World Bank Documentdocuments.worldbank.org/curated/en/602671468762000729/... · 2016-07-17 · is expected to increase up to 70-80 tons/day in 2010. Due to the increase of healthcare

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Building up the plan for healthcare waste management and treatment

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HCWM Plan:“Healthcare for the Poor in 7 Northern Upland Provinces”

Report on “Building up the plan for HCW Management and treatment” 1

Table of contents Introduction ............................................................................................................................................... 4 TASK 1. ASSESSMENT OF LEGISLATIVE FRAMEWORK FOR HEALTHCARE WASTE MANAGEMENT .................................................................................................................... 5

1.1. Existing legislation, regulatory framework for HCWM............................................................ 5 1.1.1 Governmental law and local regulation on healthcare waste management................5

1.2. Review of definitions and standards relating to healthcare waste ............................................ 14 1.2.1 Definitions of HCW: .................................................................................... 14 1.2.2 Healthcare waste identification and classification, treatment................................ 14 1.2.3 Proposal on the main items to be reviewed on HCWM......................................15

1.3 Comparison with international standards and identification of gaps ........................................ 15 1.3.1 Review the best HCWM requirements in the world ........................................... 15 1.3.2 Strategy for healthcare waste treatment in some countries .................................. 16 1.3.3 Regulation on healthcare waste management, the Ministry of Health....................17 1.3.4 Vietnam and international standards - identification of gaps ............................... 18 1.3.5. Comparing Vietnam HCW practical regulations with WHO/international guides . 19 1.3.6 Comparison of WHO and Vietnam classification .............................................. 25 1.3.7 Healthcare waste incinerators in Vietnam......................................................... 27

1.4. Recommendations for strengthening the legislative framework.............................................. 27 TASK 2. ASSESSMENT OF INSTITUTIONAL FRAMEWORK ........................................... 29

2.1 Roles, responsibilities, interactions: environmental, health institutions, stakeholders ................. 29 2.1.1. Role of environmental sector ........................................................................ 29 2.1.2. Role of healthcare sector .............................................................................. 30 2.1.3 Role of healthcare facilities ............................................................................ 31 2.1.4.Role of public service.................................................................................... 31 2.1.5. Inter-institutional issues................................................................................ 31 2.1.6 Budget line for HCWT..................................................................................31

2.2. Different staff groups: assessment of associated capacity within hospital on HCWM................ 31 2.2.1 Within hospital responsibilities on HCWM ......................................................31 2.2.2 Within the Ministry of heath .......................................................................... 33

Task 3: Assessment of HCWM in the projected provinces ..................... 34 3.1 Project introduction .......................................................................................................... 34 3.2 Healthcare services in projected provinces and district hospitals of 7 mountainous provinces ... 35

3.2.1 Description of project provinces and healthcare services .................................... 35 3.2.2. Healthcare service in projected district hospital ................................................36

3.3 Assessment on HCW characteristics, rate of generation in project district hospitals .................. 38 3.3.1 Field trip survey ...........................................................................................38 3.3.2 Assessment of volume of Hz HCSW, generation rate at projected DHs ...............39 3.3.3. Assessment of Group of Hz HCSW in practices .............................................. 41 3.3.4 Assessment of Segregation, Collection, onsite Transportation of Hz HCSW in projected DH. ..................................................................................................... 41 3.3.5 Assessment of HCWM team, internal guideline, training course in HCWM...........43 3.3.6 Assessment of Hz HCW treatment .................................................................44 3.3.7. Assessment of the HCWM practices in 7 provinces .......................................... 45

3.4 Liquid infectious waste, hospital wastewater treatment .......................................................... 48 3.4.1 Situation of infectious liquid waste in projected hospitals ................................... 48 3.4.2. Assessment of Hospital waste water treatment. ................................................49



3.5 Financial source for HCWM .............................................................................................. 50 3.6 Risk associate with current HCWM practices and role of Provincial DOH in HCWM inspection50

HCWM in Bac Kan project district hospitals ...........................................................50 HCWM in Son La province. .......................................................................................51 HCWM in Cao Bang province. ..................................................................................51 HCWM in Dien Bien ..................................................................................................51 HCWM in Laocai and Laichau project district hospitals ........................................51

3.7 Recommendation on HCWM in projected provinces ............................................................ 51 3.7.1 Main findings and recommendations............................................................... 51 3.7.2 Building capacity on HCWM at projected provinces by training practices .............52 3.7.3 Waste treatment facility providing................................................................... 53 3.7.4 Creating budget for HCW management (solid and liquid). .................................. 54

Task 4: Proposal Action Plan of HCWM in 7 northern mountainous provinces ............................................................................................................................................. 54

4.1 Proposal Action plan for Enhancing Regulation, Policy framework ........................................ 55 4.1.1. Recommendations for strengthening the legislative framework........................... 55 4.1.2 Institutional Framework Development for projected provinces ........................... 56

4.2 Preparation of district hospital specific HCWM plans.......................................................... 56 4.3 Procurement HCWM equipment and supplies ..................................................................... 59

4.3.1 Supplying HzHCSW collection tools and HCSW treatment facilities ....................59 4.3.2 Standard design of waste water treatment, pilot demonstration and setup WWTF in projected DHs ....................................................................................................59

4.4 Other hazardous waste management ................................................................................... 60 Task 5: provision budget line for HCWM action plan in 7 projected provinces .................................................................................................................. 61

5.1 Estimation cost for HCWM and treatment at 7 projected provinces ....................................... 61 5.2 Schedule .......................................................................................................................... 62

Annex 1: Natural – social condition of 7 projected provinces ................................................... 63 Annex 2: District hospital and results from survey....................................................................... 63 Annex 2: District hospital and results from survey....................................................................... 64 Annex 3: Minute of meeting and pictures ....................................................................................... 68 Annex 4: References – TCVN7380, TCVN7381, TCVN7382-2004........................................... 68 Annex 5: Questionnaires ...................................................................................................................... 69

References: for task 1,2.........................................................................................70 References for task 3,4 .........................................................................................71



Abbreviation DOSTE: Department of Science, Technology & Environment DoNRE; DOSTE: Department of Science, Technology & Environment, DONRE: Department of Natural Resources and Environment DoC: Department of Construction DoF: Department of Finance EIA: Environmental Impact Assessment DH: District hospital DoH: Provincial Department of Health ICT: Infectious Control (IC) - Infectious Control Team IEC: Information Education Communication GDPM: General Depart. Preventive Medicine MP: Master Plan MoH: Ministry of Health MoNRE: Ministry of Natural Resources and Environment MoSTE: Ministry of Science Technology and Environment HCW: Healthcare waste HCSW: Healthcare solid waste HCSWM: Healthcare Solid Waste Management Hz HCSW: Hazardous Healthcare Solid Waste HCWMP: Healthcare waste management Plan HCSWT: Healthcare Solid Waste Treatment PH: Provincial hospital PGH: Provincial general hospital PL: Polyclinic PMB: Project management Board RMW: Regulated medical waste TCVN: National standard URENCO: Urban Environmental Company WWTF: Waste water treatment facility/plant WMO: Waste management Officer WMT: Waste management Team



Introduction The report on Assessment health care waste management/treatment concerns to the Project on “Healthcare Fund for the poor in 07 Northern Upland provinces” The output of this report is the following: An evaluation of Healthcare waste management regulation and recommendation on revising the HCWM legislative. Surveying and assessment of HCWM (liquid and solid waste) generation and segregation, collection, storage, transportation and treatment in 07 projected provinces and project district hospitals. A development of action plan and training course for HCWM, especially for projected district hospitals. The assessment of the findings and the development of an action plan is key outputs of the report. Minutes of meetings and filled out questionnaires during the field trips and surveys are presented in Annex, with Table B-1 to Table B-4. The methodology of assessments: Studies on the existing regulations on the Ministry of Health, related Ministries and international regulations, guidelines. The master plan of HCSWM, the documents of the local and international workshop have been referenced. Studying the previous studies on HCW generation rate to selection of the appropriate generation rates combining with the field trip surveys and collection of the questionnaires, in depth interview of the responsible staff and directly related to the HCWM to find the estimation of the generation rate of hospital waste and assessment on the HCWM activities in projected district hospitals for this report.



TASK 1. ASSESSMENT OF LEGISLATIVE FRAMEWORK FOR HEALTHCARE WASTE MANAGEMENT Vietnam currently have 13102 healthcare hospitals including 1000 state-owned ones and 40 private others with 184 484 (2003 general statistic) beds. The healthcare waste (According to the report of master plan on healthcare waste management, Department of Treatment, MOH, 2003) is estimated to be produced 30 tons/day and 11,000 tons/year. The healthcare hazardous waste is expected to increase up to 70-80 tons/day in 2010. Due to the increase of healthcare establishments, beds, health services and population and urbanization and people are day by day being more assess to health services. In spite of the Regulations on healthcare waste management issued 1999, Vietnam has no master plan on healthcare solid waste management, thereof, no direction of organizing and choosing the treatment technology throughout the country. In many healthcare establishments, all of healthcare waste are being classified and collected to dump in hospital area or outside or in public rubbish dumping. In general infectious wastes are classified in central and provincial hospitals that contrast with one in healthcare establishments at district and communal levels. In Vietnam, there are about 30% provinces lacking of equipments for healthcare waste treatment especially in remote and mountainous areas. Analyzing the list of hospital budget, there is no money to spend on the healthcare waste treatment and training activities relating to this issue. The healthcare budget is too limited. Therefore, the hospital budgets for healthcare waste treatment decided by their own directors are not united. Currently, there are comprehensive and best technical measures for healthcare waste treatment and management outside hospital and at home individually. Under the circumstance of current tropical and emerging seriousness of diseases, healthcare waste treatment and management is especial consideration.

1.1. Existing legislation, regulatory framework for HCWM

1.1.1 Governmental law and local regulation on healthcare waste management.The management of healthcare waste in Vietnam at the moment is based on

Decision 2557/BYT-QD dated on December 26th 1996 and the Regulation on HCWM issused by MoH on 29/8/1999. There are several new regulation and national standards on the technical requirement on medical solid waste incinerator, air emission discharged standard from medical waste incinerator, discharged effluent standards from hospital waste water treatment plant. The existing regulations relating to healthcare waste management and HCWT facilities are summarized as:

Table 1a: The summary of regulations relating to healthcare waste management at nation level



Name of regulation Date issued Main activities described Constitution of SRV 1999 All governmental ministries have to protect

natural resources and environment

Environmental Law (revised one)

October 2005 Ministry of Health in charge of environmental protection in healthcare sector

Decree 80 of Government August, 2006 Guiding to implement Environmental Law Decree 81 of Government Sep, 2006 EIA requirement for development project Circular 08 of MoNRE Sep, 2006 Guiding implementation of EIA and

environmental protection commitment Circular No 199/TTg by Prime Minister

3April 1997 Regulation on emergency measures on solid waste management in industrial zones.

Decision No 152/QD-TTg By Prime Minister

10th July 1999 Strategy for solid waste management in urban and industrial zones in 2020. Target 2005 -2020: Collection and treatment of solid healthcare waste by burning method in big cities.

Inter-Circular No 1590/1997/TTLT-Ministry of Science, Technology and Environment- Ministry of construction

17th Oct 1997 Guidelines of practicing The Circular No 199/TTg by Prime Minister on emergency measures on solid waste management in industrial zones.

Decision No 155/1999/QD-TTg by Prime Minister issued on the Regulation on hazardous waste management

16th July 1999 Hazardous waste classification. Identify the responsibilities and functions of workers who collect and transport and disposal wastes. Identify MoH’s responsibility on 1) Monitoring, developing effective obligations for hospitals¸ coordinating with the MONDRE, Ministry of Construction in making master plan, choosing technology/equipment/construction investment+operating system of medical waste incinerators compliant to Vietnamese environment standards. 2) Issue the regulations of HCWM

Decision No 1895/1997/BYT-QD By Ministry of Health

19th Sept1997 Regulation on hospitals

Decision No2575/1999/QD-BYT Ministry of Health

27th August 1999

Regulation on healthcare waste management

Official letter No 4527-BYT Ministry of Health

8th June 1996 Guidelines on healthcare solid waste treatment in hospital.

Official letter No 87/TTr Ministry of Health

22nd June 1996 Guidelines for inspectors in cities/provinces health services on healthcare waste management in hospitals.



Decision No 26/CP

Administrative penalties activities broke the Environment protection law and regulation.

TCVN6560:1999 Air quality – emission standard for medical solid waste incinerator

1999 Emission standard for medical solid waste incinerator

Official letter No 1153/VPCP-KGGovernment office No 1069 CP/QHQT By government office.

22th March1999 11th October 1999

Assign the Ministry of Health in actively coordinate with concerning sectors/ministers to develop the master plan of healthcare solid waste management in the whole country.

Decision No 60/2002/QD-BKHCNMT by The Minister of Science, Technology and Environment

07th August 2002

Issue on Technical guidelines on hazardous waste burying.

Decision No 67/2003/ND-CP by Government

13th June 2003 Fees for environment protection complied with waste water

Decision No 62 /2001/QD-Mnister of Science, Technology and Environment

21st Nov 2001 Regulation on technical requirements of incinerators for healthcare wastes. Minimum requirement for the second chamber of the incinerator do not less than 10500C with retention time >1s. Capacity <400kg/day should have wet spray cleaner, capacity >400kg/day should have dry cleaner

TCVN7382:2004 Water quality- Hospital waste water – discharged standards

2004 National discharged standard for hospital waste water

TCVN7381:2004 Healthcare solid waste incinerator – Method of specification appraisement

2004 Method for evaluating medical solid waste incinerator

TCVN7380:2004 Healthcare solid waste incinerator- Technical requirement

2004 National technical requirement for medical solid waste incinerator

��'HFLVLRQ�1R�� 4'�%<7��$XJXVW�� RI� WKH�0LQLVWHU� RI�+HDOWK�RQ�KHDOWKFDUH�ZDVWH�PDQDJHPHQW��The management regulations apply for all hospitals, institutes of medicine, district health centers, policlinic, lying-in stations, health post, private health services, preventive health centers and health training institutions (They are called health establishments).



This regulation is regarded as the basic foundation for the healthcare waste management and for investing the infrastructure for treating of solid, liquid and gaseous wastes derived from health establishments. However, it only concentrates on management of health solid waste.

This regulation makes concretely on classification, identification of healthcare waste and the process of healthcare solid waste collecting at heath establishments, regulations on on-site and off-site transportation of solid hazardous waste. Moreover, they also introduce some models, technology and measures for treatment and destruction of solid, liquid, gaseous waste as well as regulations for implementation, Vietnamese standards of environmental hygiene to apply.

1. Waste classification and identification

Wastes derived from health establishments can be categorised into 5 types:

- Clinical waste

- Radioactive waste

- Chemical waste

- Pressurized containers.

- General waste

- Clinic waste is divided into five groups: + Group A waste - Infectious waste: waste containing pathogenic organisms like bacteria, viruses, parasites and fungi in sufficient quantities to cause disease in susceptible hosts. Infectious wastes are materials or equipment that have been in contact with patient blood and excretion (e.g. bandages, cotton wool, dressings, gloves, swabs, cloths, etc.) + Group B waste – sharps items: All items that pose a risk of injury and infection due to their puncture and cutting properties such as discarded syringes, needles, scalpels, knives, broken glass, pipettes, blades and similar items having a pointed or sharp edge or that are likely to break during transportation and result in such an edge. + Group C waste –clinical waste: clinical wastes are generated from laboratories (e.g. pathology, haematology and blood transfusion, microbiology, histology) such as: gloves, test-tubes, cultures and stocks of infectious agents, blood bags etc. + Group G waste: Pharmaceutical waste + Group E waste: Human and animal tissues and body parts. - Radioactive waste is any solid, liquid, gaseous or pathological waste contaminated with radioactive isotopes of any kind. - Chemical waste is divided into two groups:

+ Non-hazardous chemical wastes consist of sugars, amino acids, and certain organic and inorganic salts.



+ Hazardous chemical wastes consist of Formaldehyde, Photographic chemicals, solvents, trichloroethylene, and organic and inorganic chemicals.

- Pressurized containers - General wastes is the waste generated from in- or out-patient activities that are not contaminated or stained with blood or body fluids from surgical operations, injection room (other than sharps) etc.

2. Collecting process of solid waste at health establishments

2.1: General principles: Segregation should be taken place as close as possible to where the waste is generated and hazardous waste are not mixed with the general waste.

2.2 Standards of waste bags, boxes and bag-holders

- Color coding of waste bags, boxes and bag-holders: yellow used to contain clinical wastes, marked with the symbol of biological hazard, green used for general wastes, black used for chemical wastes, radioactive material and cytotoxic drugs.

- Criteria of waste bag: waste bag should be PE and PP plastic bag with maximum capacity of 0.1 m3 and should have a horizontal line indicated when wastes reach two third capacity of the bag.

- Criteria of a box containing sharp – pointed things: a box containing sharp – pointed things should be intact without any puncture or any leak. It should be made of rigid material and can be destroyed with fire. There needs some different capacities of the box (2.5l, 6l, 12l, 20l) that be suitable for containing different kinds of sharp – pointed things. The box should have an appropriate design for containing needles, syringes and other sharp – pointed things without any leakage of waste during normal. It requires handles and a lid for sealing. That is a yellow box with a horizontal line to indicate when the box is two third full.

- Criteria of a bag - holder: a bag - holder are made of polyethylene of high density with hard, thick wall and a lid, if a bag – holder with large capacity, attached wheels are necessary. The bag - holder colour should be accordance with waste bag colour and the bag - holder is marked with a line to indicate the level of two third total its capacity.



2.3: General and hazardous waste location must be clearly defined and as close as possible to where the waste is generated.

2.4. Waste collection at the source: orderlies are responsible for collecting waste from the source to storage area. Before being taken away from department and ward, all clinical wastes should be enclosed in regulated colour plastic bags. These bags must be bound tightly. Do not close these bags by stapling.

2.5. Transportation of wastes inside health establishments: Health establishments must have regulations on route and time, means of transportation from departments to waste storage area. These means of transportation should be only used for carrying wastes; they should be washed after being operated. Designing characteristics of these means of transport should be suitable for being cleaned, disinfected, dried and also wastes can be loaded and unloaded easily.

2.6. Storage of waste in health establishments - The storage area of waste:

• should have safe distance to food stores or food preparation areas or roads. • It should be possible to lock the store to prevent access by unauthorized persons. • A supply of cleaning equipment, protective clothing, and waste bags or containers should be located conveniently. • Easy access for waste-collection vehicles is essential. • There should be a water supply for cleaning purposes. • There should be protection from the sun. • Hazardous waste should be kept separately from the general waste.

- Storage times for healthcare waste: + In hospitals: waste should be disposed daily, and storage time for hazardous waste is 48 hours. + In small health establishments: storage time for wastes in groups A, B, C, D does not exceed 1 week; waste in group E should be burned or buried immediately.

3. Off-site transportation of hazardous waste: health establishments should make a contract with waste transportation and disposal services approved by local authorities and should have consignment note. 4. Treatment and disposal technologies for healthcare solid waste:

4.1. Incinerator models for hazardous solid waste: - The regional incinerating center region is recommended for all health establishments in the city or for an incinerator for the cluster of hospitals and the industrial hazardous waste incinerator is recommended for big cities. - Incinerator for the cluster of hospitals or for each health unit is recommended for health units in town towns. - The rudimentary incinerator can be used for district health centers. - Open burning or using rudimentary incinerator are recommended for policlinic, lying in post, commune health station.



4.2. Technique for incinerating hazardous solid waste of health unit: based on incinerating models and budget, health establishments select one of the following technologies: - Double chamber incinerator with high temperature (>1000oC), large capacity (5000-7000kg/a day), having the built-in aircleaner, being used for regional incinerating centers. - Double-chamber incinerator with high temperature (>1000oC), capacity (800-1000 kg/ a day), being used for the cluster of hospitals. - Double -chamber incinerator with capacity 150-300kg/ a day, being used for the hospital with 250 beds or more. - The rudimentary incinerator made of bricks or iron drum being used for the small-scaled health units - Open burning being used only for commune health station in rural or remote areas. 4.3. Hygienical burying: this is only recommended for health unit that has no condition to incinerate hazardous healthcare wastes. Do not mix hazardous waste and general waste. Waste should be buried in regulated areas that meet environmental standards and techniques. 4.5. Method of primary treatment: - Only recommended for waste in group C and materials or equipment after contacting with blood or fruits of HIV/AIDS patients, syphilitic patients or sputum of tuberculosis patients... - Primary treatment includes boiling, chemical disinfection and wet and dry thermal sterilization. 4.6. Destruction of clinical wastes:

Waste classification Primary treatment

Incine- ration

Bury Sewer to generation source

Reuse Destroyed as general waste

1. Clinical waste

- Group A X X X

-Group B: Sharp items put into boxes X X

- Group C X X X

- Group D X X X

+ Cytotoxic High T0 X

- Group E X X

2. Chemical waste

- Non-hazardous X X

- Hazardous X X X

3. Pressurized containers X X X

There is currently no effective technical solution for healthcare waste treatment and management in each province/city. The major solution is based on the on site medical waste incinerators. Some advantages of incinerator installed and produced in Vietnam:



� Local made incinerator can be manufactured in different capacity especially for small capacity of less than 30kg/h.

� Almost of local made incinerator is suitable for air waste treatment and high economic effectiveness. Almost incinerators in Vietnam have capacity that appropriate to district hospital with less than 20kg/h. Full design of incinerator includes the air clean system and automatic control panel will be provided when needed.

� Incineration supplier often provides the guide to sharp object and ash destruction and the guide to waste separation at source in order to avoid explosive and heavy metal substances.

The Regulation on HCSW treatment is recommended to use the incinerator to destruct the HzHCSW. The fact that, there are a lot of district hospital in the upland provinces still use the rudimentary incinerator as well as the simple and unproperly designed incinerators. Commpairing with the new technical requirements on medical waste incinerator stipulated by TCVN7380-2004 and TCVN7381-2004 this type of incinerators will not be longer applicable, excluded the incinerator installed in Mai Son hopistal– Son La province and in Trung Khanh hospital – Cao Bang province. 4.7. Treatment of liquid and gaseous waste.

- Treatment of liquid waste: every hospital should have a complete system for collecting and treatment of liquid waste. The liquid waste discharged from hospital should meet Vietnam standards (TCVN 7382-2004 since 2004) for waste water discharged from hospital. Before 2004, the discharged standards for industrial waste water effluents was used. - Treatment of gaseous waste: gaseous waste from laboratories, chemical stores, and incinerators should meet Vietnam standards (TCVN 5937-1995: air quality-ambient air quality standards and TCVN 5939-1995, TCVN 7381-2004).

5. Executive provision:

5.1: Establishment of the steering committees of hospital waste management: In Ministry of Health: Lead by Ministerial leader. In provincial health services: Lead by leader of provincial health service

5.2: Training:

- The health establishments should disseminate the regulation on healthcare waste management for all health staffs and all health officers.

- The Ministry of Health develops program, compiles documents and trains leaders for waste management in health units.

- The provincial health services organize the training courses for people directly participating in management and treatment of health waste.



5.3: Monitoring and Inspection:

- Director of provincial health services coordinate with relative services to control, inspect the implementation of the regulation on health waste management in regional health units.

- Director of Treatment department, Ministry of Health coordinate with relative departments to control the implementation of the Regulation on health waste management in all establishments in Viet Nam.

- Director of General Department of Preventive Medicine is responsible for controlling and assessment of quality of health waste treatment system according to the environmental hygienical regulations.

- Inspection committee of Ministry of Health is responsible for inspecting and disciplining according to the regulations of the state law.

1.1.3 Responsibilities of Ministries/Sectors and localities

in the system of Healthcare waste management and treatment

Ministry of Health Responsible for healthcare waste management and developing master plan

Ministry of construction Grant license and classify location for waste landfills(a project>USD 1 million)

Ministry of planning and investment MOBILISE AND DISTRIBUTE INVESTMENT BUDGET FOR EACH PROVINCES

Ministry of Finance Put waste management and treatment into the list of hospital budget and environment tax

Ministry of National Resources and Environment

Identify and monitor the environment standard and technical criteria

Localities Assist in health waste treatment management

in the fields of finance, operation and management if treatment foundation outsides hospital



1.2. Review of definitions and standards relating to

healthcare waste

1.2.1 Definitions of HCW:1.1. +HDOWKFDUH� ZDVWH: substances generated in healthcare units from examination and treatment, laboratory tests, disease prevention, research, training, and nursery. Healthcare waste includes five types: clinic waste, radioactive waste, chemical waste, compressed containers, and general waste.. 1.2. +D]DUGRXV�ZDVWH: waste generated during production and other activities by society that can pose a substantial or potential hazard to human health or environment when improperly managed. 1.3. +D]DUGRXV�KHDOWKFDUH�ZDVWH: healthcare waste, which includes any of the following: blood and blood products, egesta, human and animal body parts or organs, syringes or needles, sharp objects, pharmaceutical products, chemicals, and radioactive materials used in health sector. If not properly treated, these wastes will be destroy the environment and damage human health. 1.4. +D]DUGRXV� KHDOWKFDUH�ZDVWH�PDQDJHPHQW� the process of controlling waste from the generating stage to the final stage such as preliminary waste treatment, collection, transportation, storage and destruction. 1.5. :DVWH� KDQGOLQJ�� the process of the separation, classification, collection, package and temporary storage of waste at the waste station of a health establishment. 1.6. :DVWH�WUDQVSRUWDWLRQ: the process transporting waste from generating place to section of preliminary treatment, storage and destruction. . 1.7. 3UHOLPLQDU\�ZDVWH�WUHDWPHQW: the process disinfecting or sterilizing highly-infectious waste in the area, which is near the waste generating places, before transporting them to storage or destruction place. 1.8. :DVWH�GLVSRVDO: the process using technique to isolate (including burying) and hazardous wastes, to diminish or breach down their hazardous properties on the environment and human health. 1.2.2 Healthcare waste identification and classification, treatment ( as regulated in the Regulation on HCWM issued by MoH, 1999.) 1.2.3. Standards SROLG�ZDVWH: There are current standards relating to the health solid waste management in the periods of solid waste collecting, transporting to dumping and destruction. The criteria on solid waste collection, transportation and destruction are regulated by the hospital procedure and health waste management regulations (clearly identified in I part- 3.1& 3.2) and Decision No 62/2001/QD-BKHCNMT, November 21, 2001 promulgating the technical requirements for incinerators of medical waste. - Gaseous emissions from health solid waste burning are regulated by the TCVN 6560:1999 Gas generated from healthcare solid waste incinerator – Permissible limits. - Landfills standards are made detailed in TCVN 6696-2000 requirements for environmental protection for sanitary landfills that apply for non-health hazardous waste. Besides, the technical guidelines of hazardous waste burying filing with Decision No 60/2002/QD-BKHCNMT by



The minister of Science, Technology and Environment date August 7, 2002 are applied for health hazardous waste *DVHRXV�DQG�OLTXLG�ZDVWH�GLVFKDUJH�VWDQGDUG��Currently there is no specific regulations for gaseous emissions from hospitals so TCVN 5939-1995, TCVN 5940-1995, which pertain to industries, are used for health establishment as regulated in regulations on medical waste management. - Vietnam Standard TCVN 5939-1995: Air quality – Industrial gaseous waste standards- inorganic substances and dusts. - Vietnam Standard TCVN 5940-1995: Air quality - Industrial gaseous waste standards organic substances. - Vietnam standard TCVN 6560:1999: gaseous waste emitted from healthcare solid waste incinerator– ambient air quality standards. - Vietnam standard TCVN 7380:2004: Healthcare solid waste incinerator – Technical requirements. - Vietnam standard TCVN 7381:2004: Method of specification appraisement for healthcare solid waste incinerator. - Vietnam standard TCVN 7382:2004: Water quality – Hospital waste water – Discharge standards. 1.2.3 Proposal on the main items to be reviewed on HCWM

- The identification of hazardous healthcare waste should be based on the practices of healthcare curative treatment so that the medical staff easy to practice. - The method of hazardous healthcare waste treatment should be diversified. The new method based on microwave, autoclaving or chemical neutralization should be standardized and introduced. - Non-combustible hazardous healthcare solid waste (explosive containers, waste with mercury...) should be awarded to practice. - Finding suitable solution for hazardous healthcare waste management and treatment in small scale of the district hospital and district hospitals of the mountainous areas. 1.3 Comparison with international standards and

identification of gaps

1.3.1 Review the best HCWM requirements in the worldThe best healthcare waste management requirements in selected countries and of the World health organization have been reviewed in order to strengthen the Vietnamese healthcare waste management legislation. a)Safe management of waste from healthcare activities developed by WHO in 1999 In 1999, the World Health Organization, together with WHO’s European Center for Environment and Health in Nancy, France, set up an international working group to produce a practical guide, addressing particularly the problems of healthcare waste management in developing countries. This provides comprehensive guidance on safe, efficient, and environmentally sound methods for the handling and disposal of healthcare wastes.



The various categories of waste are clearly defined and the particular hazards that each poses are described. All components of a waste management policy - whether at national or institutional level - are considered in detail. Although recommended policies and procedures have universal relevance, the guide gives particular attention to conditions in developing countries, where methods for the safe treatment and disposal of hazardous waste may be limited. Approaches for gradual improvements together with a catalogue of options for waste management that include both simple and highly sophisticated technologies are discussed in detail. Considerable prominence is given to the careful planning that is essential for the success of waste management; workable means of minimizing waste production are outlines and the role of reuse and recycling of waste is discussed. Most of the text, however, is devoted to the collection, segregation, storage, transport, and disposal of wastes. Details of containers for each category of waste, labeling of waste packages, and storage conditions are provided, and the various technologies for treatment of waste and disposal of final residues are discusses at length. Advice is given on occupational safety for all personnel involved with waste handling, and a separate chapter is devoted to the closely related topic of hospital hygiene and infection control. The guide pays particular attention to basic processes and technologies that are not only safe but also affordable, sustainable, and culturally appropriate. For healthcare settings in which resources are severely limited there is a separate chapter on minimal programme; this summarizes all the simplest and least costly techniques that can be employed for the safe management of healthcare waste. b)National guidelines for waste management in the health industry developed by NHMRC-Australia-1999 The Australia guidelines HCSWM aim to protect public health and professional safety; safer working environment by minimizing waste generation and the environmental impact of waste treatment and disposal and to facilitate compliance with regulatory requirements. The guidelines outline procedures for the classification, segregation, safe packaging (containment), labeling, storage, transport and disposal of clinical and related wastes. They are intended to assist authorities and practitioners, as well as other people involved in determining an appropriate waste management strategy. The unique and specific factors applicable to each situation-the local conditions, requirements and regulations, and the type and volume of waste generated-should all be taken into account when formulating policy. Healthcare wastes are defined as all types of wastes (clinical, related and general) related to the medical services with the categories: discarded sharps; laboratory and associated waste directly involved in specimen processing; human tissues, including materials or solutions containing free-flowing blood; and Animal tissue or carcasses used in research. Related waste includes: cytotoxic waste; pharmaceutical waste; chemical waste; radioactive waste.

The guideline encouraged the in real terms requires life-cycle-analysis of products used in clinical practice, and consideration/implementation of reuse/reusable, recycling and EPR (Extended Producer Responsibility) enabling producer initiated collection for re-manufacture. The guideline paid attention on Occupational health and safety and education

The strategy must ensure that all waste is handled and disposed of safety. This applies particularly to hazardous waste such as discarded sharps, cytotoxic pharmaceuticals, microbiological cultures and radioactive waste. The waste management plan and procedures should be readily available to all workers involves. Educating the public to the actual issues and risks associated with regulated medical waste, while not addressed in Public Health Law or the enabling legislation, is an important consideration.

1.3.2 Strategy for healthcare waste treatment in some countries



In USA, the use of incinerating method in solid waste treatment has reduced considerably by applying the anti-polluted air law. The method of disinfection is developing and applying widely. In Malaysia, by contrast, the incinerating method for waste collection in factory is selected as national model. All of healthcare wastes are collected and treated in 3 burning factories. In France, the burning kilns initially were equipped for central hospitals. After 1992, especially the issued guidelines of air producing by EC, these factories were close. The model of healthcare waste treatment currently are combined by burning inside and outside hospitals (5 foundations), mixed with life waste (22 foundations) and disinfection (33 hospitals). This model could be applied for every commune with their own individual conditions. In Hong Kong, more than 3000 tons of healthcare waste needs to be treated, under 60% of healthcare solid waste is burned and non infectious waste are buried. Only 5 stated own hospitals earn incinerators for non-infectious waste. With others do not have incinerators; waste could be transported to incinerators. Government has developed the incinerator for infectious waste, which expected to finalize in 2001 with 50 million USA cost. The same model is currently applied in Malaysia. In Japan, nearly 360 tons of wastes are generated per days that are destroyed in private companies. Country Malaysia France Hong Kong Japan Thailand Sri Lanka Technical assess

Incinerating

Disinfection/ incinerating

Incinerating/ Dumping

Incinerating Incinerating Disinfection

Assess by practice & management

Treat outside health stations

Treat outside health stations/ Collective

On-site treatment/ scatter




1.3.3 Regulation on healthcare waste management, the Ministry of Health

This regulation makes detail on healthcare waste management consisting of the technical principles and articles for each step of waste management in hospital (collection, separation, color coding of transportation means) and principles of initial to last steps (transportation to treatment and disposal stations) All of treatment method need depend on the health establishment place from waste incinerating stations for big cities to simple others outside or private small clinics. The separation of hazardous waste from general waste is the pivot principle in healthcare waste treatment and management that are highlighted in the regulation. The healthcare solid waste could be identified and classified into different groups under their diversified characters Under the executive provisions :



- The provincial steering committees are established by provincial health services: They have responsibilities to assist the directors of health establishment on healthcare waste management and to invest in infrastructure for treating and destroying hazardous healthcare wastes.

- The Ministry of Health sets up program, compiles documents and trains leaders for waste management in health units

- Health units organize the training courses for people who will directly joined to to management and treatment of healthcare waste.

- Invest in infrastructure. - The province health services and The Therapy Department monitor and inspect the

implementation. This regulation releases some technical solutions for waste treatment and destruction that is considered to the basic regulations on collecting technology and investment for materials of solid, liquid and gaseous waste treatment. However, it only pay attention to healthcare solid waste and focuses on incineration solutions for infectious waste.

1.3.4 Vietnam and international standards - identification of gaps

Currently, Vietnam has the regulations on health solid management as well as specific regulations on waste producing resources and its treatment and destruction. Besides, these regulations make detailed the guidelines of needed measures for waste minimizing and managing under the WHO or Australian guideline handbook. While comparing Vietnam waste practical regulations with WHO and Australian’s, we found that: - WHO’s guideline are more detail on types of clinical waste to be segerated - Variety of Hz HCSW treatment technology is optioned for hospitals to be selected for treatment.



1.3.5. Comparing Vietnam HCWM practical regulations with WHO and international guides

Comparedcriteria

Vietnam WHO Australia New York

1. Implementers Hospitals, research institutes of medicine,district health centers, policlinics, lying-instations, health post, private service,preventive health centers and health traininginstitutions.

Same as Vietnam. Added for:- Blood bank- Home treatment

Same as Vietnam. Added forhome treatment

Same as Vietnam.Added for hometreatment

2. Wasteclassification

5 groups:1, Infectious waste, sharp objects,highly-infectious waste, pharmaceutical waste,human and animal tissues and body parts2, Radioactive waste- 3, Chemical waste-4,Pressurized container- 5,General waste

9 groupsSame as VietnamAdded by Waste with highcontent of heavy metals

9 groupsSame as Vietnam

5 groupsDo not mention theradioactive waste,chemical waste andgeneral waste

3. Wastemanagementplanning inhealthcareestablishments

Non-detail regulations. Only detailedguidelines of implementation at ministerialand local levels

Have guidelines on healthcarewaste management planning forhealthcare establishmentsincluding home treatment

Have guidelines ondevelopment of healthcarewaste management strategyincluding planning forhealthcare waste management

Non

4. Wasteminimization,reuse and recycle

Non regulations and guidelines Detail regulations and guidelineson waste minimization, saferecycling, and reuse

Detail regulations andguidelines on wasteminimization, safe recycling,and reuse

Non

5. Collection and storage of waste in healthcare facilities- Principles forcollection

- At the time when waste is generated and putin regulated containers.

- As same as Vietnam - As same as Viet Nam - As Viet Nam

- It's permitted for hazardous waste to mix - As same as Vietnam - As same as Vietnam - Does not mention



with living waste clearly- Regulations ofcolour andsymbol for wastepackages

- Yellow - Clinical waste- Green - Living waste- Black : Chemical and radioactive wastes- Non regulated symbol on waste container

-Yellow one for high-infectiouswaste, other pathological wasteand sharp waste- Brown one for chemical andradical and pharmaceutical waste- Black one for other healthcarewaste- Clearly regulate by simple inwaste container

- Yellow: clinical waste- Red one for radioactivewaste- Purple: poisoning waste- Other waste: non-colorregulated- Clearly regulated on samplelabel by waste container

- Does not mentionclearly

- Criteria forwaste containers

- Criteria of waste bags: PE or PP bag withmaximum volume: 0.3 m3 and horizontal slotmarking 2/3 with words: Waste exceed thisslot is not permitted.- Sharps containers: Non penetrating, yellow,labeling: for only sharp wastes and horizontalslot marking 2/3 with words: Waste exceedthis slot is not permitted.- Waste container: Poly Ethylene, hard wall,lid, colour as same as for waste bag

Waste categories- Infectious waste Strong, leak-proof plastic bag, or containercapable of being autoclaved- Other infectious waste,pathological waste: Leak-proofplastic bag or container- Sharp: Puncture-proofcontainer- Chemical and pharmaceuticalwaste: Plastic bag or container- Radioactive waste: Lead box,labeled with the radioactivesymbol- Others: Plastic bag

- Same as Vietnam Not clear

- Sites for placedwaste containers

- Clear stipulation for place of waste container - Have regulation - No regulation - No regulation

-Waste collectioncontainers atsites generated

- Hospital orderly responsible for wastecollection- Gas waste put in container with regulated

- Same as Vietnam- Added by: The bags orcontainers should be replacedi di t l ith f

- No detail regulation onwaste collection

- No detailed regulationon waste collection



colour and labeling with generated original. -Yellow boxes containing sharps and wasteshould be put in PE and tied tightly aftertreatment.- Time of collection: one a day- Only tied and not to pin

immediately with new ones ofthe same type.A supply of fresh collection bagsor containers should be readilyavailableat all locations where waste isproduced.

- Transportationof waste insidehealthcarefacilities

- Defined time and way to wastetransportation, pas-by patient and clean areasis not permitted- Every health establishment should havemeans for waste transportation. Thesetransportation means should only use forwaste transportation and should be clean anddisinfecting after waste transportation. Thesetransportation means should be designed so aseasy to load in and out, and easy to lean,disinfect and drying.

- Same as Vietnam but clearlyregulation on transportationmeans (container, or cart style,non-sharp objects)

- Same as WHO but noregulation on transportationtime and route, hygiene route- Detailed guidelines in case ofleak waste

-No regulation

- Waste storageinside healthcarefacilities

- Conditions of waste storage places+ Far away to safe keeping material, storage-

houses, passing ways.+ Easy access.+ Living waste storage is separated from

hazardous waste storage+ Should have roof, fence and be possible to

lock+ Supplies of safe protection, cleaning+ Having good drainage system

- Waste storage condition sameas Vietnam

- Storage duration regulated bytemperature and seasons:+ temperate climate: 72 hours

in winter; 48 hours in summer

- Storage places condition:same as Vietnam;- Added by: measures tominimize the waste smell,chutes must not be used forthe transport of clinical andrelated wastes.

- No regulation



- Time for waste storage+ Hospital: daily treatment, 48 hours for

hazardous waste+ Small healthcare establishments: No-

exceeded one week for A, B, C, D wastecategories dumping/incinerated

+ warm climate: 48 hoursduring the cool season; 24 hoursduring the hot season

- No regulation on wastestorage duration

6.Transportationof hazardoussolid wasteoutsidehealthcarefacilities

- Transportation:+ Sign contract with transportation company

or self- transport+ Transportation means not used for other

proposed. Be cleaning after using+ Hazardous waste must be packaged in

carton box or container+ E waste category must be contained in

yellow bag and separated container incontainer/box with clear label and cap- Transportation documents:+ Each business must have own list to

monitor waste producing and monitoring noteof daily incinerated waste list+ Detail regulate on note form on waste

transportation and incineration

Detailed regulation at all steps:- System of regulation andcontrol including clear categoryand filling order intransportation note- Specific package orders whenoutside waste transportation- Detail regulate in label- Regulate on all needed stepsfor transported preparing- Regulate on transportationmeans- Regulate on street route

- Only Australian code for thetransport of dangerous goodsby road and rail- Make detailed container andtransportation means- Guidelines in case of wasteleak

- No regulation

7. Technologicalmeasures fortreatment anddisposal for solidwaste and each

- Incineration: regulate on incinerating modelfor each waste categories at provincial/districthealthcare establishment, poly-clinical ward,communal healthcare station, maternity ward+Introduce the models of waste incineration

- List the real condition whilechoosing technology fortreatment and disposal- Introduce the details andadvantages and disadvantages of

- Introduce 7 detailedtechnology for wastetreatment and disposal whileidentifying which measures foreach waste category:+ autoclaving;

- Introduce 3 technologytypes + steam+ Dumping: not applyfor healthcare non-treated waste



type of waste including outside one- Properly hygiene dumping- Junior treatment measures include: boiling,disinfection by chemical and wet thermal- Regulate on treatment and disposal measuresfor each category are clearly as above- No regulation on ash from waste burningkiln

10 technical categories fortreatment and disposal+ 3 burning methods+ Rotary kiln+ Chemical disinfection+ Wet thermal treatment+ Microwave irradiation+ Encapsulation+ Safe burying+ Inertization

- Regulation of treatment anddisposal are same as Vietnam- Apply for ash waste from wasteincinerators

+ chemical disinfection- grinding/shredding

(sodium hypochlorite)- grinding/shredding

(hydrogen peroxide and lime);+ landfill;+ microwave;+ regulated incineration;+ encapsulation; and+ sewerage (as determined byrelevant authorities).- Both for ash from wasteincinerators

+Others: waste burning,chemical and burning- No regulation on ashfrom waste incinerators

8. Treatment ofwater waste

- Regulation on waste treatment in hospital:should have system of waste collection andtreatment. Waste water must be under currentstandards- No regulation on waste treatment in privateand small business

- 2 treatment methods:+Grain waste water to machineof localities under followsconditions +if not applied theseconditions, must solve at once inhealthcare services: juniortreatment, biological cleaning..- Regulate on mud waste afterbeing treated - Regulate on wastewater reuse in agriculture- Treatment methods for smallhealth services+Destruction for separatedsmall healthcare services+Safe minimized requirements

- Disposal to sewer must meetoccupational health and safetyguidelines.- The disposal of largevolumes of blood into thesewer is subject to approvalfrom the local sewerageauthority.Healthcare establishmentsmust comply with standardsset for the ambientenvironment, as well as foreffluent and emission limits

- Not clear



for small health services that cannot developed waste treatmentsystem + Sanitation

9. Treatment ofgas waste

- Ensure the Vietnamese current standards - No regulation Healthcare establishmentsmust comply with standardsset for the ambientenvironment, as well as foreffluent and emission limits

- No regulation

9. OccupationSafe for healthstaff andcollection wasteworkers

- No regulation - Essential occupational healthand safety measuresinclude the following:• proper training of workers;• provision of equipment andclothing for personal protection;• establishment of an effectiveoccupational health programmethatincludes immunization, post-exposure prophylactic treatment,andmedical surveillance.

- Employees and contractorsmust comply with instructionsgiven for theprotection of their own andothers’ health and safety.- Employers and contractorsare responsible for providingappropriate information,education and training, andensuring that a safe workenvironment is developedand maintained.

- Not yet regulated

10. Treatment ofhealthcare wastesat household

No regulation - Have guidelines on theprogram of waste managementin small, medium health servicesin remote areas or in home

- Have regulations onhealthcare waste treatment athome

- Regulated on SharpsCollection from PrivateResidences

11. Proceduresfor emergency

No regulation - Treatment regulation in case ofwaste incidents, accidents andspillage

- Regulate in case of spillage - No



1.3.6 Comparison of WHO and Vietnam classificationFrom No 1 to 3 identify the sequence of specific waste treatment- grey zone for same group waste treatment

Waste groups WHO classification (WHO) Classification according to Vietnam Regulation on healthcare waste management (VN) WHO VN WHO VN WHO VN WHO VN WHO VN WHO WHO VN

Injectious waste Group A

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Group D Chemical waste Pressurized containers Chosed

treatment method Infectious

waste High risk infectious HIV,TB …

Others

Sharp object

Sharp object Group B

Biological waste/ tissues

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1 2 3 1 2 1 2 1 2 3 1 2 1 2 1 1 1 1 2 1 1 2 1 2 1 2 3 1 2 1 1 1 1 2 1 1 2 Neutralization X X X X X X X X

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Burning

X X

X

X

X

X X X X

Inertization/ stabilization X X

Life waste destruction X X X X X X X X X X X X X X X X X X X X X X X X X X X

Bury in cemetery X

Reuse X X Disposal to sewer X

Return to supplying X X X

Special destruction X X



1.3.7 Healthcare waste incinerators in Vietnam According to MOH regulations on HCSWM, incinerators must be two-chamber incinerators and minimum temperature in secondary chamber must be up to 1050o C. The below table presents a comparison of Vietnam and European standards for air emission from incinerators. The results show that Vietnam standards meet international standards. However, Vietnam has not got measuring equipment such as dioxin.

Table 1.3: Comparison of environment standards of incinerators for healthcare waste Ministry of

Health 1994

TCVN7381-2004 E.U. 2000

USA 1997

Temperature of air emission - 120-250°C - - Dust (mg/m3) 50 100 10 115 CO (mg/m3) 100 NOx(mg/m3) 350 SO2 (mg/m3) 300 Hg (mg/m3) - 0,5 0,005 0,55 Heavy metal (mg/m3) - 2 0,5 - HF (mg/m3) 10 2 1 - HCl (mg/m3) - 100 - 100 Dioxin-furan (ng/m3) - 1 0,1 2,3 In USA and EU regulations, threshold limit value for air emission from incinerators depends on type and capacity of incinerators. � 1.4. Recommendations for strengthening the legislative

framework

- National guidelines on safe management of waste from healthcare establishments following the WHO guidelines should be developed.

- National guidelines on occupational health and safety in healthcare establishments should be developed.

- Enhance the inspection mission as well as monitor the healthcare waste management from Central and local level.

- Standardize the means relating to the hazardous healthcare waste classification, collection, treatment and destruction that harm to the environment, to staff.

- Supplement the compulsory environment protection fee for enhancing the investment, supervising, operating the management system, healthcare solid and liquid waste management. 7KH�FRQWHQWV�QHHG�WR�EH�DGGHG�WR�WKH�KHDOWKFDUH�PDQDJHPHQW�UHJXODWLRQ�LQ�9LHW�1DP��9�Healthcare waste management in community and home individually 9�Healthcare waste management in private health stations 9�The technical standards and pilot’s demonstration for new method of safe healthcare

waste destruction (autoclave, microware, chemical neutralization...) 9�The responsibilities of private health stations (waste producer) and environmental

agencies in waste collecting and transporting and treatment



9�The inspection of healthcare waste management is not made detail and other relating procedures are not defined

9�The financial regulation for material and technological investment in waste destruction and operation

- The master plan of healthcare solid waste management should be completed and approved by Government. The priorities should be given to justify the current HCW implementation, development of standard procedure of healthcare waste treatment and management as well as adequate providing equipment for healthcare waste treatment. Provide more budget to invest techniques and to organize effectively healthcare waste management implementation.



TASK 2. ASSESSMENT OF INSTITUTIONAL FRAMEWORK 2.1 Roles, responsibilities, interactions: environmental,

health institutions, stakeholders

�+HDOWKFDUH� ZDVWH� PDQDJHPHQW� LV� RQH� RI� WKH� HQYLURQPHQWDO� DQG� KHDOWK� SURWHFWLRQ�DFWLYLWLHV�� 2.1.1. Role of environmental sector Ministry of Natural Resources and Environment (MoNRE): 5HVSRQVLELOLWLHV� RI� WKH�0LQLVWU\�RI�1DWXUDO�5HVRXUFH�DQG�(QYLURQPHQW�LQ�KD]DUGRXV�ZDVWH�PDQDJHPHQW��

a. Implement the unification of State management on hazardous waste throughout the country, and is responsible for organizing, guiding management activities on hazardous wastes;

b. Develop and submit to the Government to promulgate or self - promulgate legal documents on management on hazardous waste according to its rights;

c. Regulate registration of hazardous waste management or the environment license to the proprietors of waste source, collection, transportation, storage, treatment and destroy of waste;

d. Promulgate environmental criteria for selection of hazardous waste buried areas, specifications for designing, building and operating hazardous waste storage areas and buried areas reaching environmental sanitation requirements; select and consult treatment technologies for hazardous wastes; collaborate with the Ministry of Finance to promulgate fees for hazardous waste management;

e. Guide and examine evaluation reports of environmental impacts caused by the waste collection, transportation, storage, treatment and destroy organizations and hazardous waste buried areas;

f. Study and apply scientific and technological advances in the hazardous waste management;

g. Survey and assess environmental pollution levels in storage areas and waste collection, transportation, storage, treatment and destroy organizations and hazardous waste buried areas; inspect, examine periodically and randomly hazardous waste managing activities according to terms of this regulation;

h. Communicate and train to raise awareness on hazardous waste management; i. Annually collaborate with relative Ministries, branches and provinces to assess the

hazardous waste situation, summarize the hazardous waste management situation in the whole country in order to report to the Prime Minister.

7KHUH� DUH� WKUHH� PDLQ� GHSDUWPHQWV� ZLWKLQ� 0R15(� WKDW� SOD\� NH\� UROHV� LQ� ZDVWH�PDQDJHPHQW�LQ�JHQHUDO�DQG�KD]DUGRXV�KHDOWKFDUH�ZDVWH�PDQDJHPHQW�LQ�SDUWLFXODUO\�DV�IROORZV�a. Department of the Natural Resource and Environment (DoNRE)�is responsible for - Planning, formulating strategies, legislation, and policy on waste management including healthcare waste management. - Guiding on application of Vietnam’s environmental standards including standards related to healthcare waste (solid waste, wastewater, gaseous emission from incinerators, etc.)



b. Department of Environmental Impact Assessment and Appraisal (EIA department)- MoNRE is responsible for approving impact assessment reports related to treatment of hazardous healthcare waste projects. c. Vietnam Environmental Protection Agency (VEPA) responsible for environmental monitoring and coordinating the enforcement of health establishments. At provincial level,� DoNRE has responsibilities to the Provincial People Committee in protecting environment in its local area. 2.1.2. Role of healthcare sector According to its functions, tasks and rights, The MoH’s responsibility on 1) Monitoring, developing effective obligations for hospitals¸ coordinating with the MONDRE, Ministry of Construction in making master plan, choosing technology/equipment/construction investment operating system of medical waste incinerators compliant to Vietnamese environment standards. 2) Issue and adjustment of the regulations of HCWM 7KHUH� DUH� ILYH�PDLQ� GHSDUWPHQWV�ZLWKLQ�02+� WKDW�SOD\� NH\� UROHV� LQ� KHDOWKFDUH�ZDVWH�PDQDJHPHQW�DV�IROORZV�a. Department of Therapy is responsible for: Overseeing delivery of service for healthcare waste, formulating policies related to waste from healthcare establishments, and supervising their implementation b. General Department of Preventive Medicine is responsible for Monitoring and assessment of quality of waste treatment system under the environment sanitation regulations. Developing regulations on occupational health/safety in health establishments and oversee the implementation. c. Inspectors of Ministry of Health are responsible for supervise and discipline any breaches of the regulation on healthcare waste management. d. Department of Medical equipment: has a responsibility to chose and review the suitable destruction technology that is a foundation for the healthcare waste management and investment. e. Department of Finance and Planning is responsible for mobilizing budget then develop investment project to submit Government to supply budget for building the environment- standard waste treatment stations, provide the budget for healthcare waste treatment to regular budget of hospitals. �In fact that, the MoH’s Departments do not have enough staff and time to monitor each healthcare establishments exclude the one belonging to the Central level such as Central General Hospitals. That’s why the practices on HCWM is still weak during almost 8 years of launching the implementation. It is the duty of the provincial Department of Health to monitor and control the implementation of HCWM of district hospitals by “annual evaluation mission” with detail evaluating and marking under the title “hospital waste management and treatment”. The breaking of Regulation is normally punished based on reminding and encouraging the hospital to implement and make the effort next time. �Provincial Department of Health and projected hospital manager boards are in charge of developing and implementing of HCWM regulation in the provincial level and in side the district hospitals in which the Directors of Provincial DoH and the hospital directors will be the two responsible persons on HCWM Implementation at the provincial level.



The Person belonging Provincial DoH who will be in charge of the implementation of Healthcare waste management plan at each province will be appointed soon to sure that the healthcare waste management is being put into place effectively. 2.1.3 Role of healthcare facilities 7KH�KHDOWK�IDFLOLWLHV�LQ�SURYLQFHV�KDV�UHVSRQVLELOLWLHV�WR Coordinate with relative sectors in being inspecting, monitoring the implementation of HCWM at healthcare facilities. Making a specific plan of HCWM at the hospital as well as the plan for investment and develop the healthcare waste treatment facilities to submit the Provincial People Committee to approve in their scale is one of the important duty of HCWM and implementation. 2.1.4.Role of public service Public Urban environment companies (URENCO) under PPC or DOC URENCO is responsible for waste collection and disposal as contracted. URENCOs have allocated significant staffing to the basic tasks of waste collection, disposal, and street sweeping. However, almost 50 percent of solid waste managers surveyed indicated that they have trouble recruiting quality staff and indicated it is hard to find people that are specialized in solid waste management. 2.1.5. Inter-institutional issues The coordination between the Ministry of Health and Ministry of Science, Technology and MonDE in the field of healthcare waste treatment $�YDJXH�GLYLVLRQ�RI�UHVSRQVLELOLW\ DOVR�H[LVWV�EHWZHHQ�0R15(�DQG�02+�DQG�0R&�LQ�LQYHVWPHQW�IRU�WUHDWPHQW�DQG�PDQDJHPHQW�RI�VROLG�ZDVWH�LQ�KRVSLWDOV� The lack of clarity of roles of the agencies, along with limited interagency coordination, has led to gaps in enforcement and a lack of supervision of waste management practices. 2.1.6 Budget line for HCWT /DFN� RI� ILQDQFLDO� PHFKDQLVPV� WR� RSHUDWH� KHDOWKFDUH� ZDVWH� WUHDWPHQW� IDFLOLW\� IRU�KRVSLWDO�KRVSLWDO�FOXVWHUV��The MOH developed a preferred loan project. In the project, 25 incinerators with the capacity of 200 kg/batch or 25 kg/h for hospital clusters in 25 provinces were installed. These incinerators are located in hospitals. After being installed, the incinerator is used by only hospital, where the incinerator is located. Other hospitals in the hospital cluster do not use because clear coordinating and paying policies have not been regulated and often operate less than 50% of their total capacity. 2.2. Different staff groups: assessment of associated

capacity within hospital on HCWM.

2.2.1 Within hospital responsibilities on HCWM The Regulation on HCWM sated that Healthcare waste should be classified at the source, all health staff; should classify healthcare waste at the source and has a connection with the process



of waste classification. But there are two staff groups are more responsible of HCWM in the healthcare facilities: 1. The hospital Director is responsible for

- Organizing and assigning tasks for sections and staff involved in the waste treatment chain.

- Providing sufficiently facilities, personal protective equipment, chemicals for waste treatment and ensure safe working conditions for workers.

- Appoint one key person such as Infectious control officer/Team (ICT) or healthcare waste management officer (WMO) to monitor/ make the plan for HCWM and report the HCWM and related issues.

2. Infectious Control Department/Team is responsible for organizing the implementation and monitoring of waste treatment in the hospital. Head of Infectious Control Department is responsible for implementation, supervision and monitoring, and guiding waste treatment for all staff working in the waste treatment chain.

3. Staff working in the waste treatment chain are responsible for strictly following the regulations on technique, occupational protection and use and maintenance of equipment.

4. Waste collection and transportation workers.

a, Any people producing waste must be self-collected, self-classified at ruled location

b, Solid waste are classified with 4 groups and put into nylon or box as ruled

c, Orderlies are responsible for collecting waste from wards and departments in ruled location and cleaning everyday dustbins

d, Workers of the environmental sanitation group are responsible for waste transportation 2 times per day (early morning and afternoon and every time needed ) by trolleys from departments/wards to the central storage of waste. Human tissues, organs, limbs, body parts, placenta and human foetuses, animal carcasses from laboratories should be separately collected, transported to the distinct storage of waste for burying or burning.

5. Waste treatment and waste treatment workers:

- Hospital director is responsible for ensuring hospital having standard incinerator and waste treatment condition; urban environment company collects and treats waste daily as the contract.

- Environmental sanitation workers are responsible for



+ Burying infectious wastes under 50cm ground or burning in ruled location + Disinfection and mechanism treatment before burning or burying into the ground with sharp wastes

+ Chemical treatment with chemical and radical and toxic wastes

+ Using the needed equipment such as containers or trolleys.

- Some drivers and hospital incinerating operators are also involved in the healthcare waste management chain. These people were trained on safe operation and usage of personal protective equipment. 2.2.2 Within the Ministry of heath The Ministry of Health has issued a Regulation on Healthcare Waste Management in the year 1999 and is reviewing the Regulation to meet the environmental and infectious control requirement at national level. The Regulation of HCWM stated clearly the duty of organizing the training course on HCWM for the provincial DoH staff and hospital leaders as well as person in charge of HCWM in healthcare establishments belongings to the Department of Therapy and Treatment, MoH.

In the Regulation of HCWM, there are several Departments of MoH involved in the monitoring of HCWM in national wide healthcare services.

a. Director of Treatment department, Ministry of Health coordinate with relative departments to control the implementation of the Regulation on health waste management in all establishments in Viet Nam.

b. General Department of Preventive Medicine is responsible for Monitoring and assessment of quality of waste treatment system under the environment sanitation regulations. Developing regulations on occupational health/safety in health establishments and oversee the implementation. c. Inspectors of Ministry of Health are responsible for supervise and discipline any breaches of the regulation on healthcare waste management.

d. Director of provincial health services coordinate with relative services to control, inspect the implementation of the regulation on health waste management in regional health units.

In fact, the DoH is in charge of inspecting the healthcare facilities for compliance with the HCWM regulation and implementation of HCWM at provincial healthcare facilities through the “annual evaluation mission”, so that it is needed to enhancing a capacity assessment in the seven provinces.



The DoH also should develop the instruction for HCWM in the provinces with the reviewed HCWM regulation of the MoH, visits each district hospitals once a year to evaluate the practices there. Each healthcare facilities should have HCWM plan and organize the Implementation Organization. Clarification of the responsibly of the hospital managers, Infectious Control Team (ICT), Chief Department and chief nurses, Waste Management Officers (WMO) in Waste segregation and handling and treatment should be done as soon as possible from the initial beginning the project. Hazardous healthcare waste management, capability for waste treatment is lacking. Currently there is lack of facilities and responsible entities to treat and dispose of many types of healthcare hazardous waste. Hospital undertakes the responsibility for separation, collection and storage of hazardous healthcare waste. However, the task of healthcare waste management is often shared. For treatment and disposal of waste, hospitals typically either operate their own incinerator or have arrangements with the URENCO. There is no space for healthcare waste treatment and education in national budget. In spite of majority of healthcare services are supplied by the Government, healthcare budget is too limited. Therefore, hospital directors must self-decide to use budget, then, the budget for healthcare treatment is frequently insufficient and not united.

Task 3: Assessment of HCWM in the projected provinces

3.1 Project introduction

The project has been designed in order to improve the health care services in the project hospitals, the improvements of the quality of health care services shall improve the health care situation for the population in the provinces and if possible, it should especially improve the situation for the vulnerable population (ethnic minorities, poor, women and children). A detail activity of the project is summarized. A component: Training, human resource development for 7 projected provinces The capacity building of medical personnel and the improvement of medical services at district hospitals will require a comprehensive approach throughout the provinces. The provincial hospitals will be the main contributor to short and medium term training and the district hospitals should have an established plan to improve the quality of services of the primary level facilities. 1) Training of long term Medical doctor of specialty degree 1 The financial support from the Project will cover: the training preparation, training tuition fee for the subjects of Internal Medicine, surgery, Pediatrics, Communicable, Traditional Medicine, ICU. Upgrading training (4years) for Assistant Doctors to become a Medical Doctor

2) Short training courses:



- for curative care (1month/each) on Internal Medicine, Surgery, Obstetric, Communicable, ICU, Image, As therapy, X-ray, Lab. - for oriented programs on preventive medicine (1 year). - Other short training course on Preventive Medicine, BCC, hospital management, healthcare system management, HMIS, Equipment maintain, capacity building for fund of the poor. 3) Supporting the technological transfer to district hospitals 4) Supporting for the policy that encourage the new medical doctor come and work at 7 project provinces. Total: estimation cost is 6,064,380 $ B Component: Improvement of healthcare quality services and preventive medicine in 7 project provinces

1) Behaviors Communication Change The component will cover the support for BCC documents, supplying the communication means and equipment as well as implementation of the campaign and communication program. 2) The supportive activities for provincial preventive medical center. 3) The supportive fund for miner repair of the departments and upgrading of district

hospitals 4) Supplying the basic equipment for district hospitals. The medical equipment will cover

basic medical equipment, which is in most hospitals, outdated and need replacement.

The total estimation cost for B component is 27,178,581$. C Component: Fund for the poor and ethnic people The project will support the government policy on financial support for the poor based on the Decision 139. The allocation for the beneficiaries will be increased annually, from the current VND 50,000 to VND 75,000 whereby the Project will initially contribute VND 25,000 per beneficiary. On a yearly basis, funding through the Project will be gradually reduced but will be “top-up” by the provincial governments to maintain the VND 75,000 allocation. Beside that, the project support for the mobile team consulting and carried out the curative for the poor at the villages and support for management of Healthcare fund for the poor and Fund for creative ideas that dedicate the improvement of the healthcare service and health of the poor in 7 project provinces. C component is estimated of 9,143,199$ D Component: Project Management D component is designed for consultancy services, workshop, surveys, M&E survey and report and others. The total proposal estimation budget is 60 million $US 3.2 Healthcare services in projected provinces and

district hospitals of 7 mountainous provinces

3.2.1 Description of project provinces and healthcare services In 2005, 7 projected provinces include Lai Chau, Lao cai, Son la, Hagiang, Cao



Bang, Bac kan, Dien Bien have had over 5336 district hospital includes bed of polyclinics and planed to be more than 5916 beds in 2010. (Detail figures, see the annex 1 and annex 2). There are 66 district general hospitals having about 30-150beds located the large areas of the boundary areas along Vietnam- Chine boundary. There are 9 of the 56 DHs will be upgraded to be come inter-district hospital over 150 beds with diversified departments to meet the medical service of the population and healthcare of the minorities in the Northern Mountainous provinces of Vietnam. Generally, comparing with other countries in South East Asian Region, the amounts of healthcare establishments especially the ones in mountainous provinces is abundant and considerable. However, environmental sanitation issues are extremely bad. There are not enough healthcare waste treatment facilities in most public district hospitals and clinical waste are often dumping in the back yard of the hospitals. The environmental sanitation will need to be upgraded to meet the requirement of primary preventive medicine.

Table 3.1: Data on population and healthcare network in 7 projected provinces

Province Population

Number

of PDH

Number

of DH

bed

Number

of DH

Number

of PC

bed

Numbe

r of PC

Rate of

beb/1000

per.

Number

of

planned

bed

Rate of

bed

increase

1 Ha Giang 673,400 250 710 9 215 21 1.7 850 20%

2 Cao B»ng 514,600 420 735 13 126 20 2.5 975 33%

3 Lao Cai 575,700 460 510 8 350 35 2.3 540 6%

4 Bac Kan 298,900 320 360 6 115 12 2.7 380 6%

5 Lai Chau 314,200 150 250 6 110 11 1.6 270 8%

6 Dien Bien 449,900 450 330 5 225 20 2.2 460 39%

7 Son La 988,500 620 1060 11 240 17 1.9 1060 0%

Total 3955 58 1381 4535 14,7%

(Source: Annual healthcare statistics, 2005 and Project Design Document). Baseline information, natural – social condition and geographical distribution of projected provinces are presented in annex 1. 3.2.2. Healthcare service in projected district hospital All thought the existing of development of inter-district hospitals, the governmental master plan on healthcare system development is recommending reducing the small one and to have instead, district hospitals with different level of services. The medical equipment standard list (including the medical solid waste incinerator) therefore developed and has 4 different standards for 50, 100, 150, and 200 bed hospitals. Based on the surveys, the recommendation to have only two categories for projected district hospitals, one with essential services between 50 beds and the second category with 100 beds. Table 3.2.a: Average number of bed in projected district hospitals



Type of DH

Number of DH

Rate (%) Average of bed

DH less than 80bed 52/66 75,8% 50

DH over 80bed 14/66 24.2% 103

Most of projected provinces belonging to the poorest provinces of Vietnam, therefore the investment of provincial budget for the healthcare services of DHs is still insufficient. One of the indicator showed the poor healthcare services is the average of inpatient curative day. This numbers is higher comparing to the nation wide figure and the highest stayed in the poorest provinces amongst 7 provinces (table 3.2b). Quality of healthcare service often reflects by the duration of curative days for inpatient Cao Bang, Bac Can, Son La and Lai Chau are provinces showed the poor curative quality comparing with the norm of the nation wide (Table 3.2b).

Table 3.2b: Average number of inpatient curative days Province

Average number of inpatient curative

days in the hospital

1 Ha Giang 5.5

2 Cao Bang 7.8

3 Lao Cai 2.3

4 Bac Kan 7.2

5 Lai Chau 6.33

6 Dien Bien 4.3

7 Son La 6.33

Nation wide 6 (Health statistics year book, 2005)

Lacking of necessary consultation and curative equipment, old and out of date equipment is often meet in the 7 provinces. Several provinces do not have enough equipment to provide to the district hospitals. Most often X-ray and ultra sound equipment, testing equipment are insufficient. See details figure on one typical healthcare service of Bac can provinces and its DHs (table 3.2c). Table 3.2c: Healthcare service of district hospitals of Bac Can Province

Bac Kan province

DH Ba Be

DH Cho Don Cho Moi

DH Nari

BVH Ngan Son

BVH Pac Nam

DH Bach Thong

Planned bed 70 80 65 70 65 50 25 Consultation times/year 28000 36000 32000 38000 31500 15000 990 Total inpatients/year 3000 4500 3650 4000 3700 1800 1500 Total inpatient curative days 20000 31500 25600 28000 25900 12600 8500 Number of testing per year 50000 39000 42000 45000 45000 15000 8000 Number of X-ray taking per year 0 1700 2300 18000 900 0 200 Total of operation cases 200 100 150 150 70 0 0



per year (Annual Report 2006, Department of Health- Bac Kan Province, Feb., 2007)

Table 3.2d: Provincial curative and consultation, 2005

(including commune healthcare)

Province/indicators Hagiang Cao bang Lao cai Bac can Lai chau Dien bien Son la Planned bed 710 80 65 70 65 50 25 Consultation times/year 786833 1043517 968473 480764 688503 894577 1187332 Total inpatients 67443 47735 175620 39254 34262 87749 110782 Total inpatient curative days 370607 373320 397087 280914 216898 368226 700486 Number of testing per year 238795 201029 201319 536786 78145 338988 432281 Number of X-ray per year 25451 25367 25010 26535 9781 33030 63066 Total of operation cases per year 3902 2782 3432 1713 1951 13096 5196

(Source: Health statistic yearbook, 2005) District hospitals in 7 projected provinces has average number of 50 bed (DH less than 80bed), accounting for over 75% of the total 56 district hospitals in 7 Northern Mountainous provinces. Comparing to other provinces, the projected district hospitals are small in the term of capacity, investment and services. Table 3.2c, table 3.2d describes typically detail district healthcare services of Bac kan province and table 3.2d provides the figure on provincial healthcare service of projected provinces. 3.3 Assessment on HCW characteristics, rate of generation

in project district hospitals

3.3.1 Field trip survey In Vietnam, during the last five years, there has been an increasing trend towards the single use of materials, which now accounts for significant amounts of healthcare solid waste generation at the district hospital level. The waste generation rate can vary substantially depending on capacity of the district hospital. To assessment the volume of waste generation at the projected DH and Polyclinic the Field trip survey has been carried out with the questionnaire, the observation, onsite evaluation. The aiming of the survey to evaluate the waste generation rate in two main type of DH in 7 projected provinces and the HCWM there.

Table: 3.2e: The questionnaire formatted information

General information about the DH Type of the DH or Polyclinic, basic key factors (number of bed, inpatients, outpatients, number of medical consultation, surgery, number of medical staffs)

Estimation of HCSW generation rate

Clinical waste, specific waste (chemical, radioactive, pressurized containers,) domestic waste.

The practice of segregation, Separation of the waste as well as the methods for



collection, storage, transportation, treatment and destruction of HCSW

segregation of sharp and pointed items. Use of colour codes for waste collection and transportation means. Facilities for waste storage and the recycling or reuse of waste

The perception of the Regulation on HCWM

Availability of document/guideline on Regulation on HCWM and elaborating themselves the guidelines for separation and treatment of waste.

Trained medical staff on HCSWM Is there any HCSWM team in DH

Facilities for disposal/treatment of hazardous HCSW

Final disposal (burying, open burning), existing incinerators, technical information about incinerators

Expenses related to HCSWM All expenses from the generation point of waste to the final disposal

3.3.2 Assessment of volume of Hz HCSW, generation rate at projected DHs The previous data on generation rate of HzHCSW during the year 1998 to 2002 through the survey of the Ministry of Health in 1998 have identified the generation rate of hazardous HCSW is about 0.1 – 0.15kg/Bed of DH/day for the district hospital and less than the discharging rate of the provincial hospitals (table 3.3). The same generation rate of HzHCSW for the year 2002 has been reported based on the surveys of the National Master Plan on HCSWM (table 3.4). The current results have been done with the questionnaires delivered to the projected DHs during the April, 2007 in order to collect the information on medical services, situation of HCWM in the projected district hospitals. The result has showed that the rate of HzHCSW is over than figure of 0.1-0.15kg/B/day for one district hospital bed in the period of 2002-2003 and reached the figure of over 0.2 kg/B/day. More details, the district hospital with less than 80planned beds reach the rate of 0.2kg/B/day and more than 0.25kg/B/day with the district hospitals more than 80 beds, in spite the fact the district hospitals are in poor provinces with low healthcare curative quality in the Northern mountainous area, (table 3.5a ). Table 3.3 : Waste generation from Vietnam hospitals during the time 1998-2002. Surveyed hospital Average

number of bed

Amount of general HCSW kg/bed/day

Amount of Hz HCSW kg/bed/day

% of Hz HCSW

24 representative hospitals in VN (1998)*

220 0.916 0.152 16,5%

17 district hospitals in Thai nguyen province (2001)**

100 0.913 0.14 15,3%

District hospital in nation wide, 2001*** 75 0.6-0.85 0.15 22.2% Policlinic, 2001*** 5 0.7-0.9 <0.1 <9.1% Source: *Thuy-MoH, 1998, **DANIDA Project on Environmental Protection of Thai Nguyen Province, 2001

*** Master plan on HCSWM 2001, MoH

Table 3.4: Generation rate of Hz HCSW different type of hospitals in Viet Nam during 2001-2002.

Hospital Average of bed

Generation rate of domestic waste

Volume of Hz HCSW

Generation rate of Hz HCSW



bed domestic waste (kg/B/day)

HCSW (kg/day)

Hz HCSW (kg/B/day)

Specific Provincial Hospital

125 0.8-0.95 25 0.15-0.25

District hospital 75 0.6-0.85 15 0.15

Polyclinic 5 0.7-0.9 <0.5 <0.1 (Source: Master plan on HCSWM report, MoH 2002)

Table 3.5 a: Generation rate of Hz HCSW from district hospitals of 7 Northern Mountainous

provinces.

Type of DH Number

of surveyed

DH Min of bed

number

Max of bed

number Average of bed

Min HzHCSW

kg/day

Max HzHCSW

kg/day

Average of waste kg/day

Rate of HzHCSW kg/B/day

DH 50beds 21/52 20 70 54 3 23 11 0.196

DH 100beds 7/14 80 140 103 13 50 26 0.253

(Source: Ngo Kim Chi, Questionnaires and surveys on HCSWM in 7 provinces, 2007) There are 52/66 district hospitals (78.8%) having average 50 planned beds. These small DHs generate the volume of HzHCSW of 0.2kg/Bed/day. There rest district hospitals (14/66) having 100 planned bed showed the higher discharged volume of waste. Among 14 projected DHs have more than 100beds, there are 7 hospitals generate more than 0.25kg of Hz HCSW/Bed/day. This is importance figure decides the capacity of medical waste treatment equipment. The volume of several type of Hz HCSW has been surveyed and recorded at Moc Chau district hospital (100 beds) – Son La Province during one month in order to evaluate discharged Hz HCSW of the sharp and pointed items of group B, group of pathogen, body waste, swabs (group E+A) and waste of group C. Data collected from 10 March to 10 April, 2007 was presented in table 3.6 The component of waste has not been studied during the survey, the observation at site recognized the waste components showed the tendency of high value of heat comparing with the studied figure in the year 2002.

Table 3.5b: Characteristics of Hz HCSW

Norms Average value Volume Density of Hz HCSW, (ton/m3) 0.13 Moisture of hazardous HCSW (%) 50 Ash proportion of hazardous HCSW, % 10.3% Heat value, kcal/kg 2153

(Source: Annual State Environmental Report, 2002)



Table 3.6a: Generation rate of group B (sharp and pointed items) in projected district hospital (Moc Chau DH with 100beds), March-April, 2007 No Type of Hz HCSW Status Volume of

waste (kg/month)

Generation rate of sharp and pointed items kg/bed/month

1 Sharp and pointed items Solid – group B Hz

HCSW

5 0.05

kg/bed/month

(Ngo Kim Chi, survey on HCSWM in 7 Northern Mountainous Provinces, 2007) The results showed that the sharp and pointed items (waste of group B) waste is accounting for less than 1% of total HzHCSW. The waste of group C is accounting for 7.4% and the major part 91.6% is waste of group A and E. Table 3.6b: Results on volume of each type of HCSW in one district hospital (100beds), March-

April, 2007. No Type of Hz HCSW Status Volume of waste

(kg/month) 1 Sharp and pointed items Solid – group B Hz HCSW 5 2 pathogen waste, body

waste Solid, waste of E, A 300

3 bandages, wound with blood, infectious waste

Group C 50

4 Other Hz HCSW Cylinders, transfusion line... 320 (Ngo Kim Chi, survey on HCSWM in 7 Northern Mountainous Provinces, 2007)

3.3.3. Assessment of Group of Hz HCSW in practices Hazardous HCSW is included clinical waste and other chemicals, substances related to Hz HCSW. The clinical waste in then divided into 5 group named A, B, C, D, E as mentioned above in the definition of HCW of the Regulation, 1999. Almost of the projected district hospitals, clinical waste, sharp items, explosive containers separated from general waste. The clinical waste is not separated by group of waste, therefore the generation rate of each group is not available in almost of the projected hospitals. Almost of projected DHs do not pay attention to the infectious liquid, liquid from the X-ray room and bulk blood, blood products, bloody body, body fluid, contamination liquid waste. This type of waste is often discharge directly to environment. Chemicals, explosive containers are disposed not regularly and stored and discharged as regulative on hazardous waste management. They should be safety storage before transportation and treatment by professional and licensed enterprise. The hazardous waste is discharged together with domestic waste is not allowed and should be strictly supervised. 3.3.4 Assessment of Segregation, Collection, onsite Transportation of Hz HCSW in projected DH. The awareness of the risks from HCW is generally high in the top management level of 07 provincial Departments of Health (DoHs) and hospitals and medical staffs. Healthcare waste



receives special attention because it is contamination waste and due to the launch of Regulation on HCWM issued by MoH scince 1999. But in fact, the HCWM practices are still poor due to many reasons. The observation through field trip and the questionnaires gathered from 28 DHs revealed that the basic level of segregation of clinical waste is done in all DHs, although collection tools and options for treatment and disposal are limited and insufficient. The clinical waste is segregated at 93% of projected DH, sharp and pointed items is segregated at 82% of projected DH. There is only 01 DH used cluster incinerator, 03 DHs incinerate Hz HCSW in simple brick incinerator, 01 DH has on site incinerator. Onsite burial of HzHCSW and open burning are most common solution for disposal of clinical waste in district hospitals of 7 provinces.

Table 3.7: Method of Hz HCSW treatment at surveyed DHs

Number of DH in survey

Hazardous waste segregation (Y/N)

Sharps segregati

on (Y/N)

Color code

(Y/N)

Municipal landfill (Y/N)

Onsite Burial (Y/N)

Incineration in cluster

incinerator (Y/N)

Onsite Incineration (Y/N)

Incineration in

simple furnace (Y/N)

Open burning (Y/N)

28 26 23 3 2 18 1 3 2 18

% 93% 82% 11% 64% 64%

(source: Survey on HCWM in 28 projected DHs, Ngo Kim Chi 2007) Several DHs use the “Box for sharp items”, properly use the clinical bag, waste bin with coded color and regulated layer. The observation revealed that the practices due to the lack of “Box for sharp items” the nurse has to remove the needle out of the plastic cylinder. Most of DHs reuse the PE water bottle to storage the needle. The boxes then buried inside the hospitals. The waste bins for “Clinical waste” are often used wrong coded color and without lids, labels. Wrong disposal of clinical waste and domestic observed during the field trip surveys. The project should include the training course on practices of HCWM with very careful disposal of regulated medical waste (RMW). Hz HCSW is put in the thin plastic bag and carried by hand to the dumping site in the back yard of the hospital. The orderly of each department does the collection of waste. More people involved in transportation of waste in side the hospital, lacking of person in charge of recording the volume of waste. Using thin plastic bag in order to contain the sharp items will cause the risk for the waste officers, the nurses and orderly. The high risks contacting with Hz HCW are not aware of risks associated with direct disease transmission from sharps (e.g., needles, syringes, blades, and other instruments capable of inflicting a wound or a puncture).



Careful disposal of clinical waste and separation into the many group of waste based on its contamination in order to easily carry out the regulated dis infection methods and safe disposal of clinical waste. Wrong disposal of Hz HCSW will make the disinfection more complicated. A system of segregation, collection and transportation waste starting at the source of generation. The system should minimize contact with patients, and public. There is need to establish clear drawing the location of waste bin for every ward and department in the hospital as well as the location of storage site for clinical waste/separate site for other waste and collection route and timetable. Type of containers, box for sharp items, security equipment, arrangements for washing and disinfecting waste-collection bin/trolleys should be specified in the hospital map. - Segregation is the most important step, which should be done at the source of generation e.g. all patient activity areas, diagnostic service areas, operation theatres, labour rooms, treatment rooms etc. All the bags/container must be labeled according to the stipulated colour-coding system (yellow for clinical waste, green for domestic waste, black for radioactive waste). Certain of waste need pre-treatment (decontamination /disinfection) at the site of generation. - It should be used plastic bag made by PE or PP material in order to avoid the pollutants causing by incineration of waste. The size of the plastic waste bins 20l-30l for clinical waste are often big comparing to the demand of the department of the projected hospitals and should be sized with smaller volume such as 10l -15l with lid but easy to put the waste into. -The common chemicals of disinfections are hypoclorite diluted 1% solution with diluted or chloramines B ..... but these chemicals are not always available. Be awakened that if the waste is disinfected with Chlorine agents then should not be incinerated. 3.3.5 Assessment of HCWM team, internal guideline, training course in HCWM There are 75% of projected DHs stated that the hospital has HCWM team, the segregation of waste is responsible of the medical staff in each professional department, the monitoring is in charged of the chief nurse, the collection and transportation to terminal site is the duty of the each department orderly. But the official assignment for key person in charge of HCWM is often not clear and most of the district hospitals have not have their own healthcare waste management plan or internal instruction on HCWM studied and elaborated by the HCWM team or person in charge of. 46% of district hospitals in 7 provinces referred the MoH Regulatory published in 1999. Therefore open burning or incinerating of waste in rudimentary oven are still existing. There is only 32% of projected DHs has staff trained in the field of HCWM.

Table 3.8: HCWM at projected district hospitals

Total surveyed

DH

Number DH has Internal

regulation on HCWM (Y)

Number of DH Use of a MoH

regulatory text (Y)

Number of DH has HCSWM

team (Y)

Number of DH has staff

trained in HCWM

No of DH has more than 1

person involved in Hz HCSW transportation

28 1 13 21 9 26

% 4% 46% 75% 32% 93%

(Source: Survey on HCWM in 28 projected DHs, Ngo Kim Chi 2007)



3.3.6 Assessment of Hz HCW treatment Clinical waste is not disinfected before disposal especially waste of group C from the laboratory. The tested blood, scalpel blade is dumping in waste hole waiting for open burning. The treatment of healthcare waste is based on simple solution due to lacking the treatment facilities and financial source for required materials and HCW collection and protective tools. Treatment of waste group A: Method of treatment of group A clinical waste included of + Burying waste in ground burial pit inside hospital + Incinerating in the brick incinerator or open burning. + Burning open air (in almost small hospital) Waste group B: Segregation of point/sharp items is implemented in almost of projected district. Container for sharp items: used PE bottle or un-punctured boxes. Treatment: Burying in ground Recommended for treatment of waste group B: Disinfection of sharp items: by sterilized solution, burying inside hospitals or incinerate if incinerator is ready. Waste group C: Lacking of disinfection reagents are often observed in district hospitals. Method of treatment of group C waste after sterilizing/disinfecting: burning inside hospital or open burning. It is recommended that the pre treatment of waste of group C by using disinfections chemicals hypochlorite, liquid Cl2 and chloramines B and other disinfections agents before burying is very important. But be awakened that incineration of chlorine bearing waste and the organic in poorly designed and operated incinerators can cause the emission of toxic pollutant such as dioxin and furan. Waste group D: + Burying waste in ground inside hospital + Discharge to public place of waste collection + Incinerate of waste in simple furnaces + Burning of waste in the open air Recommendation: following the method presented in the Regulation Waste group E: + Burning of waste in simple furnace + Open air burning + Burying in the ground Recommendation: following the method presented in the Regulation, land fill in the cemetery or specific designed cell in the landfill, incinerate in the incinerator. Chemicals, explosive container: Recommended to this type of waste is safe storage, returned to the supplier or collected by the professional waste collection and treatment in town or in the region. Radioactive waste: Related to the radio active waste, the awareness on high risk to exposure of waste as well as the ray, missing the technical basic and safety control technical control.



Domestic waste: Almost DH is located in the main town and having the contract with town’s environmental company to collect domestic waste and transported planned dumping site. Open burning and incinerating of waste in rudimentary furnace are still existing. 3.3.7. Assessment of the HCWM practices in 7 provinces HCWM practices are in poor condition with lacking appropriate facilities, trained and well-informed staff. Missing the appropriate HCW planning and appropriate financial source for HCWM. The internal guideline on HCWM as well as the HCWM plan is important document based on the event the interim measurement not elaborated in most of district hospitals of seven provinces, therefore there are not clear identification on: 1) Location and organization of collection and storage facilities (are often not clearly stated in writing document) as well as a collection timetable for waste transportation route. The arrangements for washing and disinfecting waste-collection/trolleys were not specified. 2) Lacking the assignment on responsibilities, duties, and codes of practice for each of group of hospital staff, who through their daily work, will generate waste and be involved in the segregation, storage, and handling of the waste in each ward and department in which special practices are required, e.g. for radioactive waste, hazardous chemical waste or high infectious waste. 3) Lacking of financial source for the required HCWM materials (collection bag, bin, box for sharp items, trolleys, dis infection agents..). The field trip revealed that : -The regulation states some specific equipment to be used for storage and collection of health care waste. Most likely this equipment is very difficult for the hospitals to procure as it is not directly available from medical equipment supplying companies, shops etc. or must have been ordered (e.g. thick yellow PE or PP plastic bags and yellow plastic boxes/bin with labels and lids, carts, cooling boxes. The clinical plastic bag could be ordered in the volume of 15l and type of 30-40bags/kg). -Sharp items are segregated only at several hospitals. Most of hospitals do not have enough financial sources for buying “box for sharp items”. Emptied polyethylene (PE) bottles for drinking water or metal cans are reused for storing needles after separation from syringes. Moving the needles out the syringes is very dangerous for medical workers and accompanying with high risk of scratching and of diseases contamination. - The observation revealed that although that clinical waste and sharp items is separated but the waste is not incinerated and treated in regulated incinerator or landfill in the landfill site with water proof bottom line and daily cover. - Observation right at the hospitals (Muong Cha- Dien Bien, Moc Chau _sown La, Thach An –Cao Bang) see the clinical waste is excavated by the dog and animal. So that the clinical waste, especially the waste of group E should be land filled deeply or regulated incinerating. - District hospital in mountainous provinces has large surface area and far from the residential are, so that the open burning of waste is not causing any compliance. In coming years, the



hospital location site will be crowded and more residents, business closed to the hospital, therefore the open burning will be complained and no longer existing. The poor HCWM at the district hospitals in seven provinces reflects the need of strengthening the implementation and the role of inspecting from DoH in the provincial level. Several DoHs have a Chief of Nursing Association in charge of HCWM expansion and training but they have no occasion to participate in the delegation of annual evaluation mission to each district hospitals. Lacking person in charge of HCWM at DoH raising the need of building capacity in the field of HCWM for DoH (At least 3 person/DH). The training will be led by MoH. 3.3.8 Assessment of the local proposal on HCWM The in deep discussion with the hospitals leaders revealed the urgent need of investment of hospital waste treatment. Mentioned to the treatment of Hz HCSW most of the hospital leader proposed to have financial source to install the solid medical waste incinerator to treat the Hz HCSW on-site hospital. This showed that:

- The requirement of waste volume reduces and totally destroys the contamination germ. - Technology and equipment easy to operate, labor saving comparing to the soil dig and

cover or dis infection solution Particularly, several hospitals made the proposal of buying one new incinerator instead of the installed one that do not work properly. It is showed that the selection of incinerator should take more attention on type of incinerator and its technical permormances. The fact that, the installation of medical solid waste incinerator has to consider many aspects from the investment, operation cost, the installation site, technical performance of the incinerator based on the technical requirement of TCVN7380-20004 and related evaluation method TCVN7381-2004. Moreover, due to medical waste incinerator often works with high temperature (1050C), the availability of the maintenance and operation services as well as spare part and on site training is one very important factor to consider and evaluate when decided to buy/select one type of existing incinerator.

That is why, the assessment the existing incinerators in the provinces, providing the option be to selected to suit the specific requirement of the local district hospitals is also important key before deciding to install the new ones. (several existing incinerators in Cao Bang, 01 in Son La, 3 simple incinerator in Hagiang, 01 in Bac Kan PH).

It is reported that the installed ncinerators with small two chamber and temperature is often not reach over 800C at the secondary chamber. The incinerator is run only one or one and half-month and have problems with temperature measuring. No person knows how to correct the problem and get the



incinerator start working. Because of incinerator is reported to work less than 800oC, their are several notices

Onsite and small capacity incinerator operation notices and recommendation for selection of incinerator: Small incinerator works based on batch processing, so that: - The volume of primary combustion chamber should have enough room (the Hz HCSW has low bulk density about 0,13ton/m3) for burning the waste during 4-5h to save the energy to avoid numerous starting and cooling phases that respectively low down efficiency and damage the refractory shielding. - Strict implementation of designer operation guidelines (preheating time, monitoring of fuel, air and waste admissions, of temperature evolution) has to be carefully carried out when operation of the incinerator. - The height of the chimney should respected the regulation and technical advise. The height of the chimney must higher than the highest building closely to the incinerator. -Ash should be encapsulated in cement while metal oxides and toxic organic matters (as dioxins) would thus be trapped in solid status. Main technical requirement for medical waste incinerator TCVN7380-2004. Number of combustion chamber: 2 Primary temperature >8000C Secondary temperature >=10500C Retention time of gas burning in secondary chamber: >1.5s Temperature of gas flue at the outlet of stalk <2500C Flue gas emission: TCVN6560-1999. Height of the stalk: >8m The method of specification appraisement: TCVN7381 Liquid waste from incinerator: should meet TCVN5945-1995. Has the section of ash container and neutralization of ash should be provided. These reflections from Cao Bang and Bac Kan lead to future treatment scenarios towards to the need of supplying new high quality small capacity medical incinerator with proper flue gas cleaning, and working temperature and durable materials.



Beside the use of incinerator to treat Hz HCSW, it is need to introduce sterilizing equipment (wet autoclave, dry autoclave, microware ..) to be put in use in order to evaluate its appropriateness with the condition of district hospital in poor and mountainous provinces. Table 3.9: Number and type of incinerators proposed by DHs and revision

Assessment** Incinerators proposed by DHs*

Province

Number

DH+Regional GH District

bed

Incinerator 10kg/h

Incinerator 20kg/h

Total

capacity of 30kg/h

capacity of less than

15kg/h

number of incinerator

proposed by local DH*

Ha Giang 10 710 5 3 8 1 8 9 Cao B»ng 14 735 11 2 13** 14 14 Lao Cai 8 510 8 8 8 8 Bac Kan 6+1PL 360 7 7 7 7 Lai Chau 6 250 6 6 6 6 Dien Bien 5 310 5 5 5 5 Son La 11 1060 5 4 9 8 1 9 Total 61 3935 57 58

* Number of incinerators proposed by local DH based on Project design document (** Revised by Ms. Chi based on calculation of DH planned bed and generation rate of Hz HCSW assessment of existing incinerators

in Cao Bang, Ha giang, Son La. Incinerator in Trung Khanh DH - Cao Bang is in working.)

3.4 Liquid infectious waste, hospital wastewater

treatment

3.4.1 Situation of infectious liquid waste in projected hospitals Discharging of blood, fluids, infectious liquid often pays the great concern of the guideline of EPA-US and CDC- US. The regulation on discharging of even a few milliliters of blood remaining after laboratory procedures, suction fluids or bulk blood can be inactivated in accordance with CDC and EPA approved treatment technology. The situation of liquid infectious in Vietnam is in opposite side. The discharge of blood liquid or body fluid and infectious liquid should be inactivated by dis infection chemical. After making the infectious liquid inactivated the liquid waste will be diluted and discharge to the sewer and then to septic tank system before final treatment at WWTF and discharging. The properly design and well functioning septic system is adequate for inactivating blood borne pathogen and pre- treat hospital waste water before intensive treatment to meet the requirement of discharge effluent from the hospital waste treatment facilities TCVN7382-2004. Most of the projected district hospitals do not pay attention and do not have budget to invest treatment of infectious liquid waste and hospital waste water contents blood, body fluids. This type of waste is not treated before discharging to the drainage system. Often met operation houses and maternity rooms with bloody liquid discharge directly to environment due to the break of drainage pipe and damaged pipe. The drainage pipes and system that conduct the



bloody liquid, infectious liquid should be closed to protect environmental sanitation of the hospital. Existing large number of district hospitals have separately toilets for patient out of main hospital building. These toilets often to narrow, too small, with un properly septic tank discharges the waste without any treatment, causing bad environmental sanitation for hospital and residents. Most of the district hospitals do not have hospital waste water treatment facilities and the drainage system of the main town is not existing. 3.4.2. Assessment of Hospital waste water treatment. Although the fact that , there is the governmental decree No63/NDCP-2003 on compulsory environmental fee for waste water, and discharged effluent standards TCVN7382-2004 for hospital waste water that requires the waste water has to be treated properly before discharging to environment, the investment issues on hospital waste water treatment is not able to implement in the projected DHs. Liquid infectious waste, especially products with blood should be disinfected by chemical reagent (CaOCl, chloramines B..) in the labs before discharging to the sewage system. Liquid infection waste from the patient wards flows to the septic tank of the departments/faculties of the building. Such kind of wastewater often contains high pollutant BOD, COD, SS, T-N, T-P and total coliform and need to be treated in WWTF to met the discharge standards. None of 28 questionnaire DHs has WWTF. Recommendation on Technology of Hospital Waste water treatment: hospital wastewater needs to separate from the rainy water. The waste water from departments and patient wards goes to the septic tank and then flows to the WWTF treated to meet the regulation on hospital wastewater treatment and standards of discharge effluent from WWTF regulated TCVN7382:2004. The range of DH hospital bed is more often from 40-70bed/each, the hospital use 0.7-0.9m3/day and more often 0.5-0.7m3/day, so that the capacity of WWTF for one typical district hospitals is 50m3/day. The WWTF is commonly module, compacted with tank of small size of 6x2,2x2.5m made by steel covered with epoxy, stainless material or composite/concrete. The installation of this WWTF requires small piece of land of less than 50m2 (price of 30,000$/WWTF). For larger DH with more than 80 beds, volume of waste water per day will be 100-120m3/day. The WWTF is selected based on capacity of 100-120m3/day. Same to the small DH, this kind of WWTF is available in module, compacted size (price of 50,000$/WWTF, the drainage system is not included). It is recommended the 2 demonstration sites of WWTF should be installed in two hospitals with available drainage system to evaluate and making detail plan for hospital WWT in next step.



3.5 Financial source for HCWM

The almost district hospitals do not have sufficient funds for proper waste management. For example money to buy the container/box for sharp and pointed items, color coded plastic bag or plastic waste bin and waste trolleys and need destroyer/autoclave or construct the controlled deep burial pit as well as the simple solution for disinfections of liquid waste. It is easy to estimate the financial requirement for one district hospital to treat of HCW and treatment hospital waste water based on the price to incinerate 1 kg of waste and 1m3 of waste water and tools. The problem is that permitting hospital collect the fee based on inpatient bed or giving the subside to the DHs. Creating special budget line for HCWM is one key factor to make the implementation of HCWM success. The current expenses for HCWM is very limited and accounting for small portion comparing with other expenses in DH. The monthly expenses for HCWM is surveyed and this number ranged from 150,000 – 2,500,000d. 3.6 Risk associate with current HCWM practices and role

of Provincial DOH in HCWM inspection

HCSW management begins with source separation, collection, transport and finally disposal. The disposal step requires special attention and caution since it involves technical details and needs appropriate technology, as well as supervision.

The most dangerous is scratching by sharp items and needles (group B wastes), HIV/AIDS waste of group C having blood is one source of direct contamination of the HIV/AIDS diseases as well as direct contact with the Hz HCW group A wastes containing blood, materials contacted with blood.. There are 12 DHs have 32 medical staff exposed with occupational health diseases, especially Moc Chau DH – Son la Province, there are 10 medical workers exposed with hepatitis B is reported.

Whilst these theoretical risks can be foreseen, health workers know little of the actual risks; waste workers/waste pickers and the trainees and ground water are exposed.

HCWM in Bac Kan project district hospitals Bac Kan is the province has the lowest number of bed per 10000 habitants as well as annual budget per bed. The annual provincial budget per one bed is the lowest one with 11.2 million VND/bed. The range of Bac Kan district hospital is 55-70 bed is the typical number of bed for the district hospital. The Infectious control Department is not established in the district hospital due to lack of the adequate staff. The implementation of HCWM at provincial level is done by the guiding document sent to the hospitals. The official training course in HCSWM and biohazard or occupational diseases control is not trained officially. There are not adequate staff of DoH that responsible for inspection of HCWM in district hospitals. Lacking financial source for building the front surrounding the hospital. Two of seven district hospitals visited during the field trip observed that dogs and chicken often come in and out the hospital to dig the waste in the back yard of the hospital. 7 district hospitals have the requirement on medical waste incinerator.



HCWM in Son La province. 9 projected DHs have established the Infectious Control Department. HzHCSW is recorded. Mal practiced disposal of clinical waste in most of injection room. Hz HCSW generates from Mai Son district hospital and T.B hospital is collected and incinerated in one incinerator (Made in Vietnam). The experience of sharing the operation cost to destruct of clinical waste between the two hospitals is valuable lesson for other general DH, polyclinic at well as regional polyclinic and specific hospital in the town to follow. Discussion with the leader of Provincial Department of Heath revealed the serious proposal on investment of hospital waste treatment facilities for both HzHCSW and hospital waste water. The selection of treatment equipment that most appropriate to the district level is one one the lig concern of DoH. The HCWM inspection is reported belonging to the Medical Professional Departments. None of key person directly in charge of the issues.

HCWM in Cao Bang province. There are only 10 projected DHs among 14 district hospitals. The training on HCWM was organized only one time for the responsible person from the district hospitals. Lacking budget for training course for biohazard, HCWM as occupational diseases. It is reported that there are 5 medical solid waste incinerators in use at the time. But 4 of 5 incinerators were stopped due to many reason. None of the DHs has registered the safety on radioactive for X-ray room. The HCWM inspection is responsibility of the Chief Nurse Association. She took the training course one time in 2000.

HCWM in Dien Bien 7-district hospital has range of less than 70 beds. Shortage of waste collection tool, disinfection chemicals. Land filling of both domestic and medical waste in the back yard of the hospitals. The hospital such as Muong Cha district hospital is no longer enough or sufficient land for waste burying. The Dien Bien DoH has 50 medical staffs, it is reported that the Chief Nurse Association will be in charge of HCWM issues. None of hospitals established the Infectious Control Department.

HCWM in Laocai and Laichau project district hospitals The Lao cai DoH has 64 staff of whith 14 has bachelor degree. Lai chau has 40 medical staff of which 11 has bachelor degree. None of projected district hospitals established the Infectious Control Department. The HCWM at provincial level is reported to be responsible of Medical professional Department of DoHs. Most of them were not trained in HCWM.

3.7 Recommendation on HCWM in projected provinces

3.7.1 Main findings and recommendations Poor healthcare waste management in the visited projected provinces causes bad impact to the healthcare workers and community. The main findings through the survey are the following:



/DFNLQJ� RI� WUDLQLQJ�� SUDFWLFHV� RQ� +&:0� DQG� +&:0� SODQ� LQ� SURMHFWHG� GLVWULFW�KRVSLWDOV�� -All of the medical staff in the projected provinces attempts to implementing Infectious Control and try follow the Regulation on HCWM of the MoH and does the best way to separate the clinical waste from the general domestic waste in spite lacking of training, budget and tools. The internal collection route, method of segregation, procedure and tools for storage, handling, treatment and disposal of waste has not been perfectly done at the medical service rooms as well in the patient wards. - All though a major part of DHs has established HWM team but it do not work effectively by detail discuss and making one detail HCWM plan for the hospital base on hospital condition or make the planning to be implemented. -The hospitals concern to separation of sharp and pointed items but most often do not pay attention to the bloody waste, infectious liquid, body fluid .. and hospital waste water treatment as well as the safety of radioactive. /DFNLQJ�DSSURSULDWH�VXSHUYLVRU�DQG�LQVSHFWLRQ�IURP�WKH�SURYLQFLDO�OHYHO��UDLVLQJ�WKH�QHHG�WR�FDSDFLW\�EXLOGLQJ�RI�'R+V�RQ�DVVHVVPHQW�RI�+&:0��The Ministry of Health has issued a Regulation on Healthcare Waste Management in the year 1999 and is reviewing the Regulation to meet the environmental and infectious control requirement at national level. The Regulation of HCWM stated clearly the duty of inspecting and implementing HCWM is the duty of provincial healthcare establishment and Department of Therapy; MoH will be in charge of supervising the HCWM in all nation wide healthcare establishments. But in fact this job is done by the DoH through the annual evaluation mission of the DoH to each district hospital. Therefore, the need of enhancing the capacity of HCWM assessment for staff of Medical professional department of DoH in this field should be considered as well as the need of organizing the training course on HCWM for the provincial DoH and leaders of healthcare establishments/person in charge of waste management. This duty is belongings to the Department of Therapy and Treatment, MoH and should be planned to implemented. /DFNLQJ�RI�DSSURSULDWH�WRROV�DQG�HTXLSPHQW�IRU�+&:0�DQG�WUHDWPHQW�Waste separation, collection tools and appropriate treatment facilities should be planned to be supplied and used. �3.7.2 Building capacity on HCWM at projected provinces by training practices + Regulation and legislative document disseminating through the training course: Disseminate the latest revised Regulation and directive, standards on separation, collection, treatment of HCW. Preparation of the related document and guideline on HCWM to be distributed to the trainees. +Institutional and human resource development for DHs by Training practices on HCWM: Safety occupational, infectious control, HCWM will be the main subjects of the training course to create the human sources for HCWM in practice, in self-monitoring. Elaborating the “guideline on practices of HCWM for Northern upland Provinces ” with the support of HCW consultant in order to disseminate the latest legislative document and revised



Regulation aiming at guiding the district hospitals to establish their own HCW plan to implement. The two training courses will consist: 1) First one for person in charge of waste management: WMO/chief of

ICT/ Chief of Nursing of projected DHs (01/each DH) focusing on HCWM practices. Number of trainees: 58 pers.

2) Second one for person in charge of supervising HCWM at provincial DoH (02 pers./each DoH) and projected hospital leaders. Number of participant: will be more than 72 participants/ training course for hospital leaders.

Table 3.10 and table 3.11 will describe more information training course on HCWM practices and assessment.

Table: 3.10: Information on two type of training courses on HCWM

Training course

Targeted trainees

Number of trainees

Trainer Duration Expected results

HCWM for responsible of waste management

WMO/Chief of ICT/Chief of Nursing 01 pers/each

58 MoH 1 day well practices HCWM and making plan

HCWM for DH leader

DH leaders and two from DoH s

72 MoH 1day Knowing Regulation Make and approval and assessment of HCWM plan

Table 3.11: Proposal number of staff be will trained

Province Number of

DH

Number of WMO staff

will be trained

Number of DoH staff and hospital leaders

will be trained

1 Ha Giang 9 9 2

2 Cao Bang 13 13 2

3 Lao Cai 8 8 2

4 Bac Kan 6 6 2

5 Lai Chau 6 6 2

6 Dien Bien 5 5 2

7 Son La 11 11 2

DH leader 58

Total 58 58 72

(Two training courses have been designed, 60$/trainnees) 3.7.3 Waste treatment facility providing -Providing the appropriate sharp container, waste collection tools and solid waste medical incinerator/equipment. Introduce the disinfection equipment for trial.



-Putting the plan providing hospital waste treatment facilities (for both solid and liquid waste) into practice in projected district hospitals. Given priority to the hospital waste treatment facility with low investment, low operation cost. Solid medical waste incinerator standardized by TCVN7380-2004, TCVN7381-2004 and hospital waste water treatment facility moduled, compacted and standardized by TCVN7382-2004 should put in use. -Selection of the typical district hospitals each province to set-up demonstration of hospital solid and waste water treatment. After that, develop to the rest of projected district hospitals. Due to the fact that, most common district hospital has average range of 50 bed, generation rate of HzHCSW of 0.2kg/B/day, therefore medical solid waste incinerator with capacity of 10kg/h should be introduced to select. Waste water treatment facility with capacity of 50m3/day is most appropriate for district hospital in 7 Northern mountainous provinces . There are available incinerator in Hanoi, Hochiminh market with trade named UCE, VHI, TSH... capacity of 10kg/h and 20kg/h with price of 14,000 ans 20,000$/each. WWTF capacity of 50m3/day traded name V69, VLC-NT, UCE-NT and others with price of 30,000$/each. The technical requirements: solid medical incinerator and hospital waste water treatment facility is TCVN7380-2004 and TCVN7382-2004. The high priority is given to the supplier offers an adequate on site training and good quality M & O services. 3.7.4 Creating budget for HCW management (solid and liquid). Ensure to have enough financial source for buying HCWM tools, chemicals and operation cost of solid and liquid waste treatment. One example for typical DH with 50 beds:

HzHCSW treatment: 50 beds x 0.2 kg/bed/day x 5000d/kg = 50.000d/day Waste water treatment: 50m3 x 900d/m3=45.000d/day Total treatment cost (d/day); 95.000d/day. Other expenses: 25.000d/day Total expenses: 120,000d/day Total expenses for HCWM per month: 3,600.000d/month. Total expense for HCWM per year: 43,800,000d/year. Average espenses for operation of HCWM (solid+liquid waste) is about

3,000$/DH/year.

Task 4: Proposal Action Plan of HCWM in 7 northern mountainous provinces HCWM in 57 projected district hospitals of 7 Northern upland provinces is poor and weak situation is affecting the quality of healthcare services and health of medical staff and community. Therefore, preparation an Action Plan of HCWM in 7 Northern upland provinces is one of focused work aiming at giving the directive guidance and priority on financial source distribution from both kind of the credit and provincial budget at present time. 2EMHFWLYHV�RI�$FWLRQ�3ODQ��



To improve the HCWM practices and planning in the hospitals toward better comply with regulated environmental standards and safe management of HCW. 6FRSH� improvement of HCWM practices and planning in 57 projected district hospitals of the Project: Healthcare for the poor in 7 Northern Upland Provinces with the finanical credit from WORLDBANK. Due to the Regulation on HCWM is stipulated on 1999, and needed to be revised and adjustment toward better fit with new technical requirements and environmental standard and suitable for Poor Provinces. The revised Regulation will upgrade new solution on safe and alternative destruction method as well as taking more attention to the categories of RMW. Therefore, the Action Plan is focusing on: i) the enhancing the regulation and policy framework for HCWM, ii) institutional and human resource development for HCWM, iii) guideline and making specific HCWM plan for projected DHs. iv) supplying HCWM tool and waste treatment facilities. v) Recommendation on Management of other hazardous waste and creating special financial budget line for HCWM at projected DHs. 4.1 Proposal Action plan for Enhancing legislation and

institutional framework

4.1.1. Recommendations for strengthening the legislative framework a. Revise HCWM Regulation based on the innovation of categories of regulated medical waste (RMW) upgrading the Regulation to meet the newest national technical requirements on treatment facilities. Designate major concerning categories of waste that require special handling and disposal precaution 1) infectious and microbiology laboratory waste 2) bulk blood, blood products, blood, bloody body fluid specimen 3) pathology and anatomy waste, 4) sharp items. The attention should be given to developing guideline on how each waste category should be managed. Harmonizing the new regulations on hospital waste treatment solution in to the revised HCWM Regulation. Treatment of HzHCSW is now based on incineration technology and is associated with capital investment and operation costs. The destruction of infectious waste by incineration will be paid more attention on this type of waste may have been disinfected with chlorine bearing chemicals and PVC plastic bags and materials in uncontrolled small scale incinerators would result in emission of dioxin and furan which are very hazardous pollutants. The technologies such as autoclaving and micro waving can effectively treat waste as lower costs should introduced to apply. Review of management options for various waste categories and prepare a revised HCWM regulation integrating with WHO guideline for developing countries. Development of a guideline on occupational health and safety in health-care centers as well as development of safe disposal and waste minimization, cost effective solution in HCWM should be included in the MoH 's HCWM Regulation to suit the condition of DHs and DHs in poor provinces. b. Technology standards for Regulated medical waste treatment based on disinfection, neutralization or chemical treatment in order to facilitate the alternative technology to put in use. Preparation of the standards design, technologies and operation in order to introduce to the HCWM legislation. Their permitting, monitoring, reporting requirements will be involved fully. The options of using incineration, autoclaving, microwaving, deep burial waste pit, landfills are



will based on its characteristics compliance with the technology standards. The standards will be referred from the available one of the developed countries, developing countries and suitable with Vietnamese condition. In addition, encourage the hospitals using the environmental company services if recognized the condition for HzHCSWT is sufficient. Introducing of WWTF, standard design or assessment of existing one, recommendation the appropriate technology for the poor provinces. c. Guideline for HCWM in projected hospitals Preparation of guidelines for all aspects of HCWM, including personal protection measure, containerization and labeling, waste handling within the healthcare facility transportation and storage, on site transportation to disposal and treatment site. 4.1.2 Creating budget line for HCWM especially for the projected hospitals and encouraging HCWMT a. Implementation the compulsory environmental protection fee for the hospitals which do not respect the regulated discharged effluent standard on waste water and those do not respect the Regulation on Hazardous waste management in order to force the hospitals concern to the hospital waste management and treatment. The provincial DoH cooperate with the provincial Department of Natural Resources and Environment (DoNRE) will proposal the administration and compulsory fee or enforce any punishment with the district hospital that did not strictly follow the Regulation. b. Creating appropriate financial fund for HCWM especially for the projected hospitals. It is necessary to make the proposal on mobilization of financial source for operation and maintenance of HCW practices at projected DHs submitted by the provincial DoH to Provincial People Committee. This source will be involved from patient fee or from the provincial subsides to the DH to ensure the budget for HCWM. 4.2 Development institution, human resource and district

hospital specific HCWM plans

Based on the guideline or instruction on provincial HCWM and MoH’s Revised Regulation each district hospitals should develop human resource, Healthcare facility specific HCWM plan and training course on HCWM. 4.2.1 Institutional and human resource development for projected provinces Assignment of responsibilities that clearly state the duties and assignments of the staff involved of waste and means. At each of the hospitals there will develop the HCWM plan and appoint the Waste Management Team or Infection Control Teams (ICT). The ICTs will be responsible for HCWM implementation at the district hospital level. and reporting in case needed. Training on HCWM: Preparation of a training based on the concepts of "training of the trainers" involve in HCWM: Practice of Segregation, handling and Treatment of RMW. The



WMO/ chief of ICT/chief of nursing will the person to be appointed to attend to the training course for waste handling practices. They will make the expansion to the related staff. DH leader and staff of DoH will be trainner of the training course on monitoring and assessment of HCWM activities. Training content for DoH staff in charge of assessment of HCWM and hospital leaders: - General introduction to hospital acquired infections and means of transmission. - MoH's Regulation on HCWM and latest revised version, international trends - Occupational health hazards and Infection Control duties. - Reduce infections and risk of occupational exposure. - Protective equipment, i.e. what, when and how to use, operate and maintain. - HCWM Plan, Segregation, treatment and disposal methods for waste management - Outline of operations of the treatment equipment - Reporting of program implementation. - Equipment ordering and stock management. -Reporting of inventory of hazardous waste, storage calendar. Equipment suppliers or the constructors based on the technical performances and standards will do training of equipment. Training requirements for waste officer: Chief of ICTs/ WMO or Chief of Nursing directly contact with RMW on practices of HCWM: - General introduction to hospital acquired infections and means of transmission. - MoH's Regulation on HCWM and latest revised version - Occupational health hazards and Infection Control duties. - Reduce infections and risk of occupational exposure, identifying RMW. - Protective equipment, waste treatment facilities i.e. what, when and how to use, operate and maintain. - Segregation, treatment and disposal methods for waste management Awareness and Information Education Communication (IEC): IEC material on correct handling and disposal of health care waste will be developed, building upon sources available. Awareness of correct disposal of waste will be promoted amongst health care workers. The aware of risk from unhygienic conditions and mismanagement of HCW are designed for general public awareness. ��3UHSDUDWLRQ�RI�GLVWULFW�KRVSLWDO�VSHFLILF�+&:0�3ODQ��7KH�GHWDLO�KHDOWKFDUH�ZDVWH�PDQDJHPHQW�SODQ�ZLOO�FRYHU�WKH�IROORZLQJ�SRLQWV�� Location and organization of collection and storage facilities . Drawings of the hospital showing designated waste bin sites for every ward and department in the hospital; . Drawings showing the storage site for clinical waste and the separate site for other waste. Details of the type of containers, security equipment, arrangements for washing and disinfecting waste-collection bin/trolleys should be specified in the hospital map. . Drawings showing the paths of waste-collection through the hospital, with clearly marked individual collection routes.



. A collection timetable of waste collection. The storage point in the hospital should be identified. Choosing the appropriate bag/bin/ waste container, sharp container with code color and label for clinical waste or sharp items. Required material and human resources . An estimate of the number and cost of bag/bin and collection trolleys, sharps containers, yellow plastic bags to be used annually. . An estimate of the number of personnel required for waste collection. Responsibilities The proper management of health-care waste depends largely on organization of practical body. The head of the hospital should form a healthcare waste management team (HWMT) or ICT to develop a healthcare waste management plan in writing (HCWMP). The team should have the following members: Head of Hospital (as chairperson) Heads of Hospital Departments, Infection Control officer, Chief Pharmacist, Radiation Officer, Senior Nursing Officer and appoint Waste management officer (WMO) or key person with the responsibilities of development of waste management plan and waste monitor in detail (for examples waste generated each month, by waste category in each department; treatment and disposal methods, proposal financial issues and public health aspects). Before development one HCWMP the assessment of waste generation of the hospital should be done by WMO. . Definitions of responsibilities, duties, and codes of practice for each of the personnel through their daily work, that will generate waste and be involved in the segregation, storage, and handling of the waste, especially where special practices are required, e.g. for infectious waste, radioactive waste or hazardous chemical waste. Procedures and practices . Simple guide showing procedure for waste segregation, storage, handling include waste that requiring special arrangements such as autoclaving or medical waste incinerator. . Outline of monitoring procedures for waste categories and their destination. . Contingency plans, instructions on storage or evacuation of healthcare waste in case of breakdown of the treatment unit/closure down for maintenance. . Be awaked that organize good and efficient separation from the waste stream at the point of generation can reduce the total volume of hazardous and clinical waste and hence reduces the costs of the specialized treatment or disposal of waste for district hospital in the circumstance of lacking financial source. .Incineration to destroy the clinical and hazard waste; priority to the use of cluster incinerator manufactured based on TCVN7381-2004, TCVN7380-2004. Treatment of hospital wastewater to meet the TCVN7382-2004. Proposals to cut the pathway of contamination: Eliminate direct contact between people and hazardous HCSW by: providing personal protective equipment e.g. heavy duty gloves, safety glasses, thick clothes; Restricting access to healthcare waste dumping site; Improving awareness of dangers of contamination from HCW. Eliminate indirect contact between people and hazardous healthcare waste by Applying vector control methods e.g. covering waste; Protecting water supplies from contamination; Implementing good hygiene practices when dealing with waste by hand washing; Hazard reduction: Encouraging the use alternative solution for safe disposal of clinical such as autoclave/chemicals to initial disinfection of clinical waste before safe disposal of waste in



separate sanitary burial pit/cell at disposal site. In case use the incineration method, the good designed and qualified incinerator should be used. 4.3 Procurement HCWM equipment and supplies HCWM Regulation and associated technical standards will form the bases of HCWM practices from the aspect of segregation, collection, treatment of waste in projected hospitals. 4.3.1 Supplying HzHCSW collection tools and HCSW treatment facilities + Providing Hz HCSW collection tools (waste collection bag/waste bins, boxes for sharp items) based on waste generation rate. The average number of HzHCSW tool is calculated based on the rate of 0.2kg/bed/day or 60-72kg HzHCSW/bed/year or 150 bag/bed/year (bag 10l) 1kg of sharp and pointed item/bed/year or 10 boxes/bed/year.

+ For Hz HCSW treatment facilities supply: Evaluation and assessment of current incinerators (design and operation) should be conducted in 2007 and beginning of 2008 in order to select appropriate medical incinerators for 7 provinces. At the same time, the evaluation of technical standards, as well as evaluation of alternative technologies (autoclaving, micro waving) should be completed and put in to effect. With respecting of recommendation of the Regulation, clinical waste should be incinerated in medical waste incinerator standard by TCVN7380-2004 and TCVN7381-2004. 4.3.2 Standard design of waste water treatment, pilot demonstration and setup WWTF in projected DHs + Standard design of WWTF -Immediate applying initial disinfections of infection liquid waste by using chemical reagent before discharging to the septic tank and WWT before discharging to environment. - Based on the HCWM plan and DH map the standard design for WWTF for two type of projected district hospitals (50beds and 100beds) will be carried out. The development of a standard design for waste water from healthcare facilities based on the following assumption: wastewater from healthcare facility discharges to the municipal treatment facilities; wastewater from healthcare facility discharge to surface water + Setting up pilot demonstration of WWTF Choice the two DH to be set up WWTF as demonstration site. Building up several demonstrations cost effective WWTF as case studies for evaluation of investment- maintenance-operation lesions. The WWTF should apply settlement/purifying process and biological treatment in order to obtain the high efficiency of organic and nitrogen matter treatment as well as disinfection and discharged effluent meet TCVN7382:2004 for the discharged waste water effluent and maximizing reduction of sludge generated from the WWTF. + WWT facilities setting up in the projected DHs -The budget for hospital waste water treatment should be based on the standard designs for each district hospitals. -To ensure that the septic tank has been properly designed and well operated. - Having the plan of setting up WWTF for healthcare facilities after 2008 and consider as one of the urgent solution to solve the back spot of the pollution.



4.4 Other hazardous waste management

Based on the HCWM Plan and Regulation the other type of waste such as chemicals, drugs waste or hazardous chemical waste with no contents of chlorine, heavy metal, explosion or radioactive can be properly incinerated. Otherwise, the hazardous waste should be returned to the suppliers, safety storage waiting to deliver to professional transportation to the right treatment site to destruct.



Task 5: provision budget line for HCWM action plan in 7 projected provinces Relating to above mentioned action plans for 7 projected provinces, the following budget line proposed using the credit and provincial budget with two implementation steps for the HCW treatment (demonstration and disseminating steps). 5.1 Estimation cost for HCSW treatment at 7 projected

provinces

Table 4: Estimation cost for Action Plan on HCWM in 7 projected provinces Description of action plan Cost (US$)

Enhancing Guideline-Regulation-Policy Framework

1

Revised guideline Elaborating the guideline Getting the opinion for local hospital and DoH Disseminating

5,000

Development of Institution, human resource and DH specific HCWM plan 2.1 Organize 02 training course on HCWM for 7 projected provinces -Training course on HCWM practices for waste management officer - Training course on HCWM evaluation and assessment for DoH and hospital leaders. See table 3.10 and table 3.11 Allowances +document for Participants: 130 x60$=7800$ Training room, coffee break, services 2day *600$ = 1200$

9,000

2

2.2 IEC materials for 7 projected hospitals 2.3 Making HCWM Plan and Consultancy fee for upgrading, elaborating, HCWM plan of projected district hospital

3,000

7,000 Supply HCSW collection tools and HCSWT facilities 3.1 HCSW tools (PE plastic bag, boxes for sharp items) 7 Provincesx3000$ (250 kg/provinces x 12$/kg= 3000$)

21,000

3

3.2 Procurement of HzHCSW treatment facilities for projected DH Solid waste incinerators: Incinerator 20kg/h (11x 20,000$=220,000$) Incinerator 10kg/h (46x14,000$ =658,000$) 864,000 Hospital waste water treatment standard design, demonstration and disseminating 4.1 Standard design and Demonstration of hospital waste water treatment facility WWTF with 100 m3/day (1x50,000= 50,000$) WWTF with 50m3/day (1x30,000=30,000$

80,000 4

4.2 Setup WWTF in the projected district hospitals 45*30.000$/ WWTF 50m3/day + 10*50.000$/WWTF 100m2/day = 1.850.000$. 1,850,000

5 Management of other hazardous wastes (DHs self-doing)

6

Creating financial source for HCWM at projected DH (use provincial budget). Average 3,000$/DH/year or 171,000$/year

in kind (From provincial

budget)



7 Implementation good practices on HCWM in almost projected DH up to year 2012 From credit and

provincial budget

Total estimation cost for HCWM action plan

2,839,000 and provincial

budget 5.2 Schedule

Action plan Solution 1st

year

2nd

year

3rd

year

4th

year

5th

year

1 Enhancing

regulation and

legislation

Revise

regulation

Elaboration

guideline

2 Institutional

Human

development

and IEC in

HCWM

Training

courses

HCWMP

advisory and

carrying IEC

3 HCSW practices:

segregation,

collection and

medical solid

waste treatment

Supply tools,

equipments

and treatment

4 HC liquid

waste

treatment

Standard

design, pilot

demo and

setup

5 Creating

financial

source for

HCWM from the

provincial

budget

Subsidies

from

Provincial

People

Committee or

patient fee

6 Other

hazardous

waste

management

HCWM

practices

7 Implementation

HCWMP

HCWM

practices



Annex 1: Natural – social condition of 7 projected provinces

In the Northern Highlands, there are two sub-regions: the Northeastern and the Northwestern. The Northeastern region stretches from the Chinese border to the Red River. It is closely linked with southern China in terms of geology, topography, climate, flora and fauna. The topography generally consists of hills and low mountains averaging less than 600 meters. Mountains over 1,000 meters account for only 10% of the area and only a few peaks surpass 2,000 meters. Between the mountains, there are large depressions, formerly tertiary lakes or river valleys that are often flooded with land highly suitable for cultivation. These are the inhabited areas. The Northwestern region is linked to upper and central Laos. The region is sheltered by a mountain range and is less exposed to the northeastern monsoon. The winters are short with temperatures below 18oC during only one or two months of the year. The narrow western slope descends gently toward the Red River. Thus protected, the region is sheltered from the northeast and southwest monsoons, hence a dry winter. The northern mountainous region contains 31 of the 54 ethnic groups. The Red River can be considered the boundary between the Tay - Nung linguistic group and the Thai and other ethnic groups belonging to the Mon-Khmer linguistic group. Residents living along the Vietnam-China border belong mostly to the Tang- Mien linguistic group while those along the Vietnam-Laos border belong to the Mon- Khmer linguistic group. Today it is common for many ethnic groups to live in the same area. There are exceptions, for example, the Tay, Muong and Thai live mostly in the lowlands, and in the valleys of foothills. The Nung, the San Chay and San Diu are mostly concentrated on the less fertile hilly and mountainous areas, having migrated from China to Vietnam after the settlement of other groups. Living in the middle areas are the Dao, and the Kho Mu and on the uplands are the H’Mong. The most typical characteristic of the ethnic groups in the northern mountainous provinces is their mixed residence. The ethnic minority people live mainly on rice farming. Besides rice, other food crops such as maize, sweet potatoes, cassava, wheat, soy beans and vegetables also play an important role in the economy of the ethnic minority groups. In some places people also grow tea, cinnamon and oranges. Highlanders have shifted to growing fruit trees (such as plump and peach) or medicinal herbs. Livestock raising such as buffaloes, cows, goats, pigs, horses, chicken, duck is very popular, but only on very small scale. Ha Giang shares a common border with China. Ha Giang is a mountainous community with an average height of 800-1200 meters; the highest peak is 2419 meters. The geography consists of 3 sub-regions: Region I: high mountains with an average height from 1000 to 1600 meters; Region II has medium level mountains with an average height between 900-1000 meters. The geography of this region is characterized by sloping mountains. Region III has a low mountainous terrain with the most favorable land for agriculture. All provinces in the Project area are topographically very similar to that of Ha Giang. Cao Bang shares a 311-km-long borderline with China and has an area of 6,690 square kilometers. The economy consists of industry which accounts for 15%, agriculture and forestry 54% and services 31%. Cao Bang, similar to other of the Project provinces, has rich natural mineral resources. Lao Cai borders China to the north. The provincial capital of Lao Cai is close to the borderline between Vietnam and China, about 300 km from Hanoi and around 300 km from Kunming City. The town has emerged as a major economic center in the northern region as the result of trade and tourism activities. Lao Cai’s terrain is divided into two distinct natural areas: the highlands at an elevation of 700 meters or more are home to ethnic minorities, such as H’mong, Dao, Ha Nhi, Phu La, KhangLa, La Chi etc. The lowlands comprise valleys along the bank of the Red River and the third biggest valley of Muong Than in the Northwest. Bac Kan is situated along Highway No. 3 from Hanoi. This is an important transport link of the North East. Bac Kan is surrounding by provinces with relatively good economic potentials: Thai Nguyen to the South, Cao Bang to the North, Lang Son to the East, Tuyen Quang to the West. Forestry and agriculture production play a major role in the economy. Lai Chau is a border gate province with China to the north. It is one of the poorer provinces with all of the challenges resulting from its geographic and topographic position in the northern region of the country. It was separated from Dien Bien in 2004. Son La has a borderline with Laos. It is home to more than 1 million people of 12 ethnic groups, including Thai, Kinh, Mong, Muong, Xinh Mun, Kho Mu, Khang, La Ha, Dao and etc. The province has plenty of advantages and



Annex 2: District hospital and results from survey

Table B-1: List of district hospitals in 7 Northern Mountainous Provinces in Viet Nam.

STT Full Name of Hospital Planned

bed Beds in

2010

Type of DH “1”-DH <80bed “2”-DH over 70beds

Cost of Incinerator

$

Cost of Waste water

treatment facility

$

SON LA PROVINCE 1060 1060 1 DH PHU YEN REGIONAL GENERAL HOSPITAL - SON LA 140 2 20 000 2 DH THUAN CHAU DISTRICT HOSPITAL - SON LA 100 2 20 000 3 DH BAC YEN 60 4 DH SOP COP 50 1 14 000 5 DH PHU YEN (II) DISTRICT HOSPITAL 120 2 20 000 6 DH MOC CHAU DISTRICT HOSPITAL 100 2 20 000 50 0007 DH MAI SON DISTRICT HOSPITAL 120 8 DH QUYNH NHAI DISTRICT HOSPITAL 100 2 20 000 9 DH SONG MA DISTRICT HOSPITAL 100 2 20 000

10 DH MUONG LA DH 70 1 14 000 12 BH AGRICULTURAL HOSPITAL - SON LA PROVINCE 100 2 20 000 LAI CHAU PROVINCE 250 270 1 DH PHONG THO DISTRICT HOSPITAL - LAI CHAU 40 1 14 000 2 DH THAN UYEN DISTRICT HOSPITAL - LAI CHAU 50 1 14 000 3 DH TAM DUONG 50 1 14 0004 DH MUONG TE 50 1 14 000 5 DH SIN HO DISTRICT HOSPITAL 30 1 14 000 6 DH THAN THUOC REGIONAL HOSPITAL - LAI CHAU 30 1 14 000 BAC KAN PROVINCE 360 380 1 DH NARI DISTRICT HOSPITAL -BACKAN PROVINVE 60 1 14 000 2 DH CHO DON DISTRICT HEALTH CENTER - BAC KAN 70 1 14 000 3 DH BABE DISTRICT HOSPITAL - BAC KAN 50 1 14 000 4 DH NGAN SON DISTRICT HOSPITAL - BAC KAN 50 1 14 000 5 DH BACH THONG DISTRICT HOSPITAL- BAC KAN 15 1 14 000 30 0006 DH BAC CAN health care 15 7 DH PAC NAM DISTRICT HOSPITAK 50 1 14 000 8 DH CHO MOI DISTRICT HOSPITAL 50 1 14 000 LAO CAI PROVINCE 510 540 1 DH BAC HA DISTRICT HOSPITAL - LAO CAI PROVINCE 50 1 14 000 2 DH SAPA DISTRICT HOSPITAL - LAO CAI PROVINCE 50 1 14 0003 DH MUONG KHUONG DISTRICT HOSPITAL - LAO CAI 50 1 14 000 4 DH BAT SAT DISTRICT HOSPITAL - LAO CAI 50 1 14 000 5 DH BAO YEN DISTRICT HOSPITAL - LAO CAI 80 1 14 000 6 DH SI MA CAI DISTRICT HOSPITAL-LAO CAI 50 1 14 000 7 DH VAN BAN DISTRICT HOPSITAL - LAO CAI 60 1 14 000 8 DH BAO THANG DISTRICT HOSPITAL - ;AO CAO 120 1 14 000 CAO BANG PROVINCE 735 975 1 DH HA QUANG DISTRICT HOSPITAL - CAO BANG 50 1 14 000 2 DH NGUYEN BINH DISTRICT HEALTH CENTER - CAO BANG 50 1 14 000

3 DH QUANG UYEN DISTRICT HEALTH CENTER - CAO BANG 70 1

14 000

4 DH THACH AN DISTRICT HOSPITAL -CAO BANG PROVINCE 55 1 14 000 5 DH HOA AN DISTRICT HOSPITAL 80 2 20 0006 DH HA LANG DISTRICT HOSPITAL 50 1 14 000



7 DH PHUC HOA DISTRICT HOSPITAL 40 1 14 000 8 DH TRUNG KHANH DISTRICT HOSPITAL 60 9 DH BAO LAC DISTRICT HOSPITAL 60 1 14 000

10 DH TRA LINH DISTRICT HOSPITAL 50 1 14 000 11 DH TINH TUC DISTRICT HOSPITAL 50 1 14 000 12 DH THONG NONG 40 1 14 000

13 DH BAO LAM 40 1 14 000

14 DH MEDICAL CENTER OF CAO BANG 40 1 14 000

HAGIANG PROVINCE 710 810 1 DH BAC QUANG DISTRICT HOSPITAL - HA GIANG 145 2 20 000 2 DH QUANG BA DISTRICT HOSPITAL 50 1 14 000 3 DH XIN MAN 60 1 14 000 4 DH DONG VAN DISTRICT HOSPTAL - HA GIANG 50 5 DH MEO VAC DISTRICT HOSPITAL 70 1 14 000 6 DH BAC ME DISTRICT HOSPITAL 40 1 14 000 7 DH HOANG SU PHI DISTRICT HOSPITAL 65 1 14 000 8 DH YEN MINH 100 2 20 000 9 DH VI XUYEN 80 2 20 000

10 DH QUANG BINH 50 1 14 000 DIEN BIEN PROVINCE 330 460 1 DH DIEN BIEN DONG DISTRICT HOSPITAL - DIEN BIEN PROVINCE 30 1 14 000 2 PL MEDICAL CENTER MUONG NHE - DIEN BIEN 30 1 3 DH REGIONAL GENERAL HOSITAL MUONG LAY 70 1 14 000 4 DH TUAN GIAO DISTRICT HOSPITAL 60 1 14 000 5 DH GENERAL HOSPITAL MUONG CHA - DIEN BIEN 50 1 14 000 6 PL POLYCLINIC MUONG CHA 10 7 DH HOSPITAL TUA CHUA - DIEN BIEN 50 1 14 000 8 PL POLYCLINIC TUA CHUA 10 9 PL POLYCLINIC THANH TRUONG - DIEN BIEN 20

Total 864 000 80 000

PL: Polyclinic, DH; District hospital



Table B-2: Data on HCSM in 28 district surveyed hospitals (March- April, 2007)

Code

Full Name of Hospital No of planned beds

No of inpatients

No of consultations

No of surgery acts

Bed Oc

No of staff

Total Hazardous HCSW (kg/d)

Total domestic solid waste (kg/d)

Total solid waste (kg/d)

Rate HzHCSW kg/B/day

8 DH TRUNG KHANH DH 60 45 80 0.16 75 61 11 45 56 0.18

3 DH REGIONAL GH- MUONG LAY 70 55 48 0.2 79 69 13 40 53 0.19

28 PL POLY THANH TRUONG – DIEN BIEN 20 20 0.01 100 19 3 10 13 0.15

24 DH DIEN BIEN DONG DH - DIEN BIEN 30 40 55 2 133 41 8 40 48 0.27

10 DH NGAN SON DH – BAC KAN 50 55 53 0.5 105 54 10 50 60 0.2

13 DH SAPA DHL - LAO CAI 50 50 47 1 100 45 20 60 80 0.4

14 DH MUONG KHUONG DH - LAO CAI 50 60 60 2 120 45 23 50 73 0.46

15 DH SI MA CAI DH-LAO CAI 50 50 215 3 100 63 6 60 66 0.12

17 DH NGUYEN BINH DH- CAO BANG 50 32 72.5 0.14 64 49 3.1 10 13.1 0.06

21 DH THONG NONG 50 60 52 1 120 39 11 90 101 0.22

23 DH DONG VAN DH - HA GIANG 50 50 20 0.14 100 46 4 20 24 0.08

26 DH G.H. MUONG CHA - DIEN BIEN 50 55 54 0.6 105 52 12 50 52 0.24

27 DH HOSPITAL TUA CHUA - DIEN BIEN 50 55 0.1 110 66 8 35 43 0.16

11 DH BACH THONG DH-BAC KAN 55 50 64 0.5 105 50 12 50 62 0.22

19 DH THACH AN DISTRICT H. –CAO BANG 55 60 65 0.2 110 54 10 45 55 0.18

5 DH PHONG THO DH. - LAI CHAU 60 59 70 0.7 98 77 5 12 17 0.08

6 DH THAN UYEN DH - LAI CHAU 60 65 54.03 0.58 108 68 14.5 300 314.5 0.24

8 DH NARI DH -BACKAN 60 60 55 0.5 100 47 5 10 15 0.08

16 DH VAN BAN DISTRICT H - LAO CAI 60 60 55 0.5 100 59 18 40 58 0.3

25 DH TUAN GIAO DISTRICT HOSPITAL 60 88 65 0.58 147 66 8 35 43 0.13

9 DH CHO DON DISTRICT HO.-BAC KAN 70 68 88.8 0.5 97 52 6.8 60 66.8 0.1

12 DH BAC HA DH - LAO CAI 70 90 56 0.05 100 69 20 100 120 0.29

4 DH YEN CHAU DISTRICT HOSPITAL 80 90 90 3 113 64 19 100 119 0.24

18 DH QUANG UYEN DH - CAO BANG 80 12 63 0.3 15 63 39 50 89 0.49

20 DH HOA AN DISTRICT HOSPITAL 80 90 70 2 110 85 16 65 71 0.2

2 DH THUAN CHAU DH - SON LA 100 50 86 0.5 50 81 13 30 43 0.13

3 DH MAI SON DISTRICT HOSPITAL 120 122 138 0.5 102 129 22 80 102 0.18

22 DH BAC QUANG DH - HA GIANG 120 120 153 0.3 100 112 50 50 100 0.42

1 DH PHU YEN REGIONAL GH - SON LA 140 182 146 0.25 130 114 23 100 123 0.16



Table B-3: Healthcare waste treatment at the projected district hospitals

STT

Full Name of Hospital Hazardous waste segregation (Y/N)

Sharps segregation (Y/N)

Colour code (Y/N)

Municipal landfill (Y/N)

Onsite Burial (Y/N)

Incineration in cluster incinerator (Y/N)

Onsite Incineration (Y/N)

Incineration in simple furnace (Y/N)

Open burning (Y/N)

8 DH TRUNG KHANH DH-CAOBANG Y Y Y N Y N N

3 DH REGIONAL GH- MUONG LAY Y Y N N Y N N N Y

28 PL POLY THANH TRUONG – DIEN BIEN Y Y N N Y Y

24 DH DIEN BIEN DONG DH - DIEN BIEN Y Y Y Y Y

10 DH NGAN SON DH – BAC KAN Y N Y

13 DH SAPA DHL - LAO CAI Y Y Y

14 DH MUONG KHUONG DH - LAO CAI Y Y N Y

15 DH SI MA CAI DH-LAO CAI Y Y

17 DH NGUYEN BINH DH- CAO BANG Y Y Y

21 DH THONG NONG Y Y Y Y

23 DH DONG VAN DH - HA GIANG Y Y Y

26 DH G.H. MUONG CHA - DIEN BIEN Y Y Y Y

27 DH HOSPITAL TUA CHUA - DIEN BIEN Y Y N N Y Y

11 DH BACH THONG DH-BAC KAN Y N Y Y

19 DH THACH AN DISTRICT H. –CAO BANG Y Y Y Y

5 DH PHONG THO DH. - LAI CHAU Y Y N Y Y

6 DH THAN UYEN DH - LAI CHAU Y Y Y Y Y

8 DH NARI DH -BACKAN N Y Y

16 DH VAN BAN DISTRICT H - LAO CAI Y Y N Y

25 DH TUAN GIAO DISTRICT HOSPITAL Y Y Y Y Y

9 DH CHO DON DISTRICT HO.-BAC KAN N N Y

12 DH BAC HA DH - LAO CAI Y Y N Y

4 DH YEN CHAU DISTRICT HOSPITAL Y Y N Y Y

18 DH QUANG UYEN DH - CAO BANG Y Y Y

20 DH HOA AN DISTRICT HOSPITAL Y Y Y Y

2 DH THUAN CHAU DH - SON LA Y Y N Y Y

3 DH MAI SON DISTRICT HOSPITAL Y

22 DH BAC QUANG DH - HA GIANG Y N Y Y

1 DH PHU YEN REGIONAL GH - SON LA Y Y N Y Y



Table B-4: Healthcare waste management team at projected district hospitals

STT Full Name of Hospital Internal regulation

Use of a regulatory text (Y/N)

HCSWM team (Y/N)

No of staff directly involved in HCSWM

No of staff got training

Proposed to have

incinerator (Y)

Cost for Hz waste

treatment

8 DH TRUNG KHANH DH-CAO BANG Y Y Y 1 N? 1,500,000

3 DH REGIONAL GH- MUONG LAY N N N 4 1Y 900,000

28 PL POLY THANH TRUONG – DIEN BIEN N N Y 2 1N

24 DH DIEN BIEN DONG DH - DIEN BIEN N N Y 3 Y 170,000

10 DH NGAN SON DH – BAC KAN N N Y 3 Y 500,000

13 DH SAPA DHL - LAO CAI N N Y 3 Y 1,200,000

14 DH MUONG KHUONG DH - LAO CAI N N Y 4 Y 2,000,000

15 DH SI MA CAI DH-LAO CAI N N Y 3 Y 350,000

17 DH NGUYEN BINH DH- CAO BANG N Y Y 3 Y 119,000

21 DH THONG NONG N N Y 2 Y 150,000

23 DH DONG VAN DH - HA GIANG N Y Y 1 Y 880,000

26 DH G.H. MUONG CHA - DIEN BIEN N Y 3 1

27 DH HOSPITAL TUA CHUA - DIEN BIEN N N Y 5 1N 250,000

11 DH BACH THONG DH-BAC KAN N N Y 2 Y

19 DH THACH AN DISTRICT H. –CAO BANG N N Y 3 Y

5 DH PHONG THO DH. - LAI CHAU N Y Y 4 20Y

6 DH THAN UYEN DH - LAI CHAU N Y N 3 Y 490,000

8 DH NARI DH -BACKAN N Y N 4 N 150,000

16 DH VAN BAN DISTRICT H - LAO CAI N N Y 3 Y 1,500,000

25 DH TUAN GIAO DISTRICT HOSPITAL N Y N 6 1Y 490,000

9 DH CHO DON DISTRICT HO.-BAC KAN N N N 5 N 2,000,000

12 DH BAC HA DH - LAO CAI N N N 3 N

4 DH YEN CHAU DISTRICT HOSPITAL N Y Y 3 1Y

18 DH QUANG UYEN DH - CAO BANG N Y N 6 N 200,000

20 DH HOA AN DISTRICT HOSPITAL N N Y 3 Y 1,000,000

2 DH THUAN CHAU DH - SON LA N Y N 2 Y

3 DH MAI SON DISTRICT HOSPITAL Y Y 3 Y

22 DH BAC QUANG DH - HA GIANG N Y Y 7 14Y 1,500,000

1 DH PHU YEN REGIONAL GH - SON LA N Y Y 0 0Y 120,000

Annex 3: Minute of meeting and pictures

Annex 4: References – TCVN7380, TCVN7381, TCVN7382-2004



Annex 5: Questionnaires



References: for task 1,2 1. Basel Convention on the Control of Transboundary movements of hazardous

wastes and their disposal adopted by the Conference of the Plenipotentiaries on 22 March 1989.

2. Environmental Protection in Healthcare Facilities. Department of Preventive Medicine, 9/2002.

3. Environmental Protection in Healthcare Facilities. Nguyen Huy Nga, 2004. 4. Guidelines for the management of clinical and related wastes in hospital and

healthcare establishments. Ministry of Malaysia. May 1993. 5. Healthcare Waste Management Component for Samoa - draft. World Bank,

1999. 6. Healthcare waste management- Guidance for the development of National

Action Plan – Draft version. World Health Organization. 2002 7. Healthcare Waste Management Handbook- A WHO Guide for Developing

Countries. World Health Organization, May 1997. 8. Healthcare Waste Management in Ghana. MOH Policy and Guidelines for

Health Institutions. Ghana Ministry of Health. 9. Healthcare Waste Management System for Samoa Vietnam Environmental

Standards. Ministry of Science – Technology and Environment, Hanoi 1995 10. Hospital Regulation. Medical Publishing House, 1997. 11. Hospital waste management and relevant legislations and policies, the

proceedings of Workshop on Hospital Waste Management on 19-20 June 1998. Nguyen Thi Hong Tu, 1998.

12. Infection Control and Healthcare Waste Management Plan Component for the HIV/AIDS Prevention and Control Project for Bhutan. Royal Government of Bhutan, April 2004.

13. Inspection Handbook for Environmental Protection. Department of Environment. Hanoi 2000.

14. Management of Clinical and Related Wastes in Hospitals and Healthcare Establishments. Ministry of Health of Malaysia, July 1993.

15. Managing Regulated Medical Waste. New York State Department of Health. http://www.health.state.ny.us/nysdoh/environ/waste.htm.

16. Manual on hospital waste management. Environmental Health Service- Department of Health, Manila.

17. Regulation on Healthcare Waste Management. Medical Publishing House, 1999. 18. State of the Environment -Vietnam -20010. The United Nations Environment

Programme, 2001. 19. Vietnam Environment Monitor 2004 – Solid waste. World Bank, Ministry of

Natural Resource and Environment, and Waste-ECON. 20. A-Pruss, E-Giroult, P.RushBrook. 1999. Safe management of waste from

health-care activities. WHO. 21. Department of Therapy and BUzep. Results of investigation in developing the

master plan for health care treatment.



References for task 3,4 1. Project document, 2004 2. Statistics Healthcare Year Book 2001 3. Hospital Waste Management in the Philippines - Two Case studies in Metro Manila' UWEP Case Study Report. 4. Lessons from India in Solid Waste Management' WEDC, Loughborough, UK 5. Regulation on HCSW management, Ministry of Health, 1999 6. Guideline on HCSW Management Practices, Ministry of Health, 2000 7. Thai N., T .,K., Proposed measures to treat medical waste in Hanoi. Hospital Waste Management – Workshop Proceeding, 6/1998 8. Chi N., K., Evaluation of implementation of Regulation on Healthcare Waste Management of Ministry of Health. Report of the Nation Project on Master Plan on Health care solid waste management. 5/2002 9. State of Environmental Status 2002, Ministry of Natural Resources and Environment. 10. Thuy Tran Thu et all (1998), Result the survey on Healthcare solid waste in 24 hospitals, Ministry of Health, Joint project between Ministry of Health & World Health Organization, 5/1998 11. Thuy Tran Thu et all (1998), Result of the survey on Healthcare solid waste in 80 hospitals, Ministry of Health - Joint project between Ministry of Health & World Health Organization, 5/1998 12. Chi N., K., Healthcare Waste Management survey in Phu Tho Province, May-2003 13. Chi N.,K., Healthcare Waste Management for HIV/AIDS prevention control in Vietnam, World bank project, 2005.



Documents

World Bank Documentdocuments.worldbank.org/curated/en/602671468762000729/... · 2016-07-17 · is expected to increase up to 70-80 tons/day in 2010. Due to the increase of healthcare