Edition 65
Reverse Logistics of Dangerous Chemical Waste in São Paulo Hospitals
by Orlando Cattini Junior Vital de Oliveira Ribeiro Filho, Professor, EAESP/FGV

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In this article we relate how some hospitals, in São Paulo city, handle the dangerous chemical waste generated by their diagnostics process.

••1. The Problem/••
The 3PSP services in Health is growing in production’s volume and mainly in its complexity and diversity. The Hospital assistance develops in an environment with many pressures about technical evolution and quality and diversity of the services as well – increase of medical specialties, diagnostics methods, procedures, etc. There are challenges in the ventures in health area, difficulties with structure as the competitiveness of the markets and the reduction of the profits that affects private hospitals, while the public hospitals face problems with low money.

In this article we relate how some hospitals, in São Paulo city, handle the dangerous chemical waste generated by their diagnostics process. Our goal is discuss in which models and management process of the supply chain and, in a special way, the Reverse Logistics. How they are improving their process of waste management and reduction of costs, as well as converting in environmental marketing and following legal requirements. Even recognizing that the use of Reverse Logistics in Brazil is one small practice structured and sometimes informal, we consider that some studies have highlighted the advantages of a systemic approach, where the generation of waste, in any part of the chain, is understood as part of the production process.

Analyzing the management waste plans of 20 hospitals in São Paulo, we notice that only six of them demonstrate the proper types of dangerous chemical waste generated by them. On the contrary what happens with the usual RSS (Waste of Health services), every type of chemical waste has been originated from one specific process, considering the chain of products and services involved in its generation; as an example: waste of radiology sector, pharmacy or clinical analysis laboratory. Our goal in this article is not to deepen the analysis of each one of these chains, but to discuss general aspects of the management as health chemical waste, with emphasis in the perspective and conditioning of the supply chain and reverse logistics as tools that make possible solutions to reduce the costs and environmental impacts and contributes to make the production and consumption more sustainable in the hospital sector.



2. Rating and Risks of Waste in Health Services
The Hospital Assistance is an active potential polluter in many ways. However, the solid waste generated in the hospitals and other similar establishments, have been highlighted by environmental authorities, motivating the creation of specifics regulations as resolutions of (“National Council of Environment”) National Sanitary Surveillance (RDC 33/2003). Although these conclusions prioritizes the regulation of infectious waste, specifically in health services, the deepen of studies to classify RSS (Waste of health services) highlights the importance of another group within it: the ones who offer risks in chemical nature. Although generated in less quantity, the RSS (Waste of health services) represents more risks to the environment.

The solid waste generated by health services was grouped following their own regulation and they are called RSS – Health Services Waste.

The quantity of waste is generated in variable quantities because of the complexity of the developed process in the health area and as the activities made in the hospitals as well. Although, it reflects the composition of waste in quality and quantity and it depends on the technology and resources available. In this way the same product or service can involve the generation of different kinds of waste following the production way, the technology and material used on it as an example: if the process is realized manually or automatically, it uses disposables or reusable or if the technology used is older or not.

The main criteria used in the classifications is the type of risk that each group represents. There is (in a simple way) 4 main groups of RSS(Health Services Waste):

Group A (GA) Infectious Waste
Group B(GB) Chemical Waste
Group C(GC) Radioactive
Group D(GD) Common Waste

The first three are waste that requires specials care and the 4th follows recommendations equivalent as waste domiciles. According to the framing of the waste in a risk group will be definied the security measures in their handling and the alternatives treatments and final disposal and legally accepted

The waste GB – Chemicals - are certainly that ones that present more of a diversity of risks. Included in this group are toxic waste, inflammable waste, reactive or explosives and chemical waste. The toxic wastes have a big potential of environmental contamination involving loss for the human health and other animals. The inflammable, reactive or explosives further the environmental risks; they require more care to prevent accidents in the stockpiling and transportation. As medicines expire, the main risk is their inappropriate use, involving illegal commercialization. In some cases as chemotherapy can show, offers risks in their handling and environmental contamination.

3. Rules of Reverse Logistics
The Reverse Logistics is considered by many people only one resource to return goods to the manufacturers in recalls or because of warranty defects. Another mode of reverse logistics has been the return of the packages or recipients returns when reverse logistics offers an economic option.
None of these traditional enforcements search for better sustainability in the production process or consumer process.

The Reverse Logistics Association (http://www.rla.org/), one association without profit funds that congregates professionals and professors in the industry and has the mission to educate and inform RL professionals around the world, and all industries, about the reverse logistics process, defines Reverse Logistics and all activities associated with a product/service after the point of sale, the ultimate goal to optimize or make more efficient aftermarket activity, thus saving money and environmental resources.

Based on this vision, we can identify the following activities as part of Reverse Logistics scope:
1) Goods returns processing because of damages, seasonality, recall and so on
2) Recycling of materials and packages
3) Repair and remanufacturing or product’s renovation
4) Disposal of obsolete equipments
5) Dangerous or Hazardous products program
6) Recovery of assets

Figure 1, there is the relation of activities and processes in Reverse Logistics:



4. Analysis of the situation
There are no indicators that have an evaluation of the environmental impacts by the RSS and there are some difficulties to development studies about the problems generated by management the RSS (in its generation, transportation and final disposal stages)

Between April of 1999 to November 2001 , the Environmental Secretary of São Paulo City developed one pilot project with the implementation of the PGRSS (Plan of Waste Health Services Management) that involves about 20 hospitals. This project was supported by the law SMA 102/99, created specifically to define the criteria of the PGRSS((Plan of Waste Health Services Management).

The first group was defined by aiming the acquisition of one example of generation conditions in RSS ((Waste of health services) in hospitals in São Paulo City. For the composition of these groups, 12 hospitals had been selected (middle public and middle private). Each of these were chosen at random, within a list of all the city hospitals. Two of them in any size (small, medium and big ports) based on the number of beds.

One second group of 8 hospitals were chosen to present the PGRSS (Plan of Waste Health Services Management) due to denounces or complaints shown by the Cleaner Department of São Paulo’s municipality (PMSP).

Conforme podemos observar na Tabela 1, a amostra analisada abrange 10,75% dos 186 hospitais em operação na Cidade de São Paulo e cerca de 26,43% dos leitos disponíveis.

Table 1, the example analyzed covers 10.75% of 186 hospitals in São Paulo’s City and about 26.43% of the disposable hospital beds.



The names, localization, and other information that shows the hospital’s identification was omitted.

To facilitate the reality of this study, the Chemical RSS was divided into four subgroups.

The simplified classifications adopted was developed based on the Technical Regulation proposed by RDC 33/2003 of Anvisa (Anvisa, 2003) that originally adopts 8 subgroups. We should consider that the Anvisa resolution was not publicized yet in the time that the assessed made their PGRSS ((Plan of waste health services management). The classification that we used are presented in the table 3 :

Results
Table 4 presents the distribution of the units as the level that they were classified. By the column that presents the average proportion of chemical waste in the total RSS generated, we can see that the units where the group B was identified, the average involvement of chemical waste was higher. The results strengthen the hypothesis of the hospitals that have not included in their PGRSS systems as identification, as : waste inventory, process generator and procedures or rules tends to register smaller quantities of chemical waste or even nothing in this category (although they realize the same process as the others). Without the identification this kind of waste are classified as common waste or infectious and they will receive the wrong destination in the cleaner urban system or in not legal landfills.

The technological development in production of goods or services generated one deadlock that today represents a challenge for sustainability and to the overcoming of serious environmental and social problems. One of the more serious aspects of these questions is the growing of environmental contamination levels by chemical products widespread for all the planet mainly in the water, soil and air by the releasing of effluents and emissions or disposal of toxics waste. Reverse this strong aggravation tendency requires effort of the mobilization of the production sectors, governs the society to find solutions that involves behavior, changing values and priorities.
The examples that we discuss suggests deficiencies in the management of RSS in the hospitals despite many other questions referring to the management of materials and processes that already exists even in the embryonic form. This is the beginning of the development of new logistics flows – Reverse Logistics Chain and recycling of the waste . Involving manufacturers and suppliers with their responsibilities and solutions
On the other hand, a clear part of this changing passed directly because of economic or legal pressures and are limited by reactive attitudes. It also still depends on the increase in value of environmental aspects and dissemination of these values to the all society.

REFERENCES
• ANVISA – AGÊNCIA NACIONAL DE VIGILÂNCIA SANITÁRIA. Resolução da Diretoria Colegiada RDC 33 de 25/2/2003 – Regulamento Técnico para Gerenciamento de Resíduos de Serviços de Saúde. Brasília, 2003.
• CONAMA – CONSELHO NACIONAL DE MEIO AMBIENTE – MINISTÉRIO DO MEIO AMBIENTE. Resolução 05 de 5/8/1993. Brasília, 1993.
• CONAMA 2001 – CONSELHO NACIONAL DE MEIO AMBIENTE – MINISTÉRIO DO MEIO AMBIENTE. Resolução 283/2001. Brasília, 2001.
Orlando Cattini Junior is Professor of Production and Operation Management Department at Fundação Getúlio Vargas. Vital de Oliviera Ribeiro Filho hold a Masters in Management from Fundação Getúlio Vargas. Both of them worked together in this study and in obtaining the information given.
RLM
Orlando Cattini Junior is Professor of Production and Operation Management Department at Fundação Getúlio Vargas. Vital de Oliviera Ribeiro Filho hold a Masters in Management from Fundação Getúlio Vargas. Both of them worked together in this study and in obtaining the information given.

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