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VIETNAM HOSPITAL WASTE MANAGEMENT SUPPORT PROJECT

OPERATIONAL MANUAL

TABLE OF CONTENT

PART I PROJECT IMPLEMENTATION ARRANGEMENTChapter 1 Project backgroundChapter 2 Project implementation arrangementChapter 3 Reporting, monitoring and evaluation of project implementation

PART II GUIDELINES FOR FINANCIAL – ACCOUNTING WORKSChapter 1 Project financial planningChapter 2 Bank and accountChapter 3 Disbursement and claimChapter 4 Project accountingChapter 5 Reporting, auditingChapter 6 Project closure

PART III GUIDELINES FOR PROCUREMENTChapter 1 General introductionChapter 2 Bidding documentChapter 3 Procurement planChapter 4 Procurement of consultantsChapter 5 Procurement of goods and constructionChapter 6 Checking

PART IV GUIDELINES FOR SUB-GRANT IMPLEMENTATIONChapter 1 OverviewChapter 2 Principles in sub-grant implementationChapter 3 Relating documentsChapter 4 Guidelines for specific issuesChapter 5 Implementation arrangement

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PART V ENVIRONMENTAL RISKS MANAGEMENT

ANNEX:Annex 1 Selection of technology for healthcare solid waste treatment Annex2 Selection of technology for hospital waste water treatmentAnnex 3 Template of provincial healthcare waste management planAnnex 4 Template of hospital waste management plan

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PART V ENVIRONMENTAL RISKS MANAGEMENT

I. 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 75-90% 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

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:

1 Draft National action plan for healthcare waste management in Vietnam, 20083

Table 1: Average hospital hazardous waste generation rate

Hospitals by

level and specialization

Central general hospital

Central specialist hospital

Provincial general hospital

Provincial specialist hospital

District or branch hospital

Quantity of hazardous solid waste (kg/bed/day)

0.3 0.225 0.225 0.2 0.175

Table 2: Healthcare waste generation from Vietnam project hospitals

General hospitals Specialist hospitals

Central level

Provincial level

Inter-district

Obstetric Pediatric

Tuberculosis, infectious diseases

Mental, nursing,

traditional medicine

Cancer Others

Infectious waste

Sharps ++ + + + + + + +

Non-sharps + + + + + + + + +

Highly infectious + + + + + + + + + +

Anatomical waste + + + + + + - - +/- +/-

Chemical waste

Pharmaceuticals + + + + + + + + +

Hz.Chemicals + + + + + + + + + +

Cytotoxics + + +/- - - - - + + -

Radioactive waste + +/- - - - - + + -

Presurized containers

+ + + + + + + + +

General waste ++ ++ + ++ + + + +

Note: + + generation, larger quantities; + generation, smaller quanitities; - no generation ; +/- generation or not, depend on services;

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.

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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 BOD5

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 DO (mg/l)

H2S (mg/l)

BOD5

(mg/l)COD (mg/l)

Total Phospho

(mg/l)

Total Nitrogen

(mg/l)

SS (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- 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.

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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 inhalation of dust or aerosols, absorption through the skin, ingestion of food accidentally contaminated with cytotoxic drugs.

2.1.4 Hazards of radioactive waste

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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

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.

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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- Decision 43/2007/QD-BYT dated 30/11/2007 of Minister of Health

promulgating Healthcare waste management regulations

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- 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.

Sub-component 1.2 will focus on strengthening institutional capacities of the central and provincial level agencies responsible for regulating health care waste

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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 sub-national 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

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

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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 Plan and Facility specific plans and procured by Provincial Department of Health and project hospitals.

8.4 Vehicle for off-site transportation11

The project provides hospitals financial assistance to procure vehicle for off-site 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.

The following Figure describes hospital wastewater management scheme

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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 maintenanceThe 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 include the hospital management commitment to cover recurrent operations and

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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.

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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.

TechnologyAdequate 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 SystemsSub-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

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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.

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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 supervision of complance to standard operating procedures; (ii) monitoring of

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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.

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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 OptionsII.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.

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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.

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Table 4: Treatment and disposal methods suitable for different categories of healthcare waste

Pyrolytic incinerator

Wet thermal disinfection (autoclave)

Microwave irradition

Chemical disinfection

Safe burying

Innertiza-tion

Others

Infectious wasteSharps Yes Yes Yes Yes Yes No -Non-shaprs Yes Yes Yes Yes Yes No -Highly infectious Yes Yes Yes Yes Yes No -Anatomical Yes No No No Yes No -Chemical wastePharmaceuticals For small

quantities No No No Yes Yes Return to supplier

Cytotoxic waste No No No No No Yes Return to supplier

Hz. chemicals For small quantities No No No No No Return to

supplierRadioactive waste No No No No No No Decay by

storagePresurized containers No No No No Yes No Return to

supplier

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Table 5: Main advantage and disadvantages of solid health care waste treatment technologies

Technology Advantages Disadvantages Cost (in 2010)Non-incineration technologiesNeedle cutter - Prevent needle reuse

- Easy to operate, low cost- Syringe can be recycled

- Needles need further treatment after cut and separated

- Investment cost: 2-80 USD- Durability: 200,000 cutting times

Needle destroyer

- Needle is disinfected and destroyed by electricity- Easy to operate, low cost- Syringe can be recycled

- Require electricity- Stem of needle still exists after destroying.

- Investment cost: 100 – 150 USD

Innertization - Applicable to chemical waste and pharmaceutical waste- Simple to operate, low cost

- Not applicable to other waste - Investment cost of cement, sand

Cement bury pit

- Applicable to sharps and pathological waste- Simple to operate, low cost

- Requires land and space- Potential impact to underground water if poor design, construction

- Investment cost: 100–200 USD/m3

Safe burying - Relatively safe if access to site is restricted and where natural infiltration is limited. - Low investment and operation cost

- Only apply to hospitals in mountainous and rural area

- Investment cost: labour, roof, fence

Disinfection by steam (autoclave)

- Highly efficient disinfection - Reduction in waste volume if shredder available- Low operational cost - Environmentally sound- Well-known technology in hospitals

- 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

- Investment cost: 500 – 50,000 USD- Operational cost: 0.33 USD/kg

Disinfection by microwave irradiation


- Inadequate for anatomical, pharmaceutical and chemical waste, and waste that is not readily steam permeable. - Requires trained operator - High investment cost, requires

- Investment cost: 70,000 – 50,000 USD- Operational cost: 0.33 USD/kg

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thermal resistant waste bagsDisinfection by steam & microwave


- 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

- Investment cost: 180,000 – 250,000 USD- Operational cost: 0.33 USD/kg

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

- Inadequate for anatomical waste, sharps, chemical and pharmaceutical waste - Requires trained operator - Hazardous chemicals can cause environmental pollution

- Operational cost for disinfectants

Incineration technologiesSingle chamber incinerator

- Good disinfection efficiency- Drastic reduction of weight and volume of waste- No need for highly trained operator

- Emission of air pollutants- Inefficiency in destroying thermal resistant chemicals and drugs

- Investment cost: 1000 – 15000 USD- Operational cost: 0.6 USD/kg or more expensive

Two chamber or Pyrolytic incinerator

- Adequate for all infectious waste, most chemical waste, and pharmaceutical waste- Drastic reduction of weight and volume of waste

- Incomplete destruction of cytotoxics - Relatively high investment - High operational cost- Requires qualified operator - Emissions of air pollutants in case of improper operation and maintenance

- Investment cost: 20,000 – 100,000 USD- Operational cost: 0.6 USD/kg or more expensive

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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 DO (mg/l)

H2S (mg/l)

BOD5 (mg/l)

COD (mg/l)

Total Phospho (mg/l)

Total Nitrogen (mg/l)

SS (mg/l

)1 By referral

system1.1 Central level 6.97 1.89 4.05 119.8 263.2 2.555 46.1 218.

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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 specialist2.1 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.

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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

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.


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.

Wastewater Septic tank Collection tank+ waste screen

Biological treatment facility

Secondarysettlement tank Septic tank Outfall

Wastewater Septic tank Settlement tank Disinfection Outfall

Bio-lake or Constructed

wetland Wastewater Septic tank Settlement tank Outfall

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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

Table 7: Performance specifications: Option 1 Option 2 Option 3 Option 4

BOD load(kg/m3/day) 0.4 0.8 - 1 0.6 1.8 – 3

Suspended solid (mg/l) 400 – 500 5000 -

7000 400 - 1000 10000 – 12000

Adaptation of activated sludge Not stable Medium

adaptationMedium

adaptation High, stable

Retention time Low Medium Medium HighTreatment efficiency for 67% - 70% 85% - 95% 80% - 87% 90% - 97%

System of combined tanks

Waste water

Waste screen

Collection tank

Balancing primarytreatment

tank

Outfall

Pumping hole & submerged

pumps

Sludge tank

Secondary treatment tank

Treatment equipmentaerolift – aeroten with

high rate microbiological filting materials

Disinfection equipment

Modules of equipment

Wastewater Automatic waste screen

Collection and balancing tank

Biological treatment Sequencing Batch Reactor

Disinfection by Ozone Outfall

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Suspended solidTreatment efficiency for organic substances 75% 85% - 95% 90% > 96%

Treatment efficiency for Nitrogen Low Good Good Very good

Disinfection efficiency Medium Good Good Good

Table 8: Treatment efficiency of Options. BOD5 COD Total N Total P SS Overall

Option 1Influent 129.9 183.1 16.56 1.76 36.0Effluent 83.5 116.1 12.37 1.09 22.9Treatment efficiency 35.72 36.59 25.3 38.07 36.39 38.2


Option 3Influent 118.6 172.0 17.08 1.60 28.4Effluent 89.6 142.9 12.75 1.65 28.5Treatment efficiency 24.45 16.92 25.35 - - 27.63


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 0.95m3/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 m3 – 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:

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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 treatmentTreatment facility Technological options

Septic tankSimple septic tankBaffled septic tankBaffled septic tank with anaerobic filter

Waste removalBar or fine screen for waste removal Mechanically operated screen for waste removal

Biological treatment in aerobic or anaerobic condition

Attached growth biological treatment

Trickling biological filterSubmerged biological filterRotating biological contactor

Suspended growth biological treatment

Mixed aeration tank Aerated-Lagoon reactorsSequencing batch reactorOxidation ditch

Biological nutrient removal

Anaerobic - Anoxic - Oxic (AAO)AOAOOther nutrient removal processes

Biological treatment in natural condition

Constructed wetlandAnaerobic or aerobic or facultative Bio-lake

DisinfectionChlorine disinfectionUltraviolet disinfectionOzone disinfection

Sludge treatmentSludge compressing tank Metal tankSludge 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

substances (mg/l)

BOD5 (mg/l)

Nitrogen and phosphorus

1st level treatment 80 - -

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2nd level treatment 25– 80 -- Incompletely biological treatment

25-80 15-25

- Completely biological treatment

15-25 15 -25 Nitrification

3rd level treatment < 15 < 15 Remove 90% of NRemove 70% of P

Table 11: Choice of wastewater treatment level by Pollutants in wastewater influent

BOD5 concentration (mg/l)

Amonia exceeds standard

Total N exceeds standards ≤150 ≤30

0≤500

>500

Aerobic treatmentBy 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).

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 households and hospital facilities is more than 100 meters. Biological

Wastewater from departments

1st level treatment facilities

Biological treatment in

natural condtion

Primary disinfection

Discharge

29

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.

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 DisadvantagesNaturally 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

- Inadequate to highly polluted hospital wastewater.- Occupy large area

Activated sludge Reactor

- Highly effective in treatment of organic substances (BOD, COD) and ammonia

- Obstructed sludge sedimentation may cause poor treatment

Wastewater

Septic tank, grit remover, interceptor

Waste screen

Biological treatment facility

Primary sedimentation tank(can combined with balancing tank)

Secondary sedimentation tankSludge treatment

Disinfection

Discharge

30

- Structure of equipment is simple- Low investment cost (400 - 600 USD/m3 depend on treatment level)

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

Biological filter (trickling filter and submerged biological filter)

- Treatment effectiveness is medium, adequate to treatment of medium polluted hospital wastewater - Simple structure, easy to install, inexpensive investment cost (400-500 USD/m3)- Simple operation and maintenance, low operational cost (about 0.07 USD/m3 of wastewater) because the system consumes less electricity, - Does not requires qualified operator. - Occupies less space than activated sludge technology

- Inadequate to highly polluted wastewater due to organic substances and nitrogen - Requires balancing tank to balance raw wastewater, requires bulky secondary tank - Can not operate if electricity runs out of - Can cause odor in case of improper operation

Compacting and modular system using contact aeration

- Treatment effectiveness of organic substances and nitrogen is high. Quality of effluent is good and stable - Operation is simpler and more stable than operation of activated sludge technology- Occupies less space than activated sludge technology

- High investment cost because of biological filtration materials (800 USD/m3)- High operational cost (0.13 USD/m3) because of consumption of chemicals and electricity consumption for compulsory aeration; - Can not operate if electricity runs out of - Can cause noise and odor in case of improper operation

Compacting, prefabricated packaged system using AAO process(Anaerobic – Anoxic – Oxic)

- High effectiveness for treatment of highly polluted wastewater - Flexible in installation - Operational and maintenance cost is not high (0.09 USD/m3 of wastewater) - Occupies less space, can be install under ground, does not

- High investment cost (1200 USD/m3 of wastewater)- Filtration membrane must be maintained annually and replaced after 10 years- Requires qualified staff

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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

Project document

Facility design Appraisal and approval

< 15 billion VND( 750,000 USD)

Economical – technical proposal(Template is available in Construction Law)

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

≥ 15 billion VND(750,000 USD)

Feasibility study(Template is available in Decree 12/2009/NĐ-CP)

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

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ANNEX 3PROVINCIAL HEALTHCARE WASTE MANAGEMENT PLAN

Part 1: CURRENT SITUATION OF HCWM IN PROVINCE1 Current situation of healthcare solid waste management1.1 Healthcare solid generators1.1.1 Description of health facilities1.1.2 Total quantity of healthcare solid waste generated from health facilities1.1.3 Expansion plans of healthcare services in the province1.1.4 Estimated increase in healthcare waste generated in the future1.2. Healthcare solid waste treatment1.2.1 On-site treatment model1.2.2 Off-site treatment model1.3 Healthcare solid waste transportation for off-site treatment1.4 Healthcare solid waste disposal2 Current situation of healthcare wastewater management2.1 Volume of healthcare wastewater generation by facility2.2 Description of wastewater treatment plants in the province2.3 Wastewater quality monitoring2.4 Sludge disposal3 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 province4 Healthcare solid waste management support projects in province

Part 2: IMPROVEMENT PLAN

1 General orientation1.1 Orientation for HCWM generators1.2 Orientation for HCW treatment facilities1.3 Orientation for HCW off-site transporters2 Construction and equipment2.1 Healthcare solid waste management2.1.1 Materials for segregation, collection, on-site transportation and storage2.1.2 Vehicles for off-site hazardous HCW transportation2.1.3 Hazardous HCW treatment facility

2.1.4 Final disposal facility (concrete bury pit)2.2 Wastewater collection and treatment

33

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 organization3.3.1 Responsibility assignment and cooperation mechanism for management

agencies3.1.2 Structural organization for HCWM in health facilities

3.2 Strengthening management capacity, training and awareness raising communication for health facilities

3.2.1 For hospitals 3.2.2 For other health facilities3.3 Monitoring and enforcement

ANNEXAnnex 1: Map of provincial health systemAnnex: Organizational structure of health systemAnnex 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 disposalAnnex 3-5: Hospital wastewater treatment plant

Annex 3-6: HCW support projects in provinceAnnex 3-7: Investment needs for collection, transportation, storage, treatment and disposal of hospital w

Annex 3-8: Investment needs for waste management capacity building

34

ANNEX 4:FACILITY HEALTHCARE WASTE MANAGEMENT PLAN

PART 1: CURRENT SITUATION1 Hospital description1.1 General information1.1.1 Location, area and catchman area1.1.2 Hospital size1.1.3 Position in referral system1.1.4 Main services1.1.5 Environmental assessment and authorization1.2 Hospital performance1.3 Organizational structure1.3.1 Hospital structure1.3.2 Management and accountability1.3.3 Staff number

1.3.4 Budget2 Healthcare waste management2.1 Solid waste management2.1.1 Waste generation2.1.2 Segregation and color coding2.1.3 Collection 2.1.4 On-site transportation2.1.5 Storage2.1.6 Off-site transportation2.2 Treatment and disposal system2.2.1 Hazardous waste treatment and disposal2.2.2 General waste treatment and disposal2.2.3 Reuse and recycle2.3 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

35

4 Monitoring and supervision4.1 Monitoring and supervision inside hospital Management of HCW Monitoring and supervision of HCWM Waste and environmental impact monitoring Monitoring of training, comsumables4.2 Monitoring and supervison outside hospital5 Cost for healthcare waste management

PART 2: IMPROVEMENT PLAN1 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 treatmentSludge treatment and disposal

2 Environmental assessment and authorization3 Procurement4 Training and communication Training for key manager Training on O&M Training on technology transfer Basic training for staff Awaireness raising communication5 Monitoring and reporting Monitoring and supervision of operation Monitoring of waste and impact Reporting scheme6 Implementation arrangement Organizational structure

Integration of HCWM team into existing systems of infection control and labour safety

Tasks and responsibitlities

36

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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