E2591
VIETNAM HOSPITAL WASTE MANAGEMENT
SUPPORT PROJECT
OPERATIONAL MANUAL
TABLE OF CONTENT
PART I
PROJECT IMPLEMENTATION ARRANGEMENT
Chapter 1
Project background
Chapter 2
Project implementation arrangement
Chapter 3
Reporting, monitoring and evaluation of project implementation
PART II
GUIDELINES FOR FINANCIAL – ACCOUNTING WORKS
Chapter 1
Project financial planning
Chapter 2
Bank and account
Chapter 3
Disbursement and claim
Chapter 4
Project accounting
Chapter 5
Reporting, auditing
Chapter 6
Project closure
PART III
GUIDELINES FOR PROCUREMENT
Chapter 1
General introduction
Chapter 2
Bidding document
Chapter 3
Procurement plan
Chapter 4
Procurement of consultants
Chapter 5
Procurement of goods and construction
Chapter 6
Checking
PART IV
GUIDELINES FOR SUB-GRANT IMPLEMENTATION
Chapter 1
Overview
Chapter 2
Principles in sub-grant implementation
Chapter 3
Relating documents
Chapter 4
Guidelines for specific issues
Chapter 5
Implementation arrangement
1
PART V
ENVIRONMENTAL RISKS MANAGEMENT
ANNEX:
Annex 1
Selection of technology for healthcare solid waste treatment
Annex2
Selection of technology for hospital waste water treatment
Annex 3
Template of provincial healthcare waste management plan
Annex 4
Template of hospital waste management plan
2
PART V
I.
ENVIRONMENTAL RISKS MANAGEMENT
Background
The Hospital Waste Management Support Project (HCWM) supports an important
public health and environmental policy objective in Vietnam. The proposed
development objective is reduced environmental degradation due to health care
waste in Vietnam. This will be achieved through improved management of health
care waste in Vietnam hospitals, and through improved Government stewardship
role in regulating, providing implementation support, monitoring and enforcing good
health care waste management practices.
In 2010, Vietnam has 1186 hospitals with capacity of 187843 patient beds. They
are the largest sources of hazardous waste, generating about 350 tons/day of
healthcare waste including 40 tons/day of hazardous waste. If not managed well,
the toxic, carcinogenic, hazardous healthcare, and other hazardous properties of
this waste pose a significant threat to public health and the environment.
It is estimated that only 50% of these hospitals segregate and collect healthcare
waste according to regulations. There has been significant media coverage on
improper medical waste management practices. Achieving the goal of safe and
cost-effective management and disposal of waste is a major challenge, requiring
concerted efforts by government, industries, hospitals, solid waste operators, and
individuals.
II.
Categorization of health care waste
1.1.
Solid waste
All waste produced in a hospital is defined as hospital waste. Almost 7590% of this waste constitutes general waste and has no higher risk than general
municipal solid waste. Hazardous waste (between 10-25% by weight) refers to
waste comprising 4 categories:
-
Infectious waste: sharps, non-sharp infectious waste, pathological waste and
highly infectious waste
Chemical waste: chemicals commonly used in healthcare, formaldehyde,
photochemicals, heavy metals, pharmaceutical waste and cytotoxic waste.
Radioactive waste
Pressurized containers
3
Generation of hospital waste varies wildly, depending on hospital services and
quality and situation of hospital waste management. According to estimation of
Ministry of Health1, quantity of hazardous hospital waste is presented as follows:
Table 1: Average hospital hazardous waste generation rate
Hospitals by
Central
level and specialization general
hospital
Quantity of hazardous
solid
waste
(kg/bed/day)
0.3
Central
specialist
hospital
Provincial
general
hospital
Provincial
specialist
hospital
District or
branch
hospital
0.225
0.225
0.2
0.175
Table 2: Healthcare waste generation from Vietnam project hospitals
General hospitals
Central
level
Specialist hospitals
Provincial Interlevel
district
Obstetric
Pediatric
Tuberculosis,
infectious
diseases
Mental,
nursing,
traditional
medicine
Cancer
Others
Infectious waste
Sharps
++
+
+
+
+
+
+
+
Non-sharps
++
+
+
+
+
+
+
+
Highly infectious
++
+
+
+
++
+
+
+
Anatomical waste
++
+
+
++
-
-
+/-
+/-
Pharmaceuticals
++
+
+
+
+
+
+
+
Hz.Chemicals
++
+
+
+
+
+
++
+
Cytotoxics
++
+/-
-
-
-
-
++
-
+
+/-
-
-
-
-
++
-
Presurized
containers
++
+
+
+
+
+
+
+
General waste
++
++
+
++
+
+
+
+
Chemical waste
Radioactive waste
Note:
++
generation, larger quantities; + generation, smaller quanitities; -no generation ; +/- generation
or not, depend on services;
1
Draft National action plan for healthcare waste management in Vietnam, 2008
4
1.2
Hospital wastewater
Wastewater from healthcare facilities comprises water that is adversely
affected in quality by anthropogenic influence during providing healthcare services.
Such wastewater can contain micro-organisms, heavy metals, toxic chemicals, and
radioactive elements, in addition to general storm-water, which is non-polluting by
nature.
Each hospital may generate 0.4 – 0.95 m3 of wastewater per bed per day, the
volume depends on water supply and use, hospital services, number of patient and
their relatives. However, concentrations of suspended solids (SS), organic
substances (such as BOD5), and common nutrients (such as NO4, NO2) in hospital
wastewater may be lower than those in urban wastewater. Concentration of BOD 5
varies from 80-180 mg/l. The principal area of concern is high content of enteric
pathogens which are easily transmitted through water. Hospital wastewater
contains significant amount of pharmaceuticals, chemicals which may negatively
affect biological treatment process. Many surveys on quality of hospital influent
have been conducted and summary of main findings can be seen in the following
table.
Table 3: Polluted parameters in hospital wastewater
No
Hospitals
pH
Total
Total
DO
H2S BOD5 COD
SS
Phospho Nitrogen
(mg/l) (mg/l) (mg/l) (mg/l)
(mg/l)
(mg/l)
(mg/l)
1
By referral system
1.1
Central level
6.97
1.89
4.05
119.8
263.2
2.555
46.1
218.6
1.2
Provincial level
6.91
1.34
7.48
163.9
314.4
1.71
38.9
210
1.3
Sectoral
7.12
1.59
4.84
139.2
279.9
1.44
38.9
246
2
By specialist
2.1
General
6.91
1.3
5.61
147.6
301.4
1.57
37.2
238
2.2
Tuberculosis
6.72
1.63
2.98
143.3
307.3
1.15
46.1
222.2
2.3
Obstetric gynecology
7.21
1.33
7.73
167
321.9
0.99
53.2
251.3
III.
Hazards of health care waste
2.1
Hazards to health
Exposure to hazardous health-care waste can result in disease or injury. All
individuals exposed to hazardous health-care waste are potentially at risk, including
those within health-care establishments and those outside these sources. The main
groups at risk are the following:
- Health staff: doctors, nurses, technicians
5
- Patients
- Relatives and visitors of patients
- Workers in support services allied to health-care establishments, such as
laundries, waste handling, and transportation;
- Workers in waste disposal facilities (such as landfills or incinerators),
including scavengers.
2.1.1 Hazards of infectious waste and sharps
Pathogens in infectious waste may enter the human body by a number of
routes: through a puncture, abrasion, or cut in the skin; through the mucous
membranes; by inhalation; by ingestion. The existence in health-care
establishments of bacteria resistant to antibiotics and chemical disinfectants may
also contribute to the hazards created by poorly managed health-care waste.
Sharps may not only cause cuts and punctures but also infect these wounds if they
are contaminated with pathogens. Sharp injuries are most popular accidents in
health facilities. A survey conducted by National Institute of occupational health and
environment in 2006 found that 35% of health staff have been suffered from sharp
injuries for last 6 months and 70% of them have been suffered from sharp injuries
in their career. Sharps injury is the potentially main transmission way of several
dangerous infectious diseases such as HIV, HBV, and HCV. About 80% of
occupational infections of HIV, HBV, HCV are resulted from injuries by
contaminated needles and sharps. Recycling of untreated infectious waste,
including sharps and plastics can have long-term impact on public health.
2.1.2 Hazards of chemical and pharmaceutical waste
Many of the chemicals and pharmaceuticals used in health-care
establishments are hazardous (e.g. toxic, genotoxic, corrosive, flammable, reactive,
explosive, shock-sensitive) but commonly present in small quantities. Acute or
chronic exposure to chemicals by absorption through the skin or the mucous
membranes, or from inhalation or ingestion. Injuries to the skin, the eyes, or the
mucous membranes of the airways can be caused by contact with flammable,
corrosive, or reactive chemicals (e.g. formaldehyde and other volatile substances).
The most common injuries are burns. Disinfectants are used in large quantities and
are often corrosive. During collection, transportation and storage, hazardous waste
can be leaked and spilled. Spillage of infectious waste, especially highly infectious
waste can spread pathogens through the hospital, which could result in outbreak of
nosocomial infection among health staff and patients, or cause ground and water
pollution.
2.1.3 Hazards of cytotoxic waste
Many cancer treatment drugs are cytotoxic. They may be irritants and have
harmful local effects after direct contact with skin or eyes, and may also cause
dizziness, nausea, headache, or dermatitis. Hospital staff, especially those who are
responsible for waste collection, can be exposed to antineoplasma drugs by are
6
inhalation of dust or aerosols, absorption through the skin, ingestion of food
accidentally contaminated with cytotoxic drugs.
2.1.4 Hazards of radioactive waste
Type and extent of exposure to radioactive waste determines the impact on
human health, which can range from headache, dizziness, and vomiting to more
serious long-term and/or genetic problems.
2.2
Hazards to environment
2.2.1 Hazards to water environment
Water resources may become contaminated by certain hazardous materials
contained in hospital wastes. They can contain water-borne transmitted pathogens.
They may contain heavy metals, largely mercury from thermometers and silver
from the processing of X-ray films. Certain pharmaceuticals, if deposited without
treatment, may also cause toxic agents to leach into water supplies. In addition, the
leachate generated by the biological degradation of clinical wastes, like that from
municipal solid waste, has the potential to cause water contamination, by reason of
its high BOD.
2.2.2 Hazards to soil environment
Unsafe disposal of hazardous waste including incinerator ash and sludge
from wastewater treatment plant is very problematic as pollutants from landfill sites
have been known to seep out, polluting soil and local water sources which have
long-term health impacts.
2.2.3 Hazards to air environment
The risk of air pollution arises largely from the fact that most hazardous
wastes are incinerated or burnt in sub-optimal conditions. Inefficient combustion, for
example when temperatures are too low or when waste is loaded in too large a
quantity, will cause noxious black smoke. The presence of significant quantities of
PVC plastic in the waste, together with certain pharmaceuticals, can produce acid
gases, notably HCl and SO2. During combustion with low temperature halogen
ingredients (F, Cl,. Br, I..) in the waste are able to be transformed in e.g.
hydrochloride (HCl). This causes a risk of forming dioxins, which are extremely
toxic substances, even in small concentrations. Volatile heavy metals, notably
mercury, can be emitted from hospital incinerators.
These environmental risks can impact wildlife and biodiversity and also pose
long-term risks to public health.
2.3
Public sensitivity
7
The general public and neighboring communities are sensitive to the visual
impacts of anatomical waste, while poorly run incinerators emitting fumes cause
disturbances to neighborhoods.
IV.
Hazards resulting from inappropriate treatment and disposal
4.1
Solid waste treatment and disposal
Solid waste, if improperly treated and disposed in municipal landfills or
recycling centres, can cause impacts to human health and environment, as detailed
above. Improper operations and poor maintenance of incinerators can result in the
emission of a wide range of pollutants besides dioxins and furans, including include
heavy metals (lead, mercury and cadmium), fine dust particles, hydrogen chloride,
sulphur dioxide, carbon monoxide, and nitrogen oxides. Two surveys conduced by
Institute of health facility and equipment in 2003 and 2008 found that
concentrations of dioxin in gas emission emitted from incinerators were much
higher than allowable threshold; and most of incinerators were generating black
smoke and cause air pollution during their operation. Safe disposal of incinerator
ash is also very problematic as pollutants from landfill sites can pollute soil and
local water sources.
4.2
Wastewater treatment
Improper management, collection, treatment and disposal of wastewater and
sludge can result in the pollution of local water sources with pathogens, causing
numerous water borne diseases and vector borne diseases and the spread of
parasites. Poor maintenance and operation are the biggest problems of effective
wastewater treatment and inaccurate disposal of sludge can result in contamination
of soil and ground and surface water.
4.3
Chemical disposal
Chemical residues discharged into the sewerage system may have adverse
effects on the operation of biological sewage treatment plants or toxic effects on the
natural ecosystems of receiving waters. Similar problems may be caused by
pharmaceutical residues, which may include antibiotics and other drugs, heavy
metals such as mercury, phenols, and derivatives, and disinfectants and antiseptics.
V.
Government of Vietnam Policy Framework
There are many legal documents relating directly or indirectly to healthcare waste
management, including standards and technical regulations on incinerators.
Important documents are presented as follows:
- Law 55/2005/QH11 dated 29/11/2005 on Environmental Protection 2005
- Decree 59/2007/ND-CP dated 9/4/2007 on solid waste management
8
-
Decision 43/2007/QD-BYT dated 30/11/2007 of Minister of Health
promulgating Healthcare waste management regulations
Circular No 12/2006/TT-BTNMT dated 26/12/2006 on Guiding the practice
conditions, procedures for compilation of dossiers, registration and licensing
of practice and hazardous waste management identification numbers
In addition, there are environmental standards and technical regulations as follows:
-
QCVN 02:2008/BTNMT: National technical regulations on gas emission of
healthcare waste incinerator
TCVN 7380:2004 – Healthcare waste incinerator – Technical requirements
TCVN 7381:2004 - Healthcare waste incinerator - Assessment and
appraisal methods
TCVN 7382:2004 – Hospital wastewater – discharge standard
TCVN 5945:2005 – Industrial wastewater – discharge standard
TCVN 7957:2008 on design of drainage and sewerage external networks
and facilities
TCXDVN 365:2007 – Guidance on general hospital design
Ministry of Health developed master plan for healthcare solid waste treatment, for
environmental protection in health sector, and an Action plan for healthcare waste
management is being prepared. Proposed “Guidelines for healthcare wastewater
treatment”, proposed “Vietnam standard on hospital wastewater treatment facilities
– technical requirements for design, operation and maintenance” and proposed
“Master plan for healthcare waste management” provide suggestion of wastewater
treatment process diagrams applicable to different hospitals. In December 2009, a
review of legal documents was conducted to identify weaknesses and to provide
proposal for improvement.
VI.
Description of project
The main components of the project are as follows:
Component 1: Improving policy and institutional environment for health care
waste management
The aim of this component is to create a conducive policy environment for effective
management of health care waste generated in the health care system, and to
strengthen the institutional capacities to regulate, implement, monitor and enforce
proper health care waste management practices. Component 1 is a critical
component of the project even though it receives a modest share of the total project
costs (9 million USD). Component 1 will be composed of three sub-components.
Sub-component 1.1 will focus on streamlining and strengthening the existing policy
and regulatory framework for health care waste management.
9
Sub-component 1.2 will focus on strengthening institutional capacities of the central
and provincial level agencies responsible for regulating health care waste
management practices, monitoring the compliance of health care facilities with the
regulations, and providing technical support to hospitals in implementing health
care waste management practices. Training of the staff of health care facilities in
segregation of health care waste, and operation/management of health care waste
technologies will be done under Component 2.
Sub-component 1.3 will focus on establishing monitoring and surveillance system
for health care waste management. These outputs will be produced through
technical assistance (consulting services), training, acquisition of testing and
laboratory equipment, provision of vehicles, upgrading of offices space and
equipment, and incremental operating costs. Training in norms, standards, and
organization and execution of the monitoring and surveillance function will be done
as part of the integrated training process under Sub-Component 1.2.
Component 2: Hospital Waste Management Support Facility
This component would set up a facility to provide sub-grants linked to clear outputs
and outcomes to health care facilities to improve health care waste management
based on agreed eligibility criteria and agreed financial management arrangements.
There could be a “menu” of sub-grant components based on the type and size of
particular health care facility, technology proposed. Such menu would include
options for solid waste management upgrade, liquid waste management upgrade,
management support at the facility level, and support for recurrent cost for agreed
period of time after the upgrade will have been completed. Sub-grants will be
provided to central hospitals for upgrades for waste water treatment and
strengthening the internal health care waste management procedures and capacity,
including waste minimization, segregation, collection, and storage and worker
safety practices. Sub-grants will also be allocated to provincial level health care
facilities in one or two adjacent regions, based on readiness assessment.
Component 3: Project Implementation Support and Coordination
At the central level, a Project Steering Committee (PSC) in MOH will provide
guidance on overall project direction and project coordination, including HCWM
issues. Central Project Management Unit (CPMU) at the central level would be in
charge of project management at the central level and coordination of the subnational activities implemented through the sub-grant mechanism. An integrated
management arrangement will be put in place for sub-grant project implementation
at provincial and hospital levels.
VII.
Proposed Mitigatory Measure for Healthcare Waste management
8.1
Solid Waste Segregation
10
At the source, solid waste will be segregated into colour-coded plastic bags
and bins. Orderlies or environmental workers will transport waste to interim storage
area for storage upto a maximum of 48 hours. If central treatment and disposal
facility for hazardous waste is available in the province/town, the hazardous waste
will be transported to central facility for treatment and disposal. Only when hospital
can not access to centralized or clustering treatment and disposal facility,
hazardous waste is treated and disposed onsite. General waste will be transported
by municipal environmental company to landfill for disposal. Recyclable waste will
be sold to recycling facility having licence. Approach to safe management of
hospital solid waste is illustrated in the following figure:
8.2
Storage area
The project will provide hospitals with financial assistance to establish
interim storage facilities. sub-component 1.1 will support MoH/VIHEMA to develop
technical requirements for design and operation of hazardous waste storage.
Budget for waste storage area by hospital size is presented in the list of technology
and costing.
8.3
Equipment for segregation, collection, onsite transportation
Under component 2, the project will provide hospitals with financial
assistance to procure equipment for segregation, collection, on-site transportation
of hazardous waste. These include waste bags, bins and containers and waste
transportation trolleys. Under component 1.1, MoH/VIHEMA will develop
specification standards for such equipment which will be included in the Provincial
11
Plan and Facility specific plans and procured by Provincial Department of Health
and project hospitals.
8.4
Vehicle for off-site transportation
The project provides hospitals financial assistance to procure vehicle for offsite transportation of hazardous to central treatment facility. However, only
hospitals not having access to safe off-site transportation service or serving as
central treatment facility will receive this support. Under sub-component 1.1, MoH
will develop regulations on vehicle for off-site transportation and management of
hazardous waste outside hospitals, to be funded under Component 2.
8.5
Waste treatment technology
The project encourages hospitals to apply environmentally sound treatment
technologies. Under component 2, the project will provide hospitals with financial
assistance to use non-burn technologies. A menu of appropriate technologies from
the list of non-burn technologies and respective costing has been developed. The
table 3 in Annex 3 summarizes main advantages and disadvantages of common
non-burn technologies. Under sub-component 1.1, the project will also support
MoH to develop specifications and performance standards for non-burning
technologies.
The project will not support installation of new incinerators. However, funds
will be still available for upgrading old incinerator (such as installation of gas
emission controlling device or raising chimney) only if proposed incinerator meets
stringent criteria, which will be defined in the Eligibility Checklist.
8.6
Final disposal
Hazardous chemicals such as incinerator’s ash or heavy metal contained
chemicals will be safely buried in concrete pit, or innertized by cement, or
transported to special landfill for hazardous waste. Sludge from hospital wastewater
treatment plant which is considered as hazardous waste will be regularly removed
and disposed by waste company having special device and license. Recyclable
waste such as plastic, cardboard, metal boxes will be sold to registered recycling
facility. Domestic waste will be transported by municipal environmental company to
landfill for final disposal. To ensure proper disposal and recycle of waste, the
hospital must sign contract to waste company having license and establish a waste
documentation system to track the waste from source to final disposal. All relevant
staff and workers will be made aware of the hazards and appropriately trained to
undertake these tasks.
8.7
Wastewater collection and treatment
Under component 2, each project hospital is provided financial assistance to
construct and install wastewater treatment plant and wastewater collection system
separated from storming water collection system. In parallel, under sub-component
1.1, policy framework on hospital wastewater management will be improved.
12
The following Figure describes hospital wastewater management scheme
Hospital wastewater collection and treatment system shall be in line with
“Plumbing code” and Vietnamese standard TCVN 7957:2008 on design of drainage
and sewerage external networks and facilities and proposed Vietnamese standard
on design, operation and maintenance of hospital wastewater treatment plant.
Effluent of hospital wastewater treatment plant must meet Vietnamese standard
TCVN 7382:2004-hospital wastewater – effluent standard.
The project hospitals in urban area shall select treatment process diagrams
combining decentralized primary treatment and centralized biological treatment.
The project hospitals having large area or in rural area are encouraged to apply the
naturally biological treatment in order to reduce investment and operational cost.
Disinfection can be performed by chlorine, ozone, or ultraviolet irradiation. Sludge
which is considered as hazardous waste can be removed and disposed of by waste
company or treated onsite by dewatering, drying bed e.g. A hospital wastewater
treatment plant can apply single option or many options of biological treatment,
provided that the effluent meet Vietnamese standard TCVN 7382:2004 and the
plant is suitable to hospital’s circumstance.
Under Component 2, the project provides hospitals with financial assistance
to regularly remove and disposal of sludge from wastewater treatment plant. If
waste company for sludge removal and disposal is not available in the
province/town, the hospitals may construct or install sludge drying and treating
facility. These details will be provided in the Hospital waste management plan
8.8
Operation and maintenance
The project will take many measures to ensure proper operation and
maintenance of invested technologies. Under component 2, the Memorandum of
Understanding between the Ministry of Health and the sub-grant beneficiary will
13
include the hospital management commitment to cover recurrent operations and
management cost of waste management systems. To help to internalize O&M cost
into management practice, the project will make available to hospitals an optional
partial subsidy to operate invested waste treatment facilities in one year after finish
of investment. This financial support will help hospitals to cover the cost for training
on operation and maintenance; fuel, electricity, consumbles necessary for
operation. The supplier of technology will be required to responsible for at least 2
year warranty and preventive service. Under sub-component 1.1, cost norms will be
revised and guidelines will be complied to ensure proper operation and
maintenance of technology.
8.9
Occupational Safety and Personal protective equipment (PPE)
Component 1 will prepare the generic guidelines for occupational safety in
health care waste management in health care facilities and provide training. With
resources from sub-grants, the project hospitals will develop facility specific
guidelines and management manuals and provide training to health care facility
staff about occupational safety issues. Sub-grants will also provide resources to
purchases sufficient PPEs for staff involving in collection, transportation, storage,
treatment and disposal of healthcare waste. PPEs for different categories of
hospitals are presented the list of technologies and costing. Training on use of
PPEs for internal logistic is integrated in basic training for auxiliary staff, meanwhile,
training on use of PPEs for off-site transportation, treatment and disposal is
integrated in training on technology transfer from supplier.
The project will also organize a series of information campaigns to increase
the awareness of the general population with regard to the importance of managing
and reducing health care waste. Sub-Component 1.1 will support production of
information and reference materials (standards and technical requirements;
summary of policies and regulations, manuals for health care waste management,
etc.) for wider dissemination of policies and good practices.
8.10
Institutional capacity
 Policy and monitoring
Under Component 1, the project will support VIHEMA/MoH to design and
implement training and communication program (sub-component 1.2) and health
environmental monitoring program (sub-component 1.3). The main objective will be
to equip institutions responsible for regulating and monitoring the health care waste
management with adequate skills, knowledge, human resources, organizational
arrangements and technologies/infrastructure to perform their function prescribed
by the relevant laws and regulations. Sub-Component 1.2 will support a wide range
of training activities tailored to different professional groups.
14
The project will finance foreign technical assistance for developing the
training curricula in the above areas. The MoH’s VIHEMA will be responsible for the
overall coordination of these. In order to ensure the efficient and rapid roll out of the
training activities, the project will start training of trainers (TOT) in the above
subjects. The project will support the institutions involved in the organization and
execution of training with training materials, equipment and supplies that are
necessary for carrying out training. Also the project will finance short term
consultants (administrative assistants) to help the training institutions in the
organization of training activities.
 Technology
Adequate technologies and infrastructure are required for carrying out effectively
regulation and monitoring of health care waste management practices and
compliance. Sub-Component 1.3 will support investment for upgrading laboratory
facilities and monitoring hardware at the central and provincial levels.
 Information Systems
Sub-Component 1.3 will support development of an online database which will
include information on health care waste management practices in all hospitals in
the country, the status of their compliance with the standards and technical
requirements, the type of waste treatment equipment they operate, and statistics of
the environmental impact of their waste management practice. Establishment of
such an online database will improve the efficiency of monitoring, will improve
communication and information exchange between various agencies, and will
reduce the workload of monitoring agencies by avoiding overlapping monitoring by
several agencies. The project will finance technical assistance to develop the
database platform and train the end users in the operation and maintenance of the
database.

Hospitals
Component 2 of project provide financial support to improve healthcare waste
management capacity in central and provincial hospitals. Improvement measures
include: (i) Hospital waste management plan and manual; (ii) Training; (iii)
Communication; (iv) Monitoring and supervision.
VIII.

Process and Procedures:
Application for Sub-Grant:
At provincial level, provincial DoH will develop provincial healthcare waste
management plan according to agreed template (see Annex 1) and ensure
individual hospital waste management plan to be in line with provincial plan. To
apply for sub-grant, project hospitals must prepare a hospital waste management
15
plan for their individual facility. This plan will propose the chosen technology and
will include measures to strengthen organizational structure and improve capacity
for technology operation and maintenance (see Annex 2: Template of facility
healthcare waste management plan). The hospital shall meet the following criteria:
(i) appoint persons responsible for waste treatment facility operation and
maintenance; (ii) train appointed staff on operation and maintenance; (iii) fully
perform procedures of operation and maintenance; (iv) allocate sufficient budget for
operation and maintenance of invested technologies.
Technology suppliers shall provide hospitals with the following: (i) training course
on technology operation and maintenance; (ii) Operational manual, maintenance
manual, and illustrated part catalog; (iii) equipment to perform maintenance
processes as described in maintenance manual; (iv) at least 2 year warranty and 2
year preventive maintenance after finalzation of installation. Capacity of
maintenance shall be criteria to select supplier.
Consultants who prepare feasibility study report for sub-grant application (or
economical and technical report) shall describe operational and maintenance
processes; staff requirements; estimated cost for training, operation and
maintenance of waste treatment technology according to international practice.
At central level, MoH will revise cost norms and ensure compliance with guidelines
to ensure proper operation and maintenance of technology. Provincial inter-agency
taskforce will monitor and supervise implementation of healthcare waste plan in
hospitals.

Hospital Waste Management Plan and Manual
Each participating hospital has to develop a healthcare waste management plan
and manual according to agreed template. The plan requires situation assessment
and improvement measures including financial, technical and organizational
measures. The Hospital HCWM plans shall be in line with provincial orientation of
HCWM treatment model and technologies that are described in provincial HCWM
plan. The technical advisory group is responsible for reviewing both provincial and
hospital HCWM plan. In addition, guidelines or standards on monitoring and
verification of non-burning technologies should be developed in framework of
Component 1.
Hospital waste management manual is a tool for ensuring quality of waste
management activities in the hospital. The manual will describe clearly hospital
waste management system, including waste management objectives;
organizational structure and responsibility assignment of persons/units involving
healthcare waste management; sanctions to violence of internal regulations;
healthcare waste relating processes such as minimization, segregation, collection,
transportation, storage, reuse, recycle, treatment, disposal, planning, training,
monitoring and supervision; and working instructions such as recording and
reporting forms.
16

Environmental Assessment, Registration and Authorization
Each hospital shall submit documentation to Provincial Department of Natural
Resource and Environment (DoNRE) for: (i) registration of hazardous waste owner,
(ii) authorization of hazardous waste transportation if hospital transports hazardous
waste outside its precinct; (iii) authorization of hazardous waste treatment if
hospital having on-site hazardous waste treatment facility; and (iv) authorization of
discharging wastewater into environment. Documentation includes an application
form for registration/authorization and approved Environmental Impact Assessment
report. The procedures for registration and authorization are described in Circular
No 12/2006/TT-BTNMT dated 26/12/2006 on guiding the practice conditions,
procedures for compilation of dossiers, registration and licensing of practice and
hazardous waste management identification numbers. The procedures for
environmental assessment are described in Circular No 05/2008/TT-BTNMT dated
8/12/2008 guiding on strategically environmental assessment, environmental
impact assessment and environmental protection engagement (see Annex III: EIA
in feasibility study and project approval). Expenditures for registration, authorization
and environmental assessment are taken from counterpart fund.

Disclosure
Provincial and hospital health care waste management plans will be publicly
disclosed locally via appropriate channels, including internet, local newspaper
and/or public bulleting boards at local government and health cre facilities.

Training
The hospitals receive financial support to train their staff on healthcare waste
management. For each project hospital, three key staff will receive 3 day advanced
training on healthcare waste management; two staff will receive 3 day training on
management, operation and maintenance of waste treatment facility in additional to
training of technology transfer from supplier; all hospital staff including doctors,
nurses, members of infection control committee and auxiliary staff will receive basic
training on healthcare waste management. Training curriculum and trainers are
made available by sub-component 1.2.

Communication
Awareness raising communication program will be designed at central level, under
component 1. Hospitals will be provided with financial assistance to implement
communication program in hospitals in order to raise awareness of healthcare
waste management among patients and community.

Monitoring and supervision
Hospitals will be provided with financial assistance to implement monitoring and
supervision of healthcare waste management as regulated by MoH and MoNRE.
The monitoring and supervision program includes 2 parts: (i) monitoring and
17
supervision of complance to standard operating procedures; (ii) monitoring of
healthcare waste and environmental quality to evalute effectiveness of mitigation
measures.
A firm will be mobilized to independetly verify the results of
implementing the sub-grants.
18
Annex 1
GUIDELINES FOR SELECTION OF SOLID HEALTH CARE WASTE
TREATMENT TECHNOLOGY
I. Treatment and disposal of health care waste
1. According to Regulations on healthcare waste management and official
letter No.7164/BYT-KCB dated 20/10/2008 of Ministry of health, the
hospitals and health facilities are allowed to apply one of the following
models of treatment and disposal:
- In central managed cities where density of hospitals and healthcare
facilities is high, traffic system is favorable, hospitals apply centralized
model of hazardous healthcare solid waste treatment, one treatment
facility treat all hazardous healthcare solid waste generated in city in
order to save investment and operational cost.
- In other provinces and cities, hospitals apply cluster model of
hazardous healthcare solid treatment for hospitals, healthcare
facilities locating within or surround cities and towns (distance to
treatment facility is less than 30 km).
- Hospitals, healthcare facilities locating in remote area, traffic poor
area apply onsite waste treatment, use suitable treatment technology.
2. Centralized treatment models are being applied in Hà Nội, Hồ Chí Minh city
and some other provinces. The hospitals sign contract with waste
management companies (such as URENCO in Hà Nội and CITENCO in Hồ
Chí Minh city) to off-site transportation and treatment of hazardous
healthcare solid waste. Such models in those cities/provinces have proven
to be effective in performance and cost . In other provinces, cluster
treatment model is often applied to provincial level hospitals and other health
facilities locating in provincial center; inter-district hospitals, district hospitals,
polyclinics and commune health station often have small scale treatment
facilities.
3. Any province participating in the project shall develop a provincial healthcare
waste management plan. This plan shall analyse current situation of
healthcare waste management and select the most suitable model of
treatment for their province. The template of provincial healthcare waste
management plan is available in the Annex 4.
II. Technology Options
II.A: Incineration
4. Minister of Health issued official letter No.7164/BYT-KCB dated 20/10/2008
requesting hospitals to limit installation of new incinerator, to provide air
pollution control device for procured incinerator, and to promote application
of environmentally sound non-incineration technologies. According to
proposed Master plan for healthcare waste management, solid waste
treatment technology is expected to be environmentally sound, able to
eliminate pathogens in infectious waste and not cause secondary pollution.
19
5. The Government has promulgated several standards for medical
incinerators, including TCVN 7380:2004: Healthcare solid waste incinerator
– Technical specifications; TCVN 7381:2004: Healthcare solid waste
incinerator – Assessment and verification method; QCVN 02:2008/BTNMT:
National technical regulation on healthcare solid waste incinerator’s gas
emission
6. Operational cost of on-site incinerator is high, while the cost for off-site
transportation and treatment in a cluster model is negotiated by hospitals.
II.B Non-burn technologies
7. Non-burn technologies which are applicable under this project include:
 Wet thermal disinfection (autoclave), microwave irradiation, chemical
disinfection for infectious waste treatment;
 Shredder for waste volume reduction;
 Cutter or destroyer for needle treatment;
 Concrete bury pit for anatomical waste and sharps;
 Innertization and capsulation for hazardous chemicals and
pharmaceutical waste treatment;
 Safety storage radioactive waste decay;
 Return chemical waste and pressurized containers to supplier.
 Outsourcing to registered and eligible transportation and treatment
facilities
8. Each of these options is adequate for specific types of waste, as detailed in
Table 1, while Table 2 provides the relative advantages of each. Therefore,
it is necessary to combine different non-burn technologies to treat properly
all kind of hospital waste. The regulations on healthcare waste management
(in accordance with Decision 43/2007/QD-BYT dated 30/11/2007 of Minister
of Health) and WHO’s guidelines on healthcare waste management provide
more detailed guidelines non-burn technologies applicable to each
categories of healthcare waste
9. Investment costs of these technologies varydepending on capacity and
sophistication of the operation.
Operational costs are reasonable, and
include costs of
electricity, water, special bags and labor.Simple
technologies such as needle cutters needle destroyers, cement bury pit have
low operational costs.
10. Project hospitals need to prepare a healthcare waste management plan
which describes categories of waste generated, chosen technology options
and respective capacities and specifications. Needle cutters and destroyers
are critical for shraps management and must be maintained at all hospitals.
20
Table 4: Treatment and disposal methods suitable for different categories of healthcare
waste
Infectious waste
Sharps
Non-shaprs
Highly infectious
Anatomical
Chemical waste
Pharmaceuticals
Cytotoxic waste
Hz. chemicals
Radioactive waste
Presurized
containers
Pyrolytic
incinerator
Wet thermal
disinfection
(autoclave)
Microwave Chemical
irradition disinfection
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
No
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
No
No
No
No
For small
quantities
No
No
No
Yes
Yes
No
No
No
No
No
Yes
For small
quantities
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
No
21
Safe Innertizaburying
tion
Others
Return to
supplier
Return to
supplier
Return to
supplier
Decay by
storage
Return to
supplier
Table 5: Main advantage and disadvantages of solid health care waste treatment technologies
Technology
Advantages
Non-incineration technologies
Needle cutter
- Prevent needle reuse
- Easy to operate, low cost
- Syringe can be recycled
Needle
destroyer
Disadvantages
- Needles need further treatment
after cut and separated
- Needle is disinfected and destroyed
by electricity
- Easy to operate, low cost
- Syringe can be recycled
- Applicable to chemical waste and
pharmaceutical waste
- Simple to operate, low cost
- Applicable to sharps and pathological
waste
- Simple to operate, low cost
- Relatively safe if access to site is
restricted and where natural infiltration
is limited.
- Low investment and operation cost
- Require electricity
- Stem of needle still exists after
destroying.
Disinfection by
steam
(autoclave)
- Highly efficient disinfection
- Reduction in waste volume if
shredder available
- Low operational cost
- Environmentally sound
- Well-known technology in hospitals
Disinfection by
microwave
irradiation
- Highly efficient disinfection
- Reduction in waste volume if
shredder available
- Low operational cost
- Environmentally sound
- Well-known technology in hospitals
Innertization
Cement bury
pit
Safe burying
Cost (in 2010)
- Investment cost: 2-80
USD
- Durability: 200,000
cutting times
- Investment cost: 100 –
150 USD
- Not applicable to other waste
- Investment cost of
cement, sand
- Requires land and space
- Potential impact to underground
water if poor design, construction
- Only apply to hospitals in
mountainous and rural area
- Investment cost: 100–
200 USD/m3
- Inadequate for anatomical,
pharmaceutical and chemical waste,
and waste that is not readily steam
permeable.
- Requires trained operator
- High investment cost, requires
thermal resistant waste bags
- Inadequate for anatomical,
pharmaceutical and chemical waste,
and waste that is not readily steam
permeable.
- Requires trained operator
- High investment cost, requires
- Investment cost:
500 – 50,000 USD
- Operational cost: 0.33
USD/kg
22
- Investment cost:
labour, roof, fence
- Investment cost:
70,000 – 50,000 USD
- Operational cost: 0.33
USD/kg
Disinfection by
steam &
microwave
- Highly efficient disinfection
- Reduction in waste volume if
shredder available
- Low operational cost
- Environmentally sound
- Well-known technology in hospitals
Chemical
disinfection
- Highly efficient disinfection of
pathogen in infectious waste,
especially for liquid waste
- Reduction in waste volume if
shredder available
- Some chemical disinfectants are
inexpensive
Incineration technologies
Single chamber - Good disinfection efficiency
incinerator
- Drastic reduction of weight and
volume of waste
- No need for highly trained operator
Two chamber
or Pyrolytic
incinerator
- Adequate for all infectious waste,
most chemical waste, and
pharmaceutical waste
- Drastic reduction of weight and
volume of waste
thermal resistant waste bags
- Inadequate for anatomical,
pharmaceutical and chemical waste,
and waste that is not readily steam
permeable.
- Requires trained operator
- High investment cost, requires
thermal resistant waste bags
- Inadequate for anatomical waste,
sharps, chemical and
pharmaceutical waste
- Requires trained operator
- Hazardous chemicals can cause
environmental pollution
- Emission of air pollutants
- Inefficiency in destroying thermal
resistant chemicals and drugs
- Incomplete destruction of
cytotoxics
- Relatively high investment
- High operational cost
- Requires qualified operator
- Emissions of air pollutants in case
of improper operation and
maintenance
23
- Investment cost:
180,000 – 250,000
USD
- Operational cost: 0.33
USD/kg
- Operational cost for
disinfectants
- Investment cost:
1000 – 15000 USD
- Operational cost: 0.6
USD/kg or more
expensive
- Investment cost:
20,000 – 100,000 USD
- Operational cost: 0.6
USD/kg or more
expensive
Annex 2
GUIDELINES FOR SELECTING TECHNOLOGY FOR HOSPITAL WASTE
WATER TREATMENT
I. Treatment of hospital wastewater
1. According to current policies in Vietnam, each hospital shall install and operate
a waste water treatment plant so that hospital effluent meet Vietnamese
standard TCVN 7382:2004. These are in process of being revised and
converted into national technical regulation (QCVN). The Government has
promulgated Vietnamese standard TCVN 7957:2008 on design of drainage and
sewerage external networks and facilities. Guidelines on healthcare wastewater
treatment are being developed by Ministry of Health; and a Vietnamese
standard on design, operation and maintenance of hospital wastewater
treatment plant is being developed by Ministry of Construction.
2. Wastewater from hospitals is of a similar quality to urban wastewater. The
principal area of concern is high content of enteric pathogens which are easily
transmitted through water. If healthcare waste is not well managed, hospital
wastewater contains significant amount of pharmaceuticals, chemicals which
may negatively affect biological treatment process. Many surveys on quality of
hospital influent have been conducted and summary of main findings can be
seen in the following Table.
Table 6: Polluted parameters in hospital wastewater
No
Hospitals
pH
Total
Total
SS
DO
H2S BOD5 COD
Phosph Nitroge (mg/l
(mg/l) (mg/l) (mg/l) (mg/l)
o (mg/l) n (mg/l)
)
1
By
system
referral
1.1
Central level
6.97
1.89
4.05
119.8
263.2
2.555
46.1
218.
6
1.2
Provincial level
6.91
1.34
7.48
163.9
314.4
1.71
38.9
210
1.3
Sectoral
7.12
1.59
4.84
139.2
279.9
1.44
38.9
246
2
By specialist
2.1
General
6.91
1.3
5.61
147.6
301.4
1.57
37.2
238
2.2
Tuberculosis
6.72
1.63
2.98
143.3
307.3
1.15
46.1
222.
2
2.3
Obstetric
gynecology
7.21
1.33
7.73
167
321.9
0.99
53.2
251.
3
II. Wastewater technologies:
Hospital waste water technologies can be divided into 4 groups of options.
24
 Option 1:
Hospital wastewater is primarily treated by septic tanks, settlement tanks and then
finally treated by disinfectants, bio-lake or constructed wetland (see Figure 1).
Figure 1: Technological diagram of Option 1
Wastewater
Septic tank
Settlement tank
Wastewater
Septic tank
Settlement tank
Disinfection
Bio-lake or
Constructed
wetland
Outfall
Outfall
 Option 2:
Hospital wastewater undertakes primary treatment process (in septic tanks and
settlement tanks), man-made biological treatment process (in biological filter or
activated sludge reactor) and disinfection process (see Figure 2). Vietnamese
hospitals have applied this group of technology since 1975. Up to now, this group
of technology is the most popular in Vietnam.
Figure 2: Technological diagram of Option 2
Wastewater
Septic tank
Outfall
Collection tank
+ waste screen
Septic tank
Biological treatment
facility
Secondary
settlement tank
 Option 3:
Wastewater is primarily treated in a combined block, secondarily treated in modular
biological treatment equipment and disinfected before discharged. Examples of
wastewater treatment plants using combined and modular approach known in
Vietnam are CN2000, V69 that have been used since 1998.
25
Figure 3: Technological diagram of Option 3
System of combined tanks
Waste
water
Waste
screen
Outfall
Disinfection
equipment
Balancing
primary
treatment
tank
Collection
tank
Secondary
treatment tank
Sludge
tank
Pumping hole
& submerged
pumps
Treatment equipment
aerolift – aeroten with
high rate microbiological
filting materials
Modules of equipment
 Option 4:
These are new technologies recently imported into Vietnam including Sequence
Batch Reactor and the so-called AAO (anaerobic–anoxic–oxic) technology.
Figure 4: Technological diagram of wastewater treatment plant using Sequence
Batch Reactor
Wastewater
Automatic
waste screen
Collection and
balancing tank
Outfall
Table 7: Performance specifications:
Option 1
Option 2
BOD load
0.4
0.8 - 1
(kg/m3/day)
Suspended solid
5000 400 – 500
(mg/l)
7000
Adaptation
of
activated
Medium
Not stable
sludge
adaptation
Retention time
Low
Medium
Treatment
efficiency
for 67% - 70% 85% - 95%
26
Biological treatment
Sequencing Batch Reactor
Disinfection by Ozone
Option 3
Option 4
0.6
1.8 – 3
400 - 1000
10000 –
12000
Medium
adaptation
Medium
80% - 87%
High, stable
High
90% - 97%
Suspended solid
Treatment
efficiency
organic substances
Treatment
efficiency
Nitrogen
Disinfection efficiency
for
for
75%
85% - 95%
90%
> 96%
Low
Good
Good
Very good
Medium
Good
Good
Good
Table 8: Treatment efficiency of Options.
BOD5
Influent
129.9
Option 1 Effluent
83.5
Treatment efficiency
35.72
Influent
179.2
Option 2 Effluent
140.7
Treatment efficiency
21.48
Influent
118.6
Option 3 Effluent
89.6
Treatment efficiency
24.45
Influent
165.7
Option 4 Effluent
94.8
Treatment efficiency
42.79
COD Total N
183.1 16.56
116.1 12.37
36.59
25.3
221.5 12.29
186.2
7.23
15.94 41.17
172.0 17.08
142.9 12.75
16.92 25.35
227.5 17.23
130.8
9.09
42.51 47.24
Total P SS Overall
1.76
36.0
1.09
22.9
38.07 36.39
38.2
1.23
53.3
0.28
29.6
77.24 44.47 49.61
1.60
28.4
1.65
28.5
27.63
1.95
37.8
1.05
14.8
46.15 60.85 53.84
Source: Vietnam association of construction environment, Explanation for development of Vietnam standard on
hospital wastewater treatment facilities
III. Guidelines for technology selection
 Assessment of hospital wastewater generation
Although hospital wastewater volume is selected as 0.95m 3/bed/day in conceptual
phase, the consultants preparing feasibility study report (or economical and
technical report) shall assess real water consumption and volume of wastewater in
project hospital, estimate volume of wastewater generated by 2020, calculate
capacity of treatment plant. By literature review and selected hospital visit, it is
estimate that volume of wastewater from project hospital is 0.65 m 3 – 0.8 m3/real
bed/day by 2020. Wastewater flow Qh,max (m3/h) of hospital is 1/10 of Qd.
 Analysis of wastewater characteristics and hygienic requirements
of receiver
In feasibility phase, hospital wastewater characteristics shall be identified by
sampling and analysis of pollutants in wastewater in the morning (9h) and in the
afternoon (15h). TCVN 7382:2004 and QCVN 24:2009 provide list of parameters
need to be analyzed and requirements of receiver.
 Levels of Treatment
Hospital wastewater is treated by 3 levels:
27




Facilities for 1st level treatment of hospital wastewater include waste screen, grit
remover, primary sedimentation tank, septic tanks e.g for removal of big sized
solids and suspended substances
Facilities for 2nd level treatment of hospital wastewater include biological
treatment facilities for removal of organic substances and a part of nutrients.
removes organic substances and a part of nutrients
3rd level treatment removes nutrients and disinfection.
Sludge of hospital wastewater treatment plant shall be stabilized, eliminated
pathogens prior to off-site transportation. Sludge can be dried in area of hospital
wastewater treatment plant.
Table 9: Options of technology applicable to hospital wastewater treatment
Treatment facility
Technological options
Simple septic tank
Septic tank
Baffled septic tank
Baffled septic tank with anaerobic filter
Bar or fine screen for waste removal
Waste removal
Mechanically operated screen for waste
removal
Attached
Trickling biological filter
growth
Submerged biological filter
biological
Rotating biological
treatment
contactor
Suspended
Mixed aeration tank
Biological
growth
Aerated-Lagoon reactors
treatment in
biological
aerobic or
Sequencing batch reactor
treatment
anaerobic
Oxidation ditch
condition
Biological
Anaerobic - Anoxic - Oxic
nutrient
(AAO)
removal
AOAO
Other nutrient removal
processes
Biological
Constructed wetland
treatment
in
Anaerobic or aerobic or facultative Bio-lake
natural condition
Chlorine disinfection
Disinfection
Ultraviolet disinfection
Ozone disinfection
Sludge compressing tank
Sludge treatment
Metal tank
Sludge drying facility
A hospital wastewater treatment plant can apply single option or many options of biological
treatment, provided that the effluent meet Vietnamese standard TCVN 7382:2004 and the plant is
suitable to hospital’s circumstance.
Table 10 Choice of wastewater treatment level by requirements
Level of treatment
Suspended
BOD5
Nitrogen
substances
(mg/l)
phosphorus
(mg/l)
28
and
1st level treatment
2nd level treatment
Incompletely
treatment
Completely
treatment
3rd level treatment
80
biological
25-80
25– 80
15-25
biological
15-25
15 -25
< 15
< 15
-
Nitrification
Remove 90% of N
Remove 70% of P
Table 11: Choice of wastewater treatment level by Pollutants in wastewater
influent
BOD5
concentration Amonia Total N
(mg/l)
exceed exceeds
s
standard
≤30 ≤50 >50
standar
s
≤150
0
0
0
d
Aerobic treatment
By attached growth process
- Trickling filter
+
+
- Biological rotator
+
+
- Submerged biofilter
+
+
- High rate biofilter
+
+
+
By suspended growth process
+
+
+
+
Anaerobic treatment
+
+
+
+
Anoxic treatment
+
Note: (+) applicable;
(-) not applicable
 Location and the area of hospital wastewater treatment plant
 Hospitals located in urban areas with land large enough (> 0.5 ha)
and its proximity to surrounding households and hospital facilities is ≥
200 meters, should combine decentralized primary treatment facilities
and central biological treatment facility in natural condition (see below
Figure).
Wastewater
from
departments


1st level
treatment
facilities
Primary
disinfection
Biological
treatment in
natural
condtion
Discharge
Hospitals located in urban areas and not having large land area are
recommended to select treatment process diagrams combining
decentralized primary treatment and centralized biological treatment
(see below Figure) Hospitals locating in city and having small area
can select compacting and packaged wastewater treatment system.
The hospital applies on-site sludge treatment (sludge drying bed,
sludge dewatering equipment) only when hygienic proximity to
29
households and hospital facilities is more than 100 meters. Biological
treatment facilities that are opened to the air such as oxidation ditch
or mixed aeroten bank are applied only when hygienic proximity is
more than 100 meters too.
Wastewater
Septic tank, grit remover, interceptor
Waste screen
Primary sedimentation tank
(can combined with balancing tank)
Biological treatment facility
Secondary sedimentation tank
Sludge treatment
Disinfection
Discharge
This diagram is endorsed by proposed “Guidelines for healthcare wastewater treatment”, proposed
“Vietnam standard on hospital wastewater treatment facilities – technical requirements for design,
operation and maintenance” and proposed “Master plan for healthcare waste management”.
 Operational and maintenance requirements and affordability
To ensure sustainability, project hospitals shall select a wastewater technology
which requires operational and maintenance conditions suitable and affordable to
hospitals.
Table 12: Advantages and disadvantages of hospital wastewater treatment
plants using different biological treatment methods
Technologies
Advantages
Disadvantages
Naturally biological
treatment
(bio-lake,
constructed wet
land)
- Effective treatment of lowly and
medium polluted wastewater
- Low investment cost (300 USD/m3)
- Low operation, maintenance cost
(0.05 USD/m3)
- Easy operation and maintenance
- Does not requires qualified operator
- Highly effective in treatment of
organic substances (BOD, COD)
- Inadequate to highly
polluted hospital wastewater.
- Occupy large area
Activated sludge
30
- Obstructed sludge
sedimentation may cause
Reactor
and ammonia
- Structure of equipment is simple
- Low investment cost (400 - 600
USD/m3 depend on treatment level)
poor treatment
effectiveness and unstable
system. In order to solve
this problem, the operator
must have good
knowledge.
- Consumes much power for
compulsory aeration process,
increases operational cost (0.9
USD/m3);
- Aeration process can
make noise and disperse
pathogens to environment
- Occupy large area
- Treatment effectiveness is
- Inadequate to highly
Biological filter
medium, adequate to treatment of polluted wastewater due to
(trickling filter and
medium polluted hospital
organic substances and
submerged
wastewater
nitrogen
biological filter)
- Simple structure, easy to install,
- Requires balancing tank to
inexpensive investment cost (400- balance raw wastewater,
500 USD/m3)
requires bulky secondary
- Simple operation and
tank
maintenance, low operational cost - Can not operate if electricity
(about 0.07 USD/m3 of wastewater) runs out of
because the system consumes
- Can cause odor in case of
less electricity,
improper operation
- Does not requires qualified
operator.
- Occupies less space than
activated sludge technology
Compacting and
- Treatment effectiveness of
- High investment cost
modular system
organic substances and nitrogen because of biological
using contact
is high. Quality of effluent is
filtration materials (800
aeration
good and stable
USD/m3)
- Operation is simpler and more
- High operational cost (0.13
stable than operation of
USD/m3) because of
activated sludge technology
consumption of chemicals and
- Occupies less space than
electricity consumption for
activated sludge technology
compulsory aeration;
- Can not operate if electricity
runs out of
- Can cause noise and odor in
case of improper operation
Compacting,
- High effectiveness for treatment
- High investment cost (1200
prefabricated
of highly polluted wastewater
USD/m3 of wastewater)
packaged system
- Flexible in installation
- Filtration membrane must
using AAO process - Operational and maintenance
be maintained annually and
3
(Anaerobic –
cost is not high (0.09 USD/m of replaced after 10 years
Anoxic – Oxic)
wastewater)
- Requires qualified staff
- Occupies less space, can be
31
install under ground, does not
cause odor
Operational cost of hospital wastewater treatment facilities includes electricity
consumed by air blower and different pumps, bio-agents for biological treatment,
chemicals for disinfection, sludge removal and disposal, and salary for operators.
Annual maintenance cost shares 5% of total value of equipment and construction
(in line with international practice). The operational cost and maintenance cost of
wastewater facilities shall be described in detail in the investment project report (or
economical and technical report).
Hospitals having less revenue and limited human resource (such as specialist
hospitals of tuberculosis, mental diseases, nuring, inter-district hospitals and
financially non-autonomous hospitals) should select low-cost technologies including
physical treatment facilities, naturally biological treatment facilities (biolake,
constructed wetland), trickling filter. The hospitals having more revenue (specialist
of ophthalmology, Obstetric, provincial general hospital e.g) can select technologies
consuming more electricity and chemicals and requiring qualified operators. Finally,
investment project will be approved only when the hospitals can prove its capacity
to operate and maintain of invested wastewater treatment plant.
 Design, appraisal and approval of wastewater treatment technology
Project
investment
< 15 billion VND
( 750,000 USD)
≥ 15 billion VND
(750,000 USD)
Project
document
Economical –
technical
proposal
(Template is
available in
Construction
Law)
Feasibility study
(Template is
available in
Decree
12/2009/NĐCP)
-
Facility design
Appraisal and approval
Detailed design
(one step design)
- Investment owner is
responsible for appraisal of
proposal and detailed design
at the same time.
- Then submit to investment
decision maker for approval
Basic design
- Investment decision maker
is responsible appraisal of
feasibility study and basic
design at the same time
Detailed design
(two step design)
- Investment owner is
responsible for appraisal of
detailed design
- Then submit to investment
decision maker for approval
32
ANNEX 3
PROVINCIAL HEALTHCARE WASTE MANAGEMENT PLAN
Part 1: CURRENT SITUATION OF HCWM IN PROVINCE
1
Current situation of healthcare solid waste management
1.1
Healthcare solid generators
1.1.1
Description of health facilities
1.1.2
Total quantity of healthcare solid waste generated from health facilities
1.1.3
Expansion plans of healthcare services in the province
1.1.4
Estimated increase in healthcare waste generated in the future
1.2.
Healthcare solid waste treatment
1.2.1
On-site treatment model
1.2.2
Off-site treatment model
1.3
Healthcare solid waste transportation for off-site treatment
1.4
Healthcare solid waste disposal
2
Current situation of healthcare wastewater management
2.1
Volume of healthcare wastewater generation by facility
2.2
Description of wastewater treatment plants in the province
2.3
Wastewater quality monitoring
2.4
Sludge disposal
3
Current implementation arrangements and compliance requirements
3.1.
Legislative framework relating HCWM in the province
3.2.
Organizational structure for managing, supervising HCWM in the province
4
Healthcare solid waste management support projects in province
Part 2: IMPROVEMENT PLAN
1
General orientation
1.1
Orientation for HCWM generators
1.2
Orientation for HCW treatment facilities
1.3
Orientation for HCW off-site transporters
2
Construction and equipment
2.1
Healthcare solid waste management
2.1.1
Materials for segregation, collection, on-site transportation and storage
2.1.2
Vehicles for off-site hazardous HCW transportation
2.1.3
2.1.4
2.2
Hazardous HCW treatment facility
Final disposal facility (concrete bury pit)
Wastewater collection and treatment
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2.2.1
Hospital wastewater treatment plant
2.2.2
Wastewater treatment facilities for other health facilities
3
Strengthening institutional capacity for HCWM including training,
awareness raising communication
3.1
Structural organization
3.3.1
Responsibility assignment and cooperation mechanism for management
agencies
Structural organization for HCWM in health facilities
3.1.2
3.2
Strengthening management capacity, training and awareness raising
communication for health facilities
3.2.1
For hospitals
3.2.2
For other health facilities
3.3
Monitoring and enforcement
ANNEX
Annex 1: Map of provincial health system
Annex: Organizational structure of health system
Annex 3-1: General characteristics of hospitals
Annex 3-2: Environmental characteristics of hospitals
Phụ lục 3-3: Estimation of healthcare waste generation in 2010 and 2015
Annex 3-4: Healthcare waste treatment and disposal
Annex 3-5: Hospital wastewater treatment plant
Annex 3-6: HCW support projects in province
Annex 3-7: Investment needs for collection, transportation, storage, treatment
and disposal of hospital w
Annex 3-8: Investment needs for waste management capacity building
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ANNEX 4:
FACILITY HEALTHCARE WASTE MANAGEMENT PLAN
PART 1: CURRENT SITUATION
1
Hospital description
1.1
General information
1.1.1 Location, area and catchman area
1.1.2 Hospital size
1.1.3 Position in referral system
1.1.4 Main services
1.1.5 Environmental assessment and authorization
1.2
Hospital performance
1.3
Organizational structure
1.3.1 Hospital structure
1.3.2 Management and accountability
1.3.3 Staff number
1.3.4 Budget
2
Healthcare waste management
2.1
Solid waste management
2.1.1 Waste generation
2.1.2 Segregation and color coding
2.1.3 Collection
2.1.4 On-site transportation
2.1.5 Storage
2.1.6 Off-site transportation
2.2
Treatment and disposal system
2.2.1 Hazardous waste treatment and disposal
2.2.2 General waste treatment and disposal
2.2.3 Reuse and recycle
2.3
Hospital wastewater management
Wastewater characteristic
Treatemnt plant: technnology and capacity
Operational status
Operator
Sludge removal and disposal
Effluent monitoring
Main challenges
3
Occupational health and safety
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4
Monitoring and supervision
4.1
Monitoring and supervision inside hospital
Management of HCW
Monitoring and supervision of HCWM
Waste and environmental impact monitoring
Monitoring of training, comsumables
4.2
Monitoring and supervison outside hospital
5
Cost for healthcare waste management
PART 2: IMPROVEMENT PLAN
1
Healthcare waste managenebt process improvement
Responsibility in HCMM
Minimization
Segregation
Collection, transportation and storage
Off-site transportation
Treatment and disposal (including ash)
Reuse and recycle
Wastewater collection and treatment
Sludge treatment and disposal
2
Environmental assessment and authorization
3
Procurement
4
Training and communication
Training for key manager
Training on O&M
Training on technology transfer
Basic training for staff
Awaireness raising communication
5
Monitoring and reporting
Monitoring and supervision of operation
Monitoring of waste and impact
Reporting scheme
6
Implementation arrangement
Organizational structure
Integration of HCWM team into existing systems of infection
control and labour safety
Tasks and responsibitlities
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7
Cost estimation
ANNEX
Annex 1: Hospital layout
Annex 2: Hospital organizational structure diagram
Annex 3-1: Decision on Infection control committee establishment
Annex 3-2: Decision on Labour safety committee establishment
Annex 4: Decision on hospital development plan
Annex 5: Environmental monitoring and inspection results
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