The Hidden Side of Immunisation Success: A Mixed-Methods Implementation Research Study of Immunisation Waste Management in Nepal

Background/Objectives: Immunisation programmes generate substantial quantities of hazardous waste, yet its safe management has received considerably less attention than vaccination coverage. In Nepal, responsibility for waste disposal is divided between vertically administered immunisation services and locally governed municipal systems, and little is known about how national waste standards are implemented in practice. This study examined the governance, workforce, infrastructural and behavioural factors shaping immunisation waste management across selected provinces. Methods: A cross-sectional mixed-methods design combined a structured assessment of 246 health facilities in four provinces selected through a predefined, rank-based vaccine-utilisation stratification, direct observation of eight routine outreach sessions operating during fieldwork, and 74 key informant interviews. Within the selected study settings, local levels and facilities were sampled using multistage methods. Quantitative data were analysed descriptively and disaggregated by province and facility type; qualitative data were analysed thematically and used to interpret the quantitative findings. Results: Health Facility Operation and Management Committees were present in 92.7% of facilities. Separately, healthcare waste management was reported as a standing agenda item in 15.9% of Immunization Coordination Committees. A designated waste focal person was reported in 29.3% of facilities, and 11.8% had a verified hard copy of the national guideline. Open burning was reported as a disposal method for sharps in 67.1% of facilities and for non-sharp waste in 72.0%. Pre-disposal treatment was practised in 9.8% of facilities. Only 21.1% of facilities reported that all waste-handling staff were vaccinated against hepatitis B, with the absence of a ministerial directive and vaccine unavailability reported as the main barriers. Observations and interviews showed that the presence of committees, bins, and other formal arrangements did not consistently correspond to complete or guideline-compliant practice. Conclusions: The presence of selected formal structures did not consistently translate into functional or guideline-compliant practice. Addressing this will require infrastructure investment, administrative extension of hepatitis B vaccination to waste handlers, outreach-specific guidance and routine waste reporting.