Development of Capacity

for the Substitution and

the Environmentally
Sound Management
(ESM) of Mercury-
Containing Medical
Measuring Devices

JAM LORENZO

POLICY DEVELOPMENT AND

RESEARCH | BAN TOXICS
Project Background • a Japan-ASEAN Integration Fund (JAIF)
project endorsed by the Association of
Southeast Asian Nations (ASEAN) Working
Group on Chemicals and Waste and the
ASEAN Senior Officials on the Environment.

• The project aims to contribute to the

prevention of the adverse health and
environmental impacts of mercury through
the environmentally sound management of
used thermometers and
sphygmomanometers in ASEAN Member
States.
Situation Analysis • Situation analysis and data gathering
about used thermometers and
for MCMMDs in the sphygmomanometers discarded by or
stored in large-size (number of beds)
Philippines health care facilities (both public and
private)
• Development or updating of an
inventory from the information
gathered
The national inventory covers licensed hospitals in the country as well as
clinics and other health care facilities (when necessary)
 Category Policy
Multilateral Environmental Agreements The Minamata Convention on Mercury

The Basel Convention on the Transboundary Movements of Hazardous

Background and Data Mercury Management

Wastes and Their Disposal

Department Administrative Order 2008-0021

Collection DAO 2019-20 (Revised CCO for Mercury and Mercury Compounds)

AO 2020-0020 (Guidelines on the Phase-Out of Mercury Use in Dental

Restorative Procedures

DENR Department Administrative Order 1997-38 (Chemical Control

• Desk Research
• Historical data (if available), and
related studies, reports, and news
articles
• Legislative framework for the
management of MCMMDs
Waste Management and Related Policies
Order for Mercury and Mercury Compounds)
Joint DENR-DOH AO 2005-02 (Policies and Guidelines on the Effective
and Proper Handling, Collection, Transport, Treatment, Storage, and
Disposal of Health Care Wastes)
RA 6969 (Toxic Substances and Hazardous and Nuclear Waste Control
Act of 1990) and DENR AO 1992-0029 (Implementing Rules and
Regulations (IRR) of RA 6969)
DAO 2013-22 (Revised Procedures and Standards for the Management
of Hazardous Wastes)

DM 2011-0145 (Guidelines for the Temporary Storage of Mercury

Wastes in Healthcare Facilities)

DOH Health Care Waste Management Manual

Department Memorandum 2017-0132 (Final Disposal of Temporarily

Stored On-Site Mercury Wastes and Mercury Containing Devices)

Quality Standards Philhealth revised accreditation policy for health care facilities
 Department/ Agency/Category

Department of Environment and

Bureau
Environmental Management Bureau
Section
Chemical Management Section (EMB)
Background and
Data Collection
Natural Resources
Hazardous Waste Management
Section (EMB)
EMB-DENR Regional Offices:
Region 1
Region 2

• Key Informant Interviews

Region 5
Region 7
Region 11

Department of Health Disease Prevention and Control Bureau

(DPCB)
Food and Drug Administration (FDA)
Department of Trade and Industry Bureau of Philippine Standards (BPS)

Public Hospitals East Avenue Medical Center

Jose R. Reyes Memorial Medical
Center
Amang Rodriguez Memorial Medical
Center
Temporary Storage and Disposal
Facilities
National Survey

• The national inventory covers licensed hospitals in the country as well as clinics and
other health care facilities (when necessary)

• Surveys were disseminated by the BAN Toxics Team, EMB Regional Offices, with
support from the DOH Field Implementation and Coordination Team

• 1,383 licensed hospitals – (National Health Facility Registry)

• 1,466 healthcare facilities in total received the surveys

National Survey Outline

• Administrative Order 2008-0021 Implementation

• Purchase History

• Storage, Use, and Disposal Practices

Discussion of Results
 R E S P ONDENT S T OT AL R E S P ONSE
R E GION C ON TAC TED R E S P ONSES RATE

National Capital Region (NCR) 215 215 100%

Cordillera Administrative Region (CAR) 45 14 31.1%

Region 1 58 24 41.38%

Region 2 53 23 43.4%

Region 3 146 54 36.9%

Region 4a 280 25 8.93%

Mimaropa 69 8 11.6%

Region 5 92 14 15.22%

Region 6 85 23 27.06%

Region 7 95 16 16.84%

Region 8 62 19 30.65%

National Region 9

Region 10
64

21
18

9
28.12%

42.86%

Inventory
Region 11 71 14 19.72%

Region 12 35 16 45.7%

Region 13 75 14 18.67%

Results Bangsamoro Autonomous Region in Muslim Mindanao N/A

(BARMM)

TOTAL 1,466
1

507
N/A

34.58%
National
Inventory Results
N = Population size
• Population size: 1,466
• Confidence Level = 95% e = Margin of error
• Margin of error = 5% z = z-score
• 305 target respondents,
• 529 total respondents, 507 processed
responses

• Key Issues Encountered

• Some hospitals could not be contacted for
validation (e.g., 4,000 mercury-containing
thermometers in 2020, etc.);
• Some hospitals submitted incomplete
survey forms
 HCF CLASSIFICATIONS - RESPONDENTS
Private Government

Respondent
Profile
78
58.93% of the respondents are
3
comprised of Hospitals (Level 1 to 3)

11

113
95 39
23
63
1

27 26 25

LEVEL 1 LEVEL 2 LEVEL 3 INFIRMARY BIRTHING CLINIC

HOME
AO 2008-0021
Implementation

ASSESSES
COMPLIANCE WITH
REQUIREMENTS LISTED
UNDER THE AO
AO 2008-0021
Implementation
Question: Has your hospital implemented a phase-out of
mercury-containing devices?

Valid Cumulative
- 316 facilities (with a valid percentage of 63.1%) indicated
Frequency Percent Percent Percent
that they have implemented a phase out of mercury-
containing devices. Valid Yes 316 62.3 63.1 63.1
- However, this may not be reflective of the actual No 185 36.5 36.9 100.0
percentage of hospitals that do not use mercury-
containing devices:
Total 501 98.8 100.0
- Marikina Valley Medical Center have informed us Missing System 6 1.2
that their records were lost due to calamities in
the area Total 507 100.0
- Hospitals established after AO 2008-0021 would
not have needed to implement a phase-out
AO 2008-0021
Implementation Question: Do you have a Mercury Minimization Program?

Valid Cumulative
Frequency Percent Percent Percent
88.2% of the valid responses have Valid Yes 59 11.6 11.8 11.8
indicated that there are no current No 441 87.0 88.2 100.0
mercury minimization programs Total 500 98.6 100.0
(MMPs) in their facilities Missing System 7 1.4
Total 507 100.0
 Question: Does your hospital have the following?

Yes No Percentage of “Yes”

Responses
Policy on collection and retrieval of used/discarded mercury-containing 99 401 19.8
thermometers and sphygmomanometers

Policy on collection and retrieval of used/discarded mercury-containing 122 377 24.4

devices (lamps, dental amalgam, batteries, etc.)

Policy on the temporary storage of mercury-containing thermometers and 98 400 19.7

sphygmomanometers

Policy on the temporary storage of other mercury-containing devices 130 368 26.1

Policy and Guidelines on the management of mercury spills 109 389 21.9

Policy and Guidelines on the final disposal of MCMMDs 90 408 18.1

Policy/Program on financing mercury management activities 46 449 9.3

Purchasing policy for mercury-free alternatives 124 376 24.8

Mercury Content Disclosure Agreement with hospital equipment suppliers 44 455 8.8

AO 2008-0021
The conduct of Mercury Audits 57 444 11.4

The conduct of Mercury Monitoring 102 389 20.8

Implementation
The storage and keeping of Permanent Records 55 433 11.3
 • What are the factors contributing to low “yes”
response rates for mercury management
policies at the HCF levels?
• Potential Scenarios

Key Questions • The phaseout has been successful and these

policies are not needed due to the lack of
on MCMMDs in hospitals
The policies have not been implemented well
Implementation
•

• Validation through data

of AO 2008- • Use and purchase history

0021 • Storage and disposal

 Presents
inventory data on
MCMMDs

Purchase, Use, Data presented

can be used to
and Storage answer key
questions arising
Data from the
previous section
 Mercury-Containing Medical Measuring Devices – Purchase Data
Year Thermometers Desk-type Standing
(40 HCFs) Sphygmomanometers Sphygmomanometers
(18 HCFs) (20 HCFs)

2010 2647 165 66

2011 1577 151 57

2012 535 152 67

2013 313 186 45

2014 286 27 56

2015 80 34 23

2016 45 29 69

Purchase Data 2017

2018
25

26
22

28
35

33

- MCMMDs 2019

2020
26

50
22

26
23

43

Total Units 5,610 842 517

Purchased
Use and Storage Mercury-Containing Thermometers

Data
No. of Facilities Quantity Total
(6)

Mercury-containing Thermometers in 3 1 3

(Thermometers)
Use 1 2 2
1 3 3
1 20 20

TOTAL 28

No. of Facilities Quantity Total

(5)

Mercury-Containing Thermometers in 1 2 2
Storage 1 7 7
1 11 11
1 14 14
1 15 15

TOTAL 49
 M E R C U RY - C ON TAI NI NG S P H Y GMOM A NOM E TE R S

No. of Facilities (7) Quantity Total

Mercury-containing Sphygmomanometers (Desk-Type) in Use 1 1 1

1 2 2

1 3 3

1 8 8

1 12 12

1 19 19

1 20 20
TOTAL UNITS 65

No. of Facilities (19) Quantity Total

Mercury-Containing Sphygmomanometers (Standing) in Use 3 1 3

5 2 10

1 3 3

3 5 15

1 8 8

1 10 10

Use and Storage Data 1

2
15

20
15

40

(Desk Sphygs.) 1

1
25

35
25

35
TOTAL UNITS 164
 Mercury-Containing Sphygmomanometers
Mercury-Containing Sphygmomanometers (Desk-Type) in Storage No. of Facilities (18) Quantity Total

2 1 2

2 2 4

3 3 9

2 4 8

1 6 6

1 7 7

1 8 8

1 17 17

1 20 20

1 25 25

1 38 38

Use and
1 52 52

1 83 83

TOTAL UNITS 279

Storage Data
Mercury-Containing Sphygmomanometers (Standing) in Storage No. of Facilities (14) Quantity Total

3 1 3

4 2 8

(Standing
1 11 11

1 5 5

1 8 8

Sphygs.)
1 10 10

1 3 3

1 4 4

1 9 9

TOTAL UNITS 61
Purchase Data – Mercury-Free Medical Measuring Devices – Purchase Data

Mercury-free Year Thermometers Desk-type

Sphygmomanometers
Standing
Sphygmomanometers

Alternatives 2010 59,592 945 450

2011 58,523 753 336

Data from 266 HCFs

2012 65,124 770 344
•
2013 75,955 888 426

• In 2020, reported purchases for 2014 79,645 982 476

2015 104,919 1,139 505
MCMMDs amount to 50 (Th), 26 2016 105,149 1,312 759

(Sp-D., and 43 (Sp-S.) 2017 134,716 1,511 644

2018 152,546 2,028 691
2019 150,469 1,934 763
2020 112,826 2,897 958
Total Units 1,099,464 15,159 8,352
Purchased
Trend Analysis – Mercury-
Free Alternatives

• From L – R
Thermometers
Desk Sphygs.
Standing Sphygs.
Conclusions – Use, Storage, and Purchase

• The phase-out of MCMMDs has been mostly successful

• Mercury-Containing Thermometers – 5% of HCFs in 2010, 1% of HCFs in 2020
• Mercury-Containing Sphygmomanometers – 4% of HCFs in 2010, 0.7% of HCFs in 2020
• The shift to alternatives is also rising based on trend analysis

• Key Question
• Where did all the MCMMDs go?
Disposal
Practices
 Disposal Data Availability Per Region
18

Disposal
16

14

Practices 12

10
46 HCFs were able to provide disposal
data 8

Disposal Data Availability Per Region

 Mercury-Containing Medical Measuring Devices – Disposal Data
Year Thermometers Desk-type Standing
Sphygmomanometers Sphygmomanometers

2010 3194 456 152

2011 748 310 142
2012 332 254 120
2013 220 264 98
2014 180 226 102
2015 734 270 78
2016 38 80 80
2017 26 22 60
2018 224 56 72

Disposal 2019
2020
Total Units
20
48
5764
30
30
1998
68
80
1052

Practices Disposed
 Question: What MCMMD disposal options are employed in your

Disposal Practices
facility?
Yes No No Percentage
Response of “Yes”
Responses
Temporary Storage 127 215 168 37.1%
Facility (In Hospital
• A point of concern for disposal is the significant Area)
percentage of HCFs that are disposing MCMMDs
through municipal waste and third-party buyers. Temporary Storage 44 295 168 13%
Facility (Outside of
Hospital Area)
• May increase the risk of releasing mercury into
the atmosphere through breakage during
Municipal Waste 65 274 168 19.2%
collection and/or storage and through improper
disposal methods.
Third-Party Buyers 33 303 171 9.8%

• Disposal of MCMMDs through third-party buyers DENR Accredited 168 173 166 49.3%
often leads to the illegal recycling of mercury for Facility
use in other sectors
Temporary Storage
and Disposal Facilities Region TSD
Facilities
Total Storage
Capacity (MT)
National Capital Region 7 1626
Region 1 3 117
• Identified gap: Region 3 17 4543
Region 4a 15 15271
Specific data from TSDs is
Region 7 8 1178
unavailable
Region 8 2 4
Mercury wastes are not segregated Region 2, 5, 6, 9, 10, 11, 12, 13, 0 N/A
MIMAROPA, CAR, and BARMM
based on type and source
TOTAL 52 22,739
 Key Challenge Notes
MCMMDs Data Availability There is a lack of data on MCMMDs with no data available
from concerned agencies such as the DENR, the DOH, and

Conclusions and
the DTI, among others.

The dependence on self-monitoring for HCFs also poses a

problem, as only total mercury waste is reported without

Recommendations
distinction if the waste comes from MCMMDs.

Lack of Access to Local TSD Facilities Lack of access to accredited TSD facilities. This is also
compounded by issues such as safe transport of waste
and transportation management.

Hospitals are also more likely to store their mercury-

containing wastes for long periods of time rather than to
contact transporters and treaters within the region

Difficulties of transporting waste to other regions within

the Philippines

Lack of Technical Knowledge on Waste Need for more training and knowledge sessions on
Management managing of MCMMDs,

Lack of training at the HCF-level regarding the risk

associated with mercury, which may lead to the lack of
capacity of staff to address mercury-related incidences.
Thank you!

Jam Lorenzo
Policy Development and Research