Healthcare waste management in 7 MNPB - World Bank
Ministry of Health
Project management board
Healthcare for the poor in
7 Northern Upland Provinces
Final report on
Building up the plan for
healthcare waste management and treatment
by: PhD. MBA. Ngo Kim Chi, Local consultant
Center for consultancy and technological transfer
on safe water supply and environment
24 Sep, 2007
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 16
1.3.1 Review the best HCWM requirements in the world 16
1.3.2 Strategy for healthcare waste treatment in some countries 17
1.3.3 Regulation on healthcare waste management, the Ministry of Health 18
1.3.4 Vietnam and international standards - identification of gaps 19
1.3.5. Comparing Vietnam HCW practical regulations with WHO/international guides 20
1.3.6 Comparison of WHO and Vietnam classification 26
1.3.7 Healthcare waste incinerators in Vietnam 27
1.4. Recommendations for strengthening the legislative framework 29
TASK 2. ASSESSMENT OF INSTITUTIONAL FRAMEWORK 30
2.1 Roles, responsibilities, interactions: environmental, health institutions, stakeholders 30
2.1.1. Role of environmental sector 30
2.1.2. Role of healthcare sector 31
2.1.3 Role of healthcare facilities 32
2.1.4.Role of public service 32
2.1.5. Inter-institutional issues 33
2.1.6 Budget line for HCWT 33
2.2. Different staff groups: assessment of associated capacity within hospital on HCWM. 33
2.2.1 Within hospital responsibilities on HCWM 33
2.2.2 Within the Ministry of heath 34
Task 3: Assessment of HCWM in the projected provinces 36
3.1 Project introduction 36
3.2 Healthcare services in projected provinces and district hospitals of 7 mountainous provinces 37
3.2.1 Description of project provinces and healthcare services 37
3.2.2. Healthcare service in projected district hospital 38
3.3 Assessment on HCW characteristics, rate of generation in project district hospitals 40
3.3.1 Field trip survey 40
3.3.2 Assessment of volume of Hz HCSW, generation rate at projected DHs 41
3.3.3. Assessment of Group of Hz HCSW in practices 44
3.3.4 Assessment of Segregation, Collection, onsite Transportation of Hz HCSW in projected DH. 44
3.3.5 Assessment of HCWM team, internal guideline, training course in HCWM 46
3.3.6 Assessment of Hz HCW treatment 47
3.3.7. Assessment of the HCWM practices in 7 provinces 48
3.4 Liquid infectious waste, hospital wastewater treatment 52
3.4.1 Situation of infectious liquid waste in projected hospitals 52
3.4.2. Assessment of Hospital waste water treatment. 53
3.5 Financial source for HCWM 54
3.6 Risk associate with current HCWM practices and role of Provincial DOH in HCWM inspection 54
HCWM in Bac Kan project district hospitals 55
HCWM in Son La province. 55
HCWM in Cao Bang province. 55
HCWM in Dien Bien 56
HCWM in Laocai and Laichau project district hospitals 56
3.7 Recommendation on HCWM in projected provinces 56
3.7.1 Main findings and recommendations 56
3.7.2 Building capacity on HCWM at projected provinces by training practices 57
3.7.3 Waste treatment facility providing 59
3.7.4 Creating budget for HCW management (solid and liquid). 59
Task 4: Proposal Action Plan of HCWM in 7 northern mountainous provinces 60
4.1 Proposal Action plan for Enhancing Regulation, Policy framework 60
4.1.1. Recommendations for strengthening the legislative framework 60
4.1.2 Institutional Framework Development for projected provinces 62
4.2 Preparation of district hospital specific HCWM plans 63
4.3 Procurement HCWM equipment and supplies 65
4.3.1 Supplying HzHCSW collection tools and HCSW treatment facilities 65
4.3.2 Standard design of waste water treatment, pilot demonstration and setup WWTF in projected DHs 66
4.4 Other hazardous waste management 66
Task 5: provision budget line for HCWM action plan in 7 projected provinces 67
5.1 Estimation cost for HCWM and treatment at 7 projected provinces 67
5.2 Schedule 68
Annex 1: Natural – social condition of 7 projected provinces 69
Annex 2: District hospital and results from survey 69
Annex 2: District hospital and results from survey 70
Annex 3: Minute of meeting and pictures 74
Annex 4: References – TCVN7380, TCVN7381, TCVN7382-2004 74
Annex 5: Questionnaires 74
References: for task 1,2 75
References for task 3,4 75
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 |17th Oct 1997 |Guidelines of practicing The Circular No 199/TTg by Prime Minister on |
|Science, Technology and Environment- Ministry | |emergency measures on solid waste management in industrial zones. |
|of construction | | |
|Decision No 155/1999/QD-TTg by Prime Minister |16th July 1999 |Hazardous waste classification. Identify the responsibilities and |
|issued on the Regulation on hazardous waste | |functions of workers who collect and transport and disposal wastes. |
|management | |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 |19th Sept1997 |Regulation on hospitals |
|Health | | |
|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 |1999 |Emission standard for medical solid waste incinerator |
|Air quality – emission standard for medical | | |
|solid waste incinerator | | |
|Official letter No 1153/VPCP-KGGovernment |22th March1999 |Assign the Ministry of Health in actively coordinate with concerning |
|office No 1069 CP/QHQT By government office. |11th October |sectors/ministers to develop the master plan of healthcare solid waste |
| |1999 |management in the whole country. |
|Decision No 60/2002/QD-BKHCNMT by The Minister |07th August 2002 |Issue on Technical guidelines on hazardous waste burying. |
|of Science, Technology and Environment | | |
|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, |21st Nov 2001 |Regulation on technical requirements of incinerators for healthcare |
|Technology and Environment | |wastes. Minimum requirement for the second chamber of the incinerator |
| | |do not less than 10500C with retention time >1s. Capacity 400kg/day should have dry |
| | |cleaner |
|TCVN7382:2004 |2004 |National discharged standard for hospital waste water |
|Water quality- Hospital waste water – | | |
|discharged standards | | |
|TCVN7381:2004 |2004 |Method for evaluating medical solid waste incinerator |
|Healthcare solid waste incinerator – Method of | | |
|specification appraisement | | |
|TCVN7380:2004 |2004 |National technical requirement for medical solid waste incinerator |
|Healthcare solid waste incinerator- Technical | | |
|requirement | | |
1.1.2 Decision No. 2575/1999/QD-BYT, August 27, 1999, of the Minister of Health on healthcare waste management.
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- |Bury |Sewer | to generation |Reuse |Destroyed as |
| | |ration | | |source | |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. Healthcare waste: 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. Hazardous waste: 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. Hazardous healthcare waste: 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. Hazardous healthcare waste management: 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. Waste handling: the process of the separation, classification, collection, package and temporary storage of waste at the waste station of a health establishment.
1.6. Waste transportation: the process transporting waste from generating place to section of preliminary treatment, storage and destruction. .
1.7. Preliminary waste treatment: 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. Waste disposal: 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
Solid waste: 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
Gaseous and liquid waste discharge standard:
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 world
The 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 |Incinerating |Disinfection |
| | |incinerating |Dumping | | | |
|Assess by practice |Treat outside |Treat outside health |On-site treatment/ |Treat outside health |Treat outside health|Treat outside health |
|& management |health stations |stations/ Collective |scatter |stations/ Collective |stations/ Collective|stations/ Collective |
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
|Compared criteria |Vietnam |WHO |Australia |New York |
|1. Implementers |Hospitals, research institutes of medicine, district health |Same as Vietnam. Added for: |Same as Vietnam. Added for home treatment |Same as Vietnam. Added for home |
| |centers, policlinics, lying-in stations, health post, private |- Blood bank | |treatment |
| |service, preventive health centers and health training |- Home treatment | | |
| |institutions. | | | |
|2. Waste classification |5 groups:1, Infectious waste, sharp objects, highly-infectious |9 groups |9 groups |5 groups |
| |waste, pharmaceutical waste, human and animal tissues and body |Same as Vietnam |Same as Vietnam |Do not mention the radioactive waste,|
| |parts |Added by Waste with high content of heavy metals| |chemical waste and general waste |
| |2, Radioactive waste- 3, Chemical waste-4, Pressurized container- | | | |
| |5,General waste | | | |
|3. Waste management |Non-detail regulations. Only detailed guidelines of implementation |Have guidelines on healthcare waste management |Have guidelines on development of healthcare |Non |
|planning in healthcare |at ministerial and local levels |planning for healthcare establishments including|waste management strategy including planning | |
|establishments | |home treatment |for healthcare waste management | |
|4. Waste minimization, |Non regulations and guidelines |Detail regulations and guidelines on waste |Detail regulations and guidelines on waste |Non |
|reuse and recycle | |minimization, safe recycling, and reuse |minimization, safe recycling, and reuse | |
|5. Collection and storage of waste in healthcare facilities |
|- Principles for |- At the time when waste is generated and put in regulated |- As same as Vietnam |- As same as Viet Nam |- As Viet Nam |
|collection |containers. | | | |
| |- It's permitted for hazardous waste to mix with living waste |- As same as Vietnam |- As same as Vietnam |- Does not mention clearly |
|- Regulations of colour |- Yellow - Clinical waste |-Yellow one for high-infectious waste, other |- Yellow: clinical waste |- Does not mention clearly |
|and symbol for waste |- Green - Living waste |pathological waste and sharp waste |- Red one for radioactive waste | |
|packages |- Black : Chemical and radioactive wastes |- Brown one for chemical and radical and |- Purple: poisoning waste | |
| |- Non regulated symbol on waste container |pharmaceutical waste |- Other waste: non-color regulated | |
| | |- Black one for other healthcare waste |- Clearly regulated on sample label by waste | |
| | |- Clearly regulate by simple in waste container |container | |
|- Criteria for waste |- Criteria of waste bags: PE or PP bag with maximum volume: 0.3 m3 |Waste categories |- Same as Vietnam |Not clear |
|containers |and horizontal slot marking 2/3 with words: Waste exceed this slot |- Infectious waste Strong, leak-proof plastic | | |
| |is not permitted. |bag, or container capable of being autoclaved | | |
| |- Sharps containers: Non penetrating, yellow, labeling: for only |- Other infectious waste, pathological waste: | | |
| |sharp wastes and horizontal slot marking 2/3 with words: Waste |Leak-proof plastic bag or container | | |
| |exceed this slot is not permitted. |- Sharp: Puncture-proof container | | |
| |- Waste container: Poly Ethylene, hard wall, lid, colour as same as|- Chemical and pharmaceutical waste: Plastic bag| | |
| |for waste bag |or container | | |
| | |- Radioactive waste: Lead box, labeled with the | | |
| | |radioactive symbol | | |
| | |- Others: Plastic bag | | |
|- Sites for placed waste |- Clear stipulation for place of waste container |- Have regulation |- No regulation |- No regulation |
|containers | | | | |
|-Waste collection |- Hospital orderly responsible for waste collection |- Same as Vietnam |- No detail regulation on waste collection |- No detailed regulation on waste |
|containers at sites |- Gas waste put in container with regulated colour and labeling |- Added by: The bags or containers should be | |collection |
|generated |with generated original. - Yellow boxes containing sharps and waste|replaced immediately with new ones of the same | | |
| |should be put in PE and tied tightly after treatment. |type. | | |
| |- Time of collection: one a day |A supply of fresh collection bags or containers | | |
| |- Only tied and not to pin |should be readily available | | |
| | |at all locations where waste is produced. | | |
|- Transportation of waste |- Defined time and way to waste transportation, pas-by patient and |- Same as Vietnam but clearly regulation on |- Same as WHO but no regulation on |-No regulation |
|inside healthcare |clean areas is not permitted |transportation means (container, or cart style, |transportation time and route, hygiene route | |
|facilities |- Every health establishment should have means for waste |non-sharp objects) |- Detailed guidelines in case of leak waste | |
| |transportation. These transportation means should only use for | | | |
| |waste transportation and should be clean and disinfecting after | | | |
| |waste transportation. These transportation means should be designed| | | |
| |so as easy to load in and out, and easy to lean, disinfect and | | | |
| |drying. | | | |
|- Waste storage inside |- Conditions of waste storage places |- Waste storage condition same as Vietnam |- Storage places condition: same as Vietnam; |- No regulation |
|healthcare facilities |+ Far away to safe keeping material, storage-houses, passing ways. | |- Added by: measures to minimize the waste | |
| |+ Easy access. | |smell, chutes must not be used for the | |
| |+ Living waste storage is separated from hazardous waste storage | |transport of clinical and related wastes. | |
| |+ Should have roof, fence and be possible to lock | | | |
| |+ Supplies of safe protection, cleaning | | | |
| |+ Having good drainage system |- Storage duration regulated by temperature and | | |
| |- Time for waste storage |seasons: | | |
| |+ Hospital: daily treatment, 48 hours for hazardous waste |+ temperate climate: 72 hours in winter; 48 |- No regulation on waste storage duration | |
| |+ Small healthcare establishments: No-exceeded one week for A, B, |hours in summer | | |
| |C, D waste categories dumping/incinerated |+ warm climate: 48 hours during the cool season;| | |
| | |24 hours during the hot season | | |
| | | | | |
|6. Transportation |- Transportation: |Detailed regulation at all steps: |- Only Australian code for the transport of |- No regulation |
|of hazardous solid waste |+ Sign contract with transportation company or self- transport |- System of regulation and control including |dangerous goods by road and rail | |
|outside healthcare |+ Transportation means not used for other proposed. Be cleaning |clear category and filling order in |- Make detailed container and transportation | |
|facilities |after using |transportation note |means | |
| |+ Hazardous waste must be packaged in carton box or container |- Specific package orders when outside waste |- Guidelines in case of waste leak | |
| |+ E waste category must be contained in yellow bag and separated |transportation | | |
| |container in container/box with clear label and cap |- Detail regulate in label | | |
| |- Transportation documents: |- Regulate on all needed steps for transported | | |
| |+ Each business must have own list to monitor waste producing and |preparing | | |
| |monitoring note of daily incinerated waste list |- Regulate on transportation means | | |
| |+ Detail regulate on note form on waste transportation and |- Regulate on street route | | |
| |incineration | | | |
|7. Technological measures |- Incineration: regulate on incinerating model for each waste |- List the real condition while choosing |- Introduce 7 detailed technology for waste |- Introduce 3 technology types + |
|for treatment and disposal|categories at provincial/district healthcare establishment, |technology for treatment and disposal |treatment and disposal while identifying |steam |
|for solid waste and each |poly-clinical ward, communal healthcare station, maternity ward |- Introduce the details and advantages and |which measures for each waste category: |+ Dumping: not apply for healthcare |
|type of waste |+Introduce the models of waste incineration including outside one|disadvantages of 10 technical categories for |+ autoclaving; |non-treated waste |
| |- Properly hygiene dumping |treatment and disposal |+ chemical disinfection |+Others: waste burning, chemical and |
| |- Junior treatment measures include: boiling, disinfection by |+ 3 burning methods |- grinding/shredding (sodium hypochlorite) |burning |
| |chemical and wet thermal |+ Rotary kiln |- grinding/shredding (hydrogen peroxide and |- No regulation on ash from waste |
| |- Regulate on treatment and disposal measures for each category are|+ Chemical disinfection |lime); |incinerators |
| |clearly as above |+ Wet thermal treatment |+ landfill; | |
| |- No regulation on ash from waste burning kiln |+ Microwave irradiation |+ microwave; | |
| | |+ Encapsulation |+ regulated incineration; | |
| | |+ Safe burying |+ encapsulation; and | |
| | |+ Inertization |+ sewerage (as determined by relevant | |
| | |- Regulation of treatment and disposal are same |authorities). | |
| | |as Vietnam |- Both for ash from waste incinerators | |
| | |- Apply for ash waste from waste incinerators | | |
|8. Treatment of water |- Regulation on waste treatment in hospital: should have system of|- 2 treatment methods: |- Disposal to sewer must meet occupational |- Not clear |
|waste |waste collection and treatment. Waste water must be under current |+Grain waste water to machine of localities |health and safety guidelines. | |
| |standards |under follows conditions +if not applied these |- The disposal of large volumes of blood into| |
| |- No regulation on waste treatment in private and small business |conditions, must solve at once in healthcare |the sewer is subject to approval from the | |
| | |services: junior treatment, biological |local sewerage authority. | |
| | |cleaning.. |Healthcare establishments must comply with | |
| | |- Regulate on mud waste after being treated - |standards set for the ambient environment, as| |
| | |Regulate on waste water reuse in agriculture |well as for effluent and emission limits | |
| | |- Treatment methods for small health services | | |
| | |+Destruction for separated small healthcare | | |
| | |services | | |
| | |+Safe minimized requirements for small health | | |
| | |services that can not developed waste treatment | | |
| | |system + Sanitation | | |
|9. Treatment of gas waste |- Ensure the Vietnamese current standards |- No regulation |Healthcare establishments must comply with |- No regulation |
| | | |standards set for the ambient environment, as| |
| | | |well as for effluent and emission limits | |
|9. Occupation Safe for |- No regulation |- Essential occupational health and safety |- Employees and contractors must comply with |- Not yet regulated |
|health staff and | |measures |instructions given for the | |
|collection waste workers | |include the following: |protection of their own and others’ health | |
| | |• proper training of workers; |and safety. | |
| | |• provision of equipment and clothing for |- Employers and contractors are responsible | |
| | |personal protection; |for providing appropriate information, | |
| | |• establishment of an effective occupational |education and training, and ensuring that a | |
| | |health programme that |safe work environment is developed | |
| | |includes immunization, post-exposure |and maintained. | |
| | |prophylactic treatment, and | | |
| | |medical surveillance. | | |
|10. Treatment of |No regulation |- Have guidelines on the program of waste |- Have regulations on healthcare waste |- Regulated on Sharps Collection from|
|healthcare wastes at | |management in small, medium health services in |treatment at home |Private Residences |
|household | |remote areas or in home | | |
|11. Procedures for |No regulation |- Treatment regulation in case of waste |- Regulate in case of spillage |- No |
|emergency | |incidents, accidents and spillage | | |
1.3.6 Comparison of WHO and Vietnam classification
From No 1 to 3 identify the sequence of specific waste treatment- grey zone for same group waste treatment
|Chosed |Waste groups |
|treatment |WHO classification (WHO) |
|method |Classification according to Vietnam Regulation on healthcare waste management (VN) |
| |WHO |VN |WHO |VN |
|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.
The contents need to be added to the healthcare management regulation in Viet Nam
✓ Healthcare waste management in community and home individually
✓ Healthcare waste management in private health stations
✓ The technical standards and pilot’s demonstration for new method of safe healthcare waste destruction (autoclave, microware, chemical neutralization...)
✓ The responsibilities of private health stations (waste producer) and environmental agencies in waste collecting and transporting and treatment
✓ The inspection of healthcare waste management is not made detail and other relating procedures are not defined
✓ 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
Healthcare waste management is one of the environmental and health protection activities.
2.1.1. Role of environmental sector
Ministry of Natural Resources and Environment (MoNRE): Responsibilities of the Ministry of Natural Resource and Environment in hazardous waste management:
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.
There are three main departments within MoNRE that play key roles in waste management in general and hazardous healthcare waste management in particularly as follows
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
There are five main departments within MOH that play key roles in healthcare waste management as follows
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
The health facilities in provinces has responsibilities to 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
A vague division of responsibility also exists between MoNRE and MOH and MoC in investment for treatment and management of solid waste in hospitals. 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
Lack of financial mechanisms to operate healthcare waste treatment facility for hospital/hospital clusters.
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 |
|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 |
|Estimation of HCSW generation rate |Clinical waste, specific waste (chemical, radioactive, pressurized |
| |containers,) domestic waste. |
|The practice of segregation, collection, storage, |Separation of the waste as well as the methods for segregation of sharp and |
|transportation, treatment and destruction of HCSW |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 |Amount of general |Amount of Hz HCSW |% |
| |bed |HCSW |kg/bed/day |of Hz HCSW |
| | |kg/bed/day | | |
|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 | ................
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