Inadequate wastewater management in Dhaka's major hospitals: A Socio-Technical Systems (STS) analysis of leadership, policy, and technological challenges

Unsafe hospital wastewater is a significant concern, especially in low- and middle-income countries (LMICs) where the health impact is often underreported. Socio-technical systems (STS) theory, which examines the interplay between social and technical elements within complex systems, is widely used in developed countries but rarely applied in LMIC hospitals. We employed STS theory to evaluate the social and technical aspects of hospital wastewater treatment (WWT) and management in Dhaka City, alongside a comprehensive assessment of WWT processes. We used a mixed-methods approach, combining quantitative (structured-observations) and qualitative interviews. Structured observations assessed the availability and functionality of WWT systems in selected hospitals. We conducted 30 key-informant interviews across 13 hospitals, including 21 respondents from government and nine from private hospitals. The respondents were cleaners, key health professionals, and public works department (PWD) engineers. We also analyzed relevant government reports and policies. Among the hospitals surveyed, 10 had some form of WWT system, while the remaining three lacked any treatment infrastructure. Of those with WWT, seven utilized anaerobic baffled reactors and three had septic tanks. Interviews revealed that hospital authorities prioritize patient care and medical equipment maintenance over WWT, with limited understanding among hospital staff regarding WWT. PWD-engineers reported frequent staff shortages and bureaucratic delays, affecting the efficiency of WWT system repairs and desludging. Our study identified significant gaps in WWT in Dhaka hospitals, including the limited use of adequate treatment technologies, poor wastewater management knowledge, and many systems in disrepair, leading to hazardous liquid being discharged directly into the environment. The STS approach highlighted the need for policy formulation for HWW regulation, government leadership, adequate financing, technical assistance, and staff capacity building. Addressing these issues comprehensively can lead to safer and more sustainable wastewater management practices in healthcare facilities, ultimately benefiting public health and the environment.