& 1onstitution of South %frica, 1((: )%ct No. 1?3 of 1((:+
& National 0nvironmental 4anagement %ct, 1((2 )%ct No. 1?3 of 1((2+
& 0nvironmental 1onservation %ct, 1(2( )%ct No. 3# of 1(2(+
& ,ccupational Health and Safet! %ct, 1((# )%ct No. 2$ of 1((#+
& 4edicines and Belated Substances 1ontrol %mendment %ct, 1((3 )%ct No. (?
of 1((3+
& HaCardous Substances %ct, 1(3# )%ct No. 1$ of 1(3#+
& Health %ct, 1(33 )%ct No. :# of 1(33+
& 1ompensation for ,ccupational .n/uries and Diseases %ct, 1((# )%ct No. 1#?
of 1((#+
#.# The environmental audit was conducted in accordance with generall! accepted
government auditing standards as well as the internal guidelines for the planning,
e-ecution, reporting and follow&up of performance audits. .NT,S%.>s D'uidelines on
1onducting %udits of %ctivities with an 0nvironmental PerspectiveD too; account of
environmental issues in regularit!, performance and compliance auditing. Paragraph
*1? of the said guideline classifies performance audit with an environmental focus as
one of the following five specific t!pes, namel!5
& %udits of government monitoring of compliance with environmental laws6
& %udits of the performance of government environmental programmes6
& %udits of the environmental impact of other government programmes6
& %udits of environmental management s!stems6
& 0valuations of proposed environmental policies and programmes
#.7 The S%%S Statement, DThe 1onsideration of 0nvironmental 4atters in the %udit of
Financial Statements9 )S%%S *$?1+, provides guidance to the audit team to enable
them to establish whether the reporting entit! had appropriatel! recognised, valued
and reported environmental costs, liabilities )including contingent liabilities+ and
assets. ,nl! if, in the auditor>s /udgement, environmental matters ma! have a
material effect on the financial statements of an entit!, should significant policies and
procedures in respect to its monitoring of, and control over these environmental
matters be ta;en into account in order to plan and develop an effective audit
approach. .t is believed that the report that will be derived from an
environmentalAperformance audit will assist the regularit! auditor in hisAher
consideration of environmental matters in the auditing of financial statements.
4. OVERVIEW
7.1 %s mentioned above, the handling and disposal of medical waste is of importance to
staff at hospitals and the public. Staff at hospitals do not wish to handle medical
waste more than once or to dispose the waste in unsafe containers where used
needles could pric; them. This ris; lin;s more closel! to occupational health and
safet! issues. ,n the other hand, the public does not wish to find medicalAinfectious
waste on general landfill sites, or used needles penetrating plastic refuse bags and
in/uring the municipal waste removers.
The above&mentioned issues could all result in severe harm to public servants and
the public. 4edical waste generall! contains blood, human tissue, materials that are
covered with blood or other bod! fluids and sharps. .f these infectious contents are
disposed of at a landfill site it could have a potential or actual impact on the water
andAor soil. This theme slot in with the definition of 8environment9 as indicated in the
National 0nvironmental 4anagement %ct. The term 8environment9 is namel! defined
ver! broadl! in terms of current statutes, and includes not onl! the natural
environment and the impact on ecos!stems, fauna and flora, and natural resources,
but also the environment and human health, safet! and welfare. )See section 1 of the
National 0nvironmental 4anagement %ct, No. 1?3 of 1((2 and section 1 of the
0nvironment 1onservation %ct, No. 3# of 1(2(.+
7.* Pollution is in turn defined broadl!. The National 0nvironmental 4anagement %ct for
instance defines it as involving an! change to the environment caused b!
substances, radioactive or other waves, noise, odours, heat or dust emitted from an!
activit!, including storage or treatment of waste or substances, construction and the
provision of services. This change must have had an adverse effect on human health
or well being or on ecos!stems, or on materials useful to people, or have such an
effect in future )section 1)1+)--iv++. Note that there is a separate statutor! definition
for water pollution in the National <ater %ct, No. #: of 1((2.
5. EY FINDINGS AS WELL AS COMMENTS OF THE ACCOUNTING OFFICER AND
CORRECTIVE STEPS ENVISAGED BY HIM
5.1 N! "#$!"%& '#() *!" (+,"-,$. &)!$'/ No records could be submitted for medicine
stoc; and e-pired medicine at the National District Hospital in Eloemfontein. This
indicates a lac; of ade"uate andAor sufficient internal controls in respect of medicine
stoc; and e-pired medicine in the pharmac!, thus ma;ing it impossible to establish
the nature and e-tent of e-pired pharmaceutical stoc; being ;ept in the pharmac! at
the National District Hospital.
M,0,1#-#0) $!--#0)/ %t the beginning of ,ctober *??*, the pharmacist at the
hospital implemented the bin cards )rac; cards+ s!stem, in order to control and ;eep
record of the amount of medicine received and issued from the medicine store.
%lthough she did not ;now of an! record that should be ;ept for the e-pired stoc;, a
file has been opened to ;eep record of e-pired medicine in future and the e-pired
medicine will be ;ept separate from the other stoc; and reported upon on an annual
basis.
5.2 I023". !0 %3). "#14&)#"/ The in/ur! on dut! register has been scrutinised to view the
e-tent of needle pric; in/uries reported at the National District Hospital, but the nature
of an in/ur! was not recordedAindicated in the register. .t was thus not possible to
establish the nature of in/uries on dut! at the National District Hospital and the e-tent
of certain t!pes of in/uries.
M,0,1#-#0) $!--#0)/ %n additional column will immediatel! be added on the
in/ur! on dut! )..,.D+ register, for the inclusion of details in respect of the t!pe and
e-tent in/uries sustained.
5.3 T",40401/ No official action plan or programme e-ists for the formal training of staff
with regard to environmental issues, health haCards and occupational health and
safet! issues. No evidence could also be obtained to establish if training needs with
regard to the said issues were assessed at the institution.
.nsufficient training could lead to5
)a+ Personnel are not alwa!s being aware of legal and safet! re"uirements, which
could lead to in/uries and possible claims.
)b+ .n/uries and possible claims against the department.
)c+ .nade"uate levels of technical and environmental e-pertise at the institution.
M,0,1#-#0) $!--#0)/ %ccording to the training official training needs have been
identified and nomination were made and sent through to Personnel Development
but response has not been received. The nominees will then be responsible for
training the other personnel in respect of health and safet! at the hospital )on the /ob
training+.
5.4 E5,63,)4!0 !* $!-(64,0$# 74)+ #054"!0-#0),6 6#14&6,)4!0/ No provision has been
made in the medical waste action plan for the National District Hospital to evaluate
the institution>s compliance with the environmental legislation and regulations to
prevent an! form of non&compliance with legislation in this regard.
M,0,1#-#0) $!--#0)/ Nursing management has been re"uested to liaise with the
environmental officer at the hospital )National+ to organiCe a wor;shop, with a view of
implementing a s!stem that will monitor and evaluate the institution>s compliance to
environmental legislation and regulations.
5.5 G#0#",)!" !* 7,&)#/
)a+ The National District Hospital does not alwa!s have direct access to a
database regarding applicable legislation, regulations and procedures relating
to the control, pac;aging and disposal of medical waste and other
environmental legislation, thus ma;ing it impossible for all potential role
pla!ers in respect of environmental issues to have access to applicable
legislation. .t was further noted that the department was not in all instances
aware that the! retain the ultimate responsibilit! for ensuring that waste is
handled, stored, transported and disposed of in an environmentall! sound and
responsible manner.
)b+ .t was noted that a private firm is utilised to remove medical waste from the
National District Hospital. No documentation of assessment could, however,
be obtained to establish if the National District Hospital ensured that the
private firm complies with environmental legislation before ma;ing use of their
services. %lthough a private firm removes the medical waste the responsibilit!
for compliance with environmental legislation remains with the originator of
medical waste.
)c+ No control register e-ists for the collection of medical waste b! the private firm.
.t could therefore not be established whether follow&ups of outstanding waste
manifests were done and whether the copies of waste manifests were alwa!s
returned to the point of origin once the waste had been disposed of at a
suitable permitted facilit!. This, inter alia, increased the ris; that manifests
could be misplaced.
M,0,1#-#0) $!--#0)/ 4anagement has tas;ed an official to obtain the 1Ds and
hardcopies of the relevant legislation from the Department of <ater %ffairs, the
official responsible for maintenance and casualt! department over the wee;ends has
been assigned to contact other areas utiliCing the same waste management firm.
% register will be implemented for the different t!pes of medical waste that is being
removed from the institution and the monthl! infection control reports will include the
report of inspections performed to monitor compliance, including compliance b! the
private firm.
No historical investigation of the private firm was performed, as the National Hospital
does not have the capabilities to conduct such an investigation. However, the private
firm responsible for the removal of medical waste at the National Hospital complies
with legislation for waste removal.
5.8 S#(,",)4!0 !* -#%4$,6 ,0% -304$4(,6 7,&)#/ .t was noted during a visit to the
National District Hospital that medical waste was mi-ed with other household
)municipal+ waste and that the access to medical waste was not restricted. The
following shortcomingsAdeficiencies identified, could give rise to various ris;s,
namel!5
& 4edical waste )red bags and sharps containers+ is being stored in an
unrestricted area. The area is accessible to passers&b! and could lead to
serious health haCards and potential legal claims against the department.
& %sh from the incinerator has been stored in metal containers in an unrestricted
area since November *??*. This ash cannot be disposed of in the Free State
Province and has to be transported to one of the two approved waste disposal
sites in South %frica. The metal containers are accessible to passers&b!, while
the ash in the metal containers can be regarded as haCardous. .t was noted
that a crFche is situated within wal;ing distance of these metal containers and
medical waste. The possibilit! of children coming into contact with the medical
waste and incinerator ash cannot be ruled out since medical waste, sharps
and incinerator ash are not being ;ept in a restricted area as re"uired. This
state of affairs could lead to serious health in/uries and liabilit! claims against
the department.
- .nspection of household refuse bags revealed that medical waste is in certain
instances placed in blac; refuse bags that are reserved for household waste
onl!. The grading of the 4angaung ocal 4unicipalit! landfill site does not
allow for disposal of medical waste.
%ccording to a letter from the 4angaung ocal 4unicipalit! dated *( 4a! *??* the
management of the National District Hospital were informed that medical waste was
found in refuse bags for household waste during a visit to the hospital. The hospital
was also informed that the removal of household waste would be suspended until the
situation had been rectified. This had the implication that household waste would also
have to be removed b! the firm responsible for the removal of the medical waste at a
higher cost. This situation has not been rectified to date and the municipalit! has not
!et resumed the tas; of removing household waste.
M,0,1#-#0) $!--#0)/ The head of administration has been instructed to inform
the maintenance section to clear rooms at a building not in use. The rooms will be
used for storing red&bags and sharps container and loc;s will be provided.
Guotations will be obtained as well to fence a certain area for blac; household bags.
The "uotations from the two ash disposal sites in the countr! have been re"uested to
dispose of ash ;ept at the hospital grounds, the process commenced in %pril *??#
alread! but no response has been received to date. The ashes will be removed as
soon as the "uotation process has been finaliCed and the head of administration will
give monthl! feedbac; on the progress.
Household wastes will as from the beginning of =une *??# be placed in transparent
bags, and the entire medical waste the bags will be incinerated.
5.9 E054"!0-#0),6 (!64$./ Section *2 of the National 0nvironmental 4anagement %ct,
1((2 )%ct No. 1?3 of 1((2+ sets a re"uirement that an environmental management
s!stem, based on the principles of .S, 17??1, should be implemented b! institutions.
To date, no departmental environmental polic! which inter alia ma;es provision for an
environmental management s!stem has been formulated and implemented at the
National District Hospital. Thus there is no ade"uate polic! in place to address
following environmental issues5
& prevention of pollution6
& promotion of sustainable development6 and
& compliance with environmental legislation.
<ith no proper environmental management s!stem in place and a general lac; of
capacit! in the management of health care waste on the establishment of the
National District Hospital, compounded b! limited financial and personnel resources,
the enforcement of current legislation, regulations and procedures is, at best,
reactive and not proactive.
%n environmental information s!stem, based upon re"uirements b! regulators or the
hospital>s own evaluation of environmental ris;s, was not maintained and the
following could not be obtained5
& reports issued b! and correspondence with regulator! and enforcement
agencies6
- reports issued b! environmental e-perts about the hospital, such as site
assessments or environmental impact studies.
M,0,1#-#0) $!--#0)/ There is no structure in the staff establishment at National
to implement environmental management s!stem. Nursing management has been
instructed to re"uest the environmental officer to conduct a wor;shop on s!stems that
should be in place and how the! should be implemented. The recommended
structure after the wor;shop will be forwarded to the H,D for implementation.
5.: L#1,6 $!5#",1# ,1,40&) $6,4-&/ No polic! documentation regarding emplo!ee
claims in respect of occupational in/uries and disease could be obtained and it is not
clear in which manner emplo!ee claims are being handled in this regard.
M,0,1#-#0) $!--#0)/ There are no procedures available at the National Hospital,
this matter has been forwarded to the provincial health and safet! unit to give
necessar! proceduresAguidance and should there be no response b! the end of =une
*??#, the legal unit in the H,D>s office will be contacted.
5.; O"1,04&,)4!0,6 &)"3$)3"#/ The organisational structure of the National District
Hospital was obtained and it was noted that no provision had been made for the
environmental positions, with the result that no individuals were identified for
environmental control functions and duties.
The waste management action plan indicates certain actions to be performed b!
different ran; groups to achieve the set ob/ectives in the action plan. However, none
of the dut! sheets obtained, indicates the actions to be performed in terms of the
plan. .t is therefore doubtful if the waste management plan has !et been
implemented, although it was signed on 1? September *??*.
No dut! sheet could be obtained for a refuse department manager, and no such
position was noted in the organisational structure. .t is therefore not clear which
official will be responsible for the performance of the tas;s allocated to the refuse
department manager in the waste management plan.
M,0,1#-#0) $!--#0)/ Befer to comments made on point no. $.2 above.
5.10 I0$40#",)!" ,) )+# N,)4!0,6 D4&)"4$) H!&(4),6/ The incinerator at the National District
Hospital had been in use until appro-imatel! November *??*. No certificate for the
operation of the incinerator at the National District Hospital as re"uired b! section (
of the %tmospheric Pollution Prevention %ct, No. 7$ of 1(:$ could be obtained. %
letter dated 1* 4arch *??1, issued b! the Department of 0nvironmental %ffairs and
Tourism, was obtained from the 4angaung 4unicipalit! indicating that the incinerator
at the National District Hospital did not compl! with all set standards of the
%tmospheric Pollution Prevention %ct No. 7$ of 1(:$. Nevertheless the incinerator
was utilised until appro-imatel! November *??*.
The dut! sheet of the operator of the incinerator during *??* was obtained and
scrutinised. The dut! sheet does not indicate that the official has been appointed to
perform an! tas;s regarding the incineration of medical waste. The facts that the
operator of the incinerator was not appointed in writing to perform such a tas;6 the
incinerator did not compl! with all set standards6 and no certificate to operate the
incinerator at the National District Hospital could be obtained could lead to liabilit!
claims, should the official contract an! disease that could be related to the duties
performed in the incineration process. .t was however not possible to establish if the
official wore all the necessar! protective e"uipment and clothing during incineration
since the incinerator had been damaged and had not been in use since November
*??*.
M,0,1#-#0) $!--#0)/ The use of the incinerator has been discontinued and
should there be a need for the National Hospital to use the incinerator, the above
mentioned recommendations will be implemented.
5.11I66#1,6 %3-(401/ .t was observed that waste was dumped appro-imatel! 1?? metres
from the medical waste collection point. %ccording to section *? )1+ of the
0nvironment 1onservation %ct No. 3# of 1(2( no person shall establish, provide or
operate an! disposal site without a permit issued b! the 4inister of <ater %ffairs. No
such permit for this dumping areaAsite could be obtained and it is therefore regarded
as an illegal dumping site. 0mpt! chemical bottlesAcontainers were also noted in this
dumping area.
0mpt! chemical bottlesAcontainers were also noted at the bac; of the pharmac! and
this is also regarded as illegal dumping since these bottlesAcontainers are regarded
as haCardous waste and should be disposed of as such. The necessar! permit for
this dumping areaAsite could also not be obtained and the area is therefore also
regarded as an illegal dumping site.
M,0,1#-#0) $!--#0)/ The garden service has been instructed to remove the
waste dumped on the hospital grounds and ensure that the empt! chemical bottles
are sent for re&c!cling. These bottles have been standing in the area for more than
*? !ears, the "uotation process will be followed to remove these chemical bottles.
8. APPRECIATION
. would li;e to e-press m! appreciation of the courtes! e-tended and assistance
rendered b! the staff of the Department of Health during the audit.
E.=.H. van Nie;er;
for: %uditor&'eneral
Eloemfontein
** =ul! *??#

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