Photo: Tejendra Thapa for The German Agency for International Cooperation GIZ
Mahesh co-founded the Health Care Foundation Nepal (HECAF) in 1994. The organisation has since evolved into one of the leading providers of appropriate technology solutions for environmentally sound healthcare waste management systems in Nepal and other low-resource countries. In 2020 HECAF became the Health Environment and Climate Action Foundation (HECAF360).
The following comments from Mahesh were lifted from an interview conducted by The German Agency for International Cooperation, GIZ GmbH. The interview is featured in GIZ's comprehensive assessment of a growing movement to address health care waste in Nepal entitled NoTime to Waste. You can link to the full report here.
Mahesh Nakarmi, in his own words...
"I don’t like to copy what other people are doing. I like to work in the gaps where there are problems no one else has managed to solve. That’s how I got involved with healthcare waste management.
I was the first one to use autoclaves to treat healthcare waste in Nepal. That was in 1999, and it was a major milestone for public health in our country.
Our first autoclave-based programme was instituted at the National Kidney Center (NKC), which HECAF established to make dialysis services available to people in Nepal. NKC was clearly helping a lot of people, but one day I saw staff putting waste contaminated with blood into the municipal waste system.
I realised that, despite our good work and intentions, we were putting many people at risk through the waste we generated: community members, people living along the route used to transport waste to the municipal dump, those living near the dump, and the waste workers who are in the dump every day. I started researching our options and discovered that all the guidelines recommended incinerating healthcare waste. I’m not a medical person — I’m an engineer — but I was worried about the air pollution, toxic ash and gases that burning waste produces. After doing more research, I concluded that
autoclaving the waste would be a far better solution.
It took a while, but eventually I managed to get my hands on two autoclaves which were lying around, unused, somewhere outside Kathmandu. We brought them here, fixed them up, and started using one to disinfect medical waste and the other to disinfect equipment and instruments.
People thought I was crazy: “What’s this engineer doing, putting waste into an autoclave?” At some point, I stopped trying to convince other people, but I kept autoclaving NKC’s healthcare waste. I was sure it was the right thing to do.
In 2007, I was invited by the WHO to attend a big international meeting on healthcare waste management in Geneva. There, I met experts from Health Care Without Harm and other international organisations. They encouraged me to keep working and to share my method with other hospitals in Nepal. I tried. I was so passionate. I met with all the hospital directors in Kathmandu and even travelled to other cities in Nepal. No one listened. No one understood the issues. One hospital director even threw me out and told security not to let me back in!
Finally, in 2010, the director of Bir Hospital, Dr. Buland Thapa, called and said he’d heard had ideas about how to handle waste management differently. We agreed that I would set up and run a system there, based on the NKC model, free of cost.
I didn’t have any staff or money, but I got office space at the hospital, recruited a group of interns, and taught them what to do. Within one year, we’d made such a big change no one could believe it. When people are sick, they have to be diagnosed — through blood tests, X rays, or CT scans — before they can be treated. I do the same thing with hospitals:
My goal is to diagnose the sickness of the hospital and to treat it to make the institution healthy. I developed an assessment methodology, which I’ve trained my staff to use, that helps us understand what’s going on at the hospital. We measure the volume and types of waste produced, and we estimate the value of this waste if it were separated and sold. We look at staff attitudes and their waste handling practices, and lots of other things. After all of that, we propose a system for handling waste differently, following Zero Waste principles.
To date, HECAF360 has completed more than 100 waste assessments and has introduced new waste systems at 10 big hospitals in Nepal. Our system also serves as a model in other countries. It’s hard work. To succeed you have to go right into the “veins” of the system. You’ve got to be physically present at the hospital, every day.
It’s not just about autoclaves, or building new waste collection facilities at the hospitals, or buying segregation buckets. It’s about changing the mindset of staff. That’s the key.
My philosophy is that you can make a real difference if you have five things, which I call A-B-C-D-E: attitude, boldness, commitment, dedication and enthusiasm. I build these five things in my team, and then we build them in the staff of the hospitals where we work. HECAF360 has grown a lot. We now have a wonderful team of 15 staff, plus interns. We don’t work only in hospitals. We’re also in schools, nunneries, refugee camps in nearby countries —anywhere where there are waste problems that need a solution.
Our ideas are evolving every day. Our solutions are simple and down to earth. New things keep coming up. The waste problem is so big, you can’t imagine. There are still lots of issues to solve."