Needles in the Haystack: Biomedical Waste in Small-Town India

New hospitals, diagnostic centers, and clinics have been opening up at a frantic pace in India’s small cities. The Indian healthcare market is projected to reach $638 billion by 2025 and the Indian diagnostics industry is projected to reach $25 billion by FY28, up from $13 billion in FY23. Many health-tech organizations have shown focus in opening up clinics in small town India. In 2022, Delhi based health-tech startup My Family First shared their plans to open up 500 Digitally Enabled Smart Health (DESH) clinics in remote Indian villages and towns. By then, they had already opened up 30 DESH clinics across Uttar Pradesh, Madhya Pradesh and Jharkhand. Amidst this expansion, biomedical waste is piling up, untreated, unmanaged, and dangerously exposed to the environment.
It hasn’t been making national headlines or causing immediate outrage! But chances are that you may have seen such sights firsthand - discarded syringes, blood-stained gauze, expired medicines, and used IV tubes lying in the open. There are places where these are sometimes found next to grazing cows or scavenging dogs. In some places, rain washes the waste into nearby drains, spreading contamination through groundwater and local water bodies.

Is Biomedical Waste Just Another Garbage Pile?

Metro cities have been trying to create structured systems—incinerators, waste treatment facilities, color-coded bins, strict monitoring. But move beyond the metros, and the story changes. Around 80-85% of medical waste is non-hazardous, and only 15% is hazardous. However, owing to improper segregation and mixing the entire waste can turn into hazardous materials. 

In many cities, such waste doesn’t just disappear. It moves through invisible pathways, seeping into everyday life. In many small towns, rain washes exposed biomedical waste into local rivers, ponds, and groundwater. These same water sources may be used for drinking, bathing, and irrigation. Stray dogs, cows, and rats roam around open waste disposal sites, feeding on biomedical trash. Infected needles and bandages enter their system. Some of this waste re-enters the supply chain. Sanitation workers, hospital janitors, ragpickers and kabadiwalas often unknowingly handle infected waste, extracting plastic and glass for resale and handle this waste daily, often without gloves, masks, or any protective equipment. A single needle-stick injury can transmit deadly diseases like Hepatitis B, Hepatitis C, or even HIV.

In Maharashtra, thirty Common Biomedical Waste Treatment Facilities (CBWTFs) were found contributing to pollution due to improper segregation of biomedical waste by healthcare facilities (HCFs) and hospitals. In Ambikapur, a medical college dumps its biomedical waste in the open, violating environmental and public health regulations. The waste becomes food for stray animals. In Hathras, biomedical waste litters the backyard of the district hospital. Syringes, IV drips, and expired medicines are tossed outside, where they mix with ordinary garbage. Some of it is picked up by ragpickers, unknowingly exposing them to deadly infections. The rest decomposes slowly, seeping toxins into the soil and water supply. 

Despite strict biomedical waste regulations, these stories repeat in small towns across the country. Hospitals are either too careless, too underfunded, or too overwhelmed to handle waste properly. Municipal corporations, struggling to manage even regular garbage collection, also don’t have an option but to turn a blind eye.

And so, the waste has been piling up. When you trace these pathways, a disturbing pattern emerges—biomedical waste doesn’t just affect the hospitals that generate it. It seeps into homes, markets, water supplies, and everyday life in small cities. 

Who Pays the (real) Price?

Biomedical waste management in India is governed by the Biomedical Waste Management Rules, 2016, which mandate strict segregation, collection, transportation, and treatment of medical waste. According to these rules, healthcare facilities (HCFs), including hospitals, clinics, blood banks, and veterinary institutions, must ensure that their waste is handed over to an authorized Common Biomedical Waste Treatment Facility (CBWTF). These treatment facilities are responsible for collecting, transporting, and scientifically disposing of the waste through incineration, chemical disinfection, or deep burial, depending on its nature. In 2023, Uttar Pradesh generated recorded biomedical waste(BMW) of 99,115 kg per day, the highest in the country. This waste was treated through 25 operational Common Biomedical Waste Treatment Facilities (CBWTFs). 

Healthcare providers are required to pay waste disposal fees to these CBWTFs, which vary based on location and facility size. For example, in Delhi, HCFs/ Clinics which are non-bedded have to pay a one-time fee of Rs. 5000. Similarly in Chandigarh, clinics, pathological laboratories, blood banks, veterinary institutions, dispensaries, animal houses have to pay a one-time fee of Rs. 5000. Both small and big cities in India have their own saga of biomedical waste disposal. In Bengaluru, many government hospitals are finding it hard to get their waste disposed of at reasonable rates. This is because of the less number of companies that run the common biomedical waste (BMW) treatment facilities in Bengaluru Urban and Rural districts. In 2021, a biomedical waste treatment plant was commissioned in Goa but even until early 2022, several private medical establishments had not availed the facility. Despite the facility, many clinics were disposing of their BMW unscientifically. The reasons behind the same were traced to dissatisfaction with the rates chargeable. A hospital with 30 beds had to previously pay ₹9.25 per bed per day, these prices were revised to ₹9.95 per bed per day. While general practitioners were charged ₹30 per day, dental clinics, diagnostic centres, laboratories, veterinary clinics, orthopaedic facilities were charged ₹60 per day. During the CoVID-19 pandemic, the costs had shot up to an all time high. While the cost prior was estimated to be ₹50 per kg, the price during the pandemic had tripled. The National Accreditation Board for Hospitals and Healthcare Providers (NABH) had found that smaller clinics, despite generating less waste, were paying higher sums to BMW companies. For CoVID waste upto 100kg, the disposal costs were as much as ₹11,500. In smaller cities private hospitals are refusing to pay ₹20 per bed for biomedical waste disposal, arguing that the same service costs only ₹6-7 per bed in larger cities. 

In such cases, hospitals may return to old disposal methods such as digging pits inside hospital premises and burning the waste. But the real cost isn’t paid by hospitals, it is paid by patients, sanitation workers, and the urban poor who live near these waste sites.

Why Small Cities Struggle More?

The rules for biomedical waste disposal are clear. The guidelines exist, the penalties are defined, and the responsibility is assigned. Yet, in India’s small cities, biomedical waste continues to find its way into drains, water bodies, open fields, and garbage dumps. Why does this happen? Why do small cities struggle to manage their medical waste safely?

One major reason is the lack of infrastructure. Unlike metro cities that have multiple facilities, Common Biomedical Waste Treatment Facilities (CBWTFs), many small towns have either none or just one for an entire district. Not only this, as of Aug 2024, 7 States/UTs in India did not have even one CBWTF. These included Andaman & Nicobar, Arunachal Pradesh, Ladakh, Lakshadweep, Mizoram, Nagaland, and Sikkim. This absence forces hospitals and clinics to look for alternatives which may be illegal and unsafe. A hospital generating infectious waste every single day cannot afford to store it indefinitely. When disposal is expensive or inaccessible, dumping becomes an easy way out. On the policy front, the Healthcare Waste Management Rules, 2016, mandate that all bedded healthcare facilities create a dedicated webpage to display key information, including their authorization under the BMW Rules, 2016, consent under the Water and Air Pollution Acts, and monthly records of biomedical waste generation. According to the guidelines, this information was to be made available on hospital websites by March 15, 2020. However, such transparency remains a rare sight.

Municipal corporations, already stretched thin with managing household and commercial waste, are not equipped to handle biomedical waste. Most local governments are still struggling with basic waste collection systems, grappling with overflowing garbage bins, understaffed sanitation teams, and unregulated landfills. The expectation that they will actively monitor and enforce biomedical waste rules, something that requires specialized knowledge, training, and infrastructure may be unrealistic. In Tirunelveli, burning of a large volume of biomedical, plastic and paper waste by Tirunelveli Medical College sparked outrage. Residents filed complaints demanding action. Even when violations are reported, action is difficult. 

The problem is not just limited to hospitals. The National Green Tribunal (NGT) has ruled against unauthorized waste treatment plants and illegal disposal sites, but enforcement remains weak. 

The Central Pollution Control Board (CPCB) has issued comprehensive guidelines, and penalties for non-compliance are well-defined. However, many healthcare facilities continue to flout these norms without facing significant consequences. For instance, in 2018, the Karnataka State Pollution Control Board identified 4,066 violations by healthcare establishments, leading to the issuance of show-cause notices. While penalties exist on paper, enforcement is often weak, allowing hospitals and clinics to evade accountability for improper waste management. 

As of 2019, the National Green Tribunal had directed all States and UTs to observe the bio-medical waste management or pay a fine of ₹ 1cr every month till the State/UT remains non-compliant. In Chennai, despite TNPCB’s directive even the registered biomedical facilities do not take waste from residences. Despite the directive of asking the public to collect hazardous waste (diapers, needles, sanitary napkins, etc.) separately, there is hardly any compliance on the ground. 

However, instances of violation remain common, such as the incident from Ambikapur where animals were seen feeding upon improperly disposed biomedical waste. 

Municipal corporations in such cities are also often overwhelmed, struggling to manage even regular waste collection. Expecting them to monitor specialized biomedical waste disposal is unrealistic without additional resources and training. This systemic inadequacy contributes to the persistent problem of improper biomedical waste management in India’s smaller cities.

Even when hospitals do have waste segregation systems—marked bins, separate bags, and designated disposal processes—these rules may break down in practice. Workers handling the waste mix everything together out of habit or ignorance. This means that carefully sorted waste still ends up in landfills or dumps, instead of being treated properly. These problems had furthered during CoVID-19. Private ambulances, NGOs, and other entities using PPEs often lacked partnerships with waste management centers. With access only to regular dustbins, biomedical waste was improperly disposed of in them. Even today, some hospitals have incinerators on-site, but the imperative question here is - Is the biomedical waste reaching them?

What can the future look like?

The crisis of biomedical waste in small cities is not inevitable. Other developing nations such as China and Vietnam have tackled similar issues with low-cost, high-impact solutions, and India can too. But solutions require more than just regulations, most importantly, a fundamental shift in how we perceive medical waste.

Decentralized waste treatment facilities can improve waste management in small cities. The current regulatory framework still prioritizes centralized facilities where available, potentially limiting the development of onsite or cluster-based solutions in those areas. Instead of relying on a single facility for an entire district, setting up localized, small-scale treatment plants can make disposal easier, cheaper, and more accessible for hospitals. Portable, automated waste sterilization machines like the ‘Srijanam’ rig recently introduced in AIIMS Delhi, with a scalable capacity of 10 kg/day (initial phase) to 400 kg/day (full scale) could be tailored to smaller healthcare centers, reducing reliance on centralized systems. As per studies, on an average, hospitals generate between half to 1 kg of waste per bed per day. So a 100-bed hospital in a small city will generate anywhere between 50-100 kg of medical waste per day, which the Srijanam rig could handle even at quarter of its full capacity. This flexibility can allow tier-2/3 cities to adopt modular systems that grow with their needs, from single clinics to district-level clusters, while avoiding the environmental hazards of incineration or open dumping. Vietnam offers a case of decentralised systems and its implementation of three distinct models for waste treatment demonstrates a flexibility that India could learn from. The healthcare waste regulations introduced three models of treatment and disposal: onsite treatment facility, treatment facility serving cluster of hospitals, and centralized treatment facility and accommodated different facility sizes and geographical contexts. While this information comes primarily from project completion report and their review, the reported outcomes regarding the infrastructure remain instructive: Vietnam's model encouraged better waste management practices, with monitoring data showing a 12% reduction in staff infections, 50% fewer patients requiring antibiotics due to hospital infections, and 95% positive feedback in community opinion polls.  

Financial incentives can also make a difference. If small hospitals struggle to afford waste disposal fees, the government can subsidize these costs. The Delhi government’s subsidy program supports bio-degradable waste-to-biofuel plants, offering 33.3% subsidies (up to ₹5 lakhs) for non-commercial institutions and 33% subsidies (up to ₹10 lakhs) for commercial setups. Such models could be replicated for biomedical waste management in small cities to alleviate costs for hospitals. Prof. Ashok K Agarwal, President of the Indian Society of Hospital Waste Management, highlights that many government hospitals struggle to afford Common Biomedical Waste Treatment Facility (CBWTF) fees due to insufficient budget allocations. Direct subsidies or earmarked funds for waste management could address this gap. 
Biomedical waste is not just the responsibility of Health Care Facilities. Addressing biomedical waste in India’s small cities is not just an environmental necessity, it’s a public health imperative. Without actionables, the invisible pathways of mismanaged medical waste will continue to seep into everyday life.