Healthcare waste management plan - Central North Region Health Support Project

E2264 Public Disclosure Authorized

Building up the plan for Healthcare waste management and treatment Public Disclosure Authorized Public Disclosure Authorized Public Disclosure Authorized 18 October, 2009

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Table of contents

CHAPTER 1. HEALTHCARE WASTE MANAGEMENT AND LEGISLATIVE FRAMEWORK...... 4 CHAPTER 4: BUILDING THE PLAN FOR POLLUTION MITIGATION...... 5 CHAPTER 1. HEALTHCARE WASTE MANAGEMENT AND LEGISLATIVE FRAMEWORK...... 9 1. 1 Introduction...... 9 1.1.1 HCWM ...... 10 1.1.2 Decision No. 43/2007/QD-BYT, November, 30 2007, of the Minister of Health on healthcare waste management...... 11 1.1.3. Standards...... 11 1.1.4. TCVN7380-2004 and TCVN7381-2004 on medical solid waste incinerator ...... 13 1.1.5 Review of requirement on HCWM practices in Vietnam and in the world ...... 13 1.2 Comparison with international standards ...... 13 1.3 Air emission from Healthcare waste incinerators ...... 15 1.4. Recommendations for strengthening the legislative framework...... 15 1.6 Environmental assessments and building HCWM plan team...... 16 1.7 Methodology...... 16 CHAPTER 2: PROJECT SITES AND STATUS OF HCWM ...... 17 2.1 Description of project sites and HCWM status...... 17 2.2. Survey and field trips to investigate the existing HCWM at the project healthcare establishments...... 23 2.2.1 Questionnaires on HCWM...... 23 2.2.2 Assessment of waste generation rate at project healthcare establishments ...... 23 2.2.3. Assessment of the type of waste/group of waste in practices ...... 24 2.2.4. Waste separation, collection, transportation, storage and treatment HzHCSW at project DGHs...... 25 2.2.5. Assessment of HCWM team, internal guideline, training course in HCWM...... 27 2.2.6. Assessment of HCSW treatment ...... 30 2.2.7 HCWM assessment ...... 30 2.2.8 Assessment of local authorities’ and DPC leader’s proposals on HCWM...... 30 2.2.9. Infectious liquid waste and waste water treatment (WWT)...... 31 2.2.10 The needs of spread out regulation on safe discharges of medical waste water..... 31 2.2.11. Assessment of Healthcare waste water management ...... 32 2.3. HCWM Budget...... 33 2.4 Risk associate with current HCWM practices and role of Provincial DOH in HCWM inspection 33 CHAPTER 3: ENVIRONMENTAL IMPACTED SOURCES FROM MEDICAL WASTE AT THE PROJECT UNITS...... 34 3.1 Environmental impact caused by medical waste water ...... 34 3.1.1 Estimation of waste water volume from the preventative DGHs in project area. ... 34 3.1.2 Specific characteristics and components of healthcare waste water ...... 34 3.2 Raising hospital waste is one environmental impact...... 36 3.2.1 The discharge of medical solid waste from DGH/DPC in the project sites...... 36 3.2.2 Objective, impacted scale of medical solid waste...... 36 3.3 Environmental impact when building the technical house for preventive medical center...... 38 3.3.1 Impacts in the preparing and the implementing phase...... 38 3.3.2 Environmental impacts in the operation phase ...... 39 3.4. Integrated assessment of environmental impacts of the project...... 40

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CHAPTER 4: BUILDING ENVIRONMENTAL MANAGEMENT PLAN AND MITIGATION SOLUTION ...... 42 4.1 Decrease the impact of medical waste by increasing practices HCWM for medical establishments in the project areas...... 43 4.1.1 Increase guideline of HCWM...... 43 4.1.2 Regulative development, human resources for HCWM...... 43 4.1.3 Building up one specific HCWM Plan for projected district general hospitals...... 44 4.2 HCWM plan and environment impacts mitigation for district general hospitals in the project area...... 45 4.2.1 Waste separation at source by group of waste based on HCWM Regulation of HCWM- Q 43/2007/QD-BYT...... 45 4.2.2 Color coding for waste bag, stored bin, waste bin...... 46 4.2.3 Responsibility of waste collection, transportation in the medical units...... 46 4.2.4 HCW treatment plan of medical units in the project area...... 47 4.2.5. Impact mitigation from radioactive waste ...... 49 4.2.6 Mitigation method of epidemic diseases ...... 49 4.2.7 Other mitigation methods ...... 50 4.2.8 Preventive and deal with environmental breakdown...... 51 4.2.9 Increasingly monitoring the information of hazardous medical waste...... 51 4.2.10. Increasing individual responsibility of HCWM...... 51 4.2.11. Preparing specific financial source for HCWM...... 52 4.2.12 Preparing to build treat HCWM based on the assessment and selection of suitable technology for project DGH/DPC...... 52 4.2.13 Implementing, building and treating medical waste for medical units with different source of capital ...... 54 4.2.14 Making and creating appropriate budget and encouraging medical waste treatment54 4.3 Mitigation of environmental pollution in the construction phase of the preventive medical center...... 54 4.3.1 Mitigation method when preparing construction...... 54 4.3.2 Mitigation impacts when preparing the building platform...... 58 4.3.3. Air pollution mitigation in the construction phase...... 58 4.3.4 Mitigation of water pollution in the construction phase ...... 59 4.3.5 Mitigation of solid waste in the construction phase...... 59 4.3.6 Safety in construction implementation and protection ...... 60 4.4. Air pollution mitigation in the operation of newly built DPC ...... 60 4.4.1. Air pollution mitigation...... 60 4.4.2 Water pollution mitigation...... 60 4.4.3. Mitigaiton method for healthcare solid waste (HCSW)...... 60 4.4.4 Sum up the method of MW treatment of preventive medical center ...... 61 CHAPTER V: INVIRONMENTAL MANGEMENT AND MONITORING PROGRAM...... 63 5.1. Environmental management and monitoring program...... 63 5.1.1 Environnemental management plan (EMP) ...... 63 5.2 Air environment monitoring ...... 65 5.3 Waste water monitoring...... 66 5.4 Solid waste monitoring ...... 66 5.5 Monitoring the sanitation condition of working environment...... 67 CHAPTER 6: ACTION PLANS AND COST OF MWM IN NORTH CENTRAL PROVINCES...... 68 6.1 Cost estimation...... 68

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6.2 Co-ordinate cost estimation for the supplying of MW treating equipment...... 68 6.3 Implementation Schedule...... 70 &KDSWHU5HFRPPHQGDWLRQVWRVWUHQJWKHQ+&:0DW1RUWK &HQWUDO3URYLQFHV ...... 71 7.1 Increase training, wide spreading, practicing HCWM based on QD43/2007 of MoH and other legal regulations...... 71 7.2 Building HCWM plan and environmental impact mitigation ...... 71 7.3 Increase the proper monitoring at the province, increase human ability of HCWM assessment for Medical Service...... 71 7.4 Increase equipment and tools for medical waste collection and disposal ...... 71 7.5 Increase testing suitable equipment for medical waste treatment; operating, collecting experiment from operation and management...... 72 References...... 73 APPENDIX 1. SOCIAL- ECONOMY INFORMATION OF 6 NCP...... 74 THANH HOA PROVINCE ...... 74 NGHE AN PROVINCE ...... 74 Appendix 3: Results of HCWM evaluated based on questionnaires ...... 95 Appendix 5: Picture of Guiding of separation and treatment of needs and syringes...... 117 Appendix 6: List of organization and Individuals participated in HCWM Plan ...... 118 Appendix 7: Picture report at from the practical observation...... 118 Annex 8: Environmental standards and related documents ...... 122

CHAPTER 1. HEALTHCARE WASTE MANAGEMENT AND LEGISLATIVE FRAMEWORK

1. 1 Introduction...... 9 1.1.1 HCWM ...... 10 1.1.2 Decision No. 43/2007/QD-BYT, 30 November 2007, of the Minister of Health on healthcare waste management...... 11 1.1.3. Standards...... 11 1.1.4. TCVN7380-2004 and TCVN7381-2004 on medical solid waste incinerator ...... 13 1.1.5 Review of requirement on HCWM practices in Vietnam and in the world ...... 13 1.2 Comparison with international standards ...... 13 1.3 Air emission from Healthcare waste incinerators ...... 15 1.4. Recommendations for strengthening the legislative framework...... 15 1.6 Environmental assessments and building HCWM plan team...... 16 1.7 Methodology...... 16

CHAPTER 2: PROJECT SITES AND STATUS OF HCWM ...... 17 2.1 Description of project sites and HCWM status...... 17 2.2. Survey and field trips to investigate the existing HCWM at the project healthcare establishments...... 23 2.2.1 Questionnaires on HCWM...... 23 2.2.2 Assessment of waste generation rate at project healthcare establishments ...... 23 2.2.3. Assessment of the type of waste/group of waste in practices ...... 24 2.2.4. Waste separation, collection, transportation, storage and treatment HzHCSW at project DGHs...... 25 2.2.5. Assessment of HCWM team, internal guideline, training course in HCWM...... 27 2.2.6. Assesment of HCSW treatment...... 30 2.2.7 HCWM assessment ...... 30 2.2.8 Assessment of local authorities’ and DPC leader’s proposals on HCWM...... 30

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2.2.9. Infectious liquid waste and waste water treatment (WWT)...... 31 2.2.10 The needs of spread out regulation on safe discharges of medical waste water..... 31 2.2.11. Assessment of medical waste water ...... 32 2.3. HCWM Budget...... 33 2.4 Risk associate with current HCWM practices and role of Provincial DOH in HCWM inspection 33

CHAPTER 3: ENVIRONMENTAL IMPACTED SOURCES FROM MEDICAL WASTE AT THE PROJECT UNITS...... 34

3.1 Environmental impact caused by medical waste water ...... 34 3.1.1 Estimation of waste water volume from the preventative DGHs in project area. ... 34 Generation of waste water in DGHs ...... 34 3.1.2 Specific characteristics and components of healthcare waste water ...... 34 3.2 Raising hospital waste is one environmental impact...... 36 3.2.1 The discharge of medical solid waste from DGH/DPC in the project sites...... 36 3.2.2 Objective, impacted scale of medical solid waste...... 36 3.3 Environmental impact when building the technical house for preventive medical center...... 38 3.3.1 Impacts in the preparing and the implementing phase...... 38 3.3.2 Environmental impact in the operation phase ...... 39 3.4. Assessment the environmental impact total...... 40

CHAPTER 4: BUILDING THE PLAN FOR POLLUTION MITIGATION

4.1 Decrease the impact of medical waste by increasing practices HCWM for medical units in the project areas...... 43 4.1.1 Increase guideline of HCWM...... 43 4.1.2 Regulative development, human resources for HCWM...... 43 4.1.3 Building up one specific HCWM Plan for projected district general hospitals...... 44 4.2 HCWM plan and environment impacts mitigation for district general hospitals in project area....45 4.2.1 Waste separation at source by group of waste based on HCWM Regulation of HCWM- Q 43/2007/QD-BYT...... 45 4.2.2 Color coding for waste bag, stored bin, waste bin...... 46 4.2.3 Responsibility of waste collection, transportation in the medical units...... 46 4.2.4 HCW treatment plan of medical units in the project area...... 47 4.2.5. Impact mitigation from radioactive waste ...... 49 4.2.6 Mitigation method of epidemic diseases ...... 49 4.2.7 Other mitigation methods ...... 50 4.2.8 Preventive and deal with environmental breakdown...... 51 4.2.9 Increasingly monitering the information of hazardous medical waste ...... 51 4.2.10. Increasing individual responsibility of HCWM ...... 51 4.2.11. Preparing private source of capital for HCWM ...... 52 4.2.12 preparing to build treat HCWM based on the assessment and selection of suitable technology for project DGH/DPC...... 52 4.2.13 Implementing, building and treating medical waste for medical units with different source of capital ...... 54 4.2.14 Making and creating appropriate budget and encouraging medical waste treatment54 4.3 Mitigation of environmental pollution in the construction phase of preventive medical center. ...54 4.3.1 Mitigation method when preparing construction...... 54

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4.3.2 Mitigation impacts when preparing the building platform...... 58 4.3.3. Air pollution mitigation in the construction phase...... 58 4.3.4 Mitigation of water pollution in the construction phase ...... 59 4.3.5 Mitigation of solid waste in the construction phase...... 59 4.3.6 Safety in construction implementation and protection ...... 60 4.4. Air pollution mitigation in the operation of newly built DPC ...... 60 4.4.1. Air pollution mitigation...... 60 4.4.2 Water pollution mitigation...... 60 4.4.3. Mitigaiton method for healthcare solid waste (HCSW)...... 60 4.4.4 Sum up the method of MW treatment of preventive medical center ...... 61

CHAPTER V: INVIRONMENTAL MANGEMENT AND MONITORING PROGRAM...... 63

5.1. Environmental management and mornitering program...... 63 5.1.1 Environnemental management plan (EMP) ...... 63 5.2 Air environment monitoring ...... 65 5.3 Waste water monitoring...... 66 5.4 Solid waste monitoring ...... 66 5.5 Monitoring the sanitation condition of working environment...... 67

CHAPTER 6: ACTION PLANS AND COST OF MWM IN NORTH CENTRAL PROVINCES...... 68

6.1 Cost estimation...... 68 6.2 Co-ordinate cost estimation for the supplying of MW treating equipment...... 68 6.3 Implementation Schedule...... 70

&KDSWHU5HFRPPHQGDWLRQVWRVWUHQJWKHQ+&:0DW1RUWK &HQWUDO3URYLQFHV ...... 71

7.1 Increase training, wide spreading, practicing HCWM based on QD43/2007 of MoH and other legal regulations...... 71 7.2 Compose planed form for HCWM and environmental impact mitigation...... 71 7.3 Increase the proper monitoring at the province, increase human ability of HCWM assessment for Medical Service...... 71 7.4 Increase equipment and tools for medical waste collection and disposal ...... 71 7.5 Increasing tests of the suitable equipment for medical waste treatment; operating, collecting experiment from operation and management...... 72 7.6 Step by step creating specific financial source for HCWM (solid waste and waste water treatment and management)

References...... 73

APPENDIX ...... 74

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Abbreviation

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

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Introduction

The report on Healthcare waste management plan has been designed to report the impacts of health care waste, building up the mitigation solutions and environmental monitoring, environmental management for the project activities that related to: i) equipment supplying to the district general hospital, ii) construct and provide medical equipment to the district preventive medical centers and healthcare training center, iii) support and improve healthcare services at the projected medical establishments aiming at the improvement of the community’s health of 6 poor provinces, improvement health of vulnerable groups of peoples (children, women, poorer, ethnic peoples). Through the project “Healthcare support for 6 North Central Provinces” activities, the healthcare services is improved and caused the increase of healthcare waste and high pressure to the existing healthcare waste management (HCWM) and treatment facilities of the projected healthcare establishments. The environmental impacts should be mitigated by appropriate and consistent solutions at projected hospitals and newly built preventive medical centers.

The report consists 7 chapters analysis the impacts to the environment and public health due to the increasing of medical services at projected sites and proposals on environmental management solutions.

Chapter 1: Healthcare waste management, related legal documents and regulations. Chapter 2: Description of project sites, existing HCWM and risks Chapter 3: Environmental impact assessments Chapter 4: Healthcare waste management plans and mitigations Chapter 5: Environmental monitoring plan Chapter 6: Estimation of financial budget for HCWM and environmental management plan (EMP) Chapter 7: Recommendation and conclusion The evaluations is revealed through the depth interview of healthcare management authorities, healthcare waste responsible staffs, medical workers, waste workers. The resurvey has been delivered questionnaires to the healthcare establishments and the questionnaires have been fulfilled and made proposals by healthcare establishment themselves. Based on these, the Action plan and Healthcare waste management Plant (HCWMP) are being developed and play important role as key outputs of the report. The information on project sites is presented in Annex 1 and Annex 2. The minutes of the meetings, questionnaires and field trip quick tests are presented in Annex 3. Annex 4 presents the construction sites of district preventive medical center (DPCs), its scales. The recommendation of safe discharges of infectious and pointed wastes is showed in Annex 5. Annex 6 consists of the list of

-8- Healthcare waste management plan - Central North Region Health Support Project organization and individuals participated in the building up HCWM plan. The environmental standards and waste effluents discharged standards as well as the related documents are consists in Annex 7, the field trip survey presented though out the photo report in Annex 8. The international Healthcare wastes management and related domestic Ministerial regulations on HCWM, the consultation on HCWM with the related organizations and individuals. In addition, the master plan of HCSWM, the documents of the local and international workshop have been referenced. Studying the previous studies on HCW generation rate to selection of the appropriate generation rates combining with the field trip surveys and collection of the questionnaires directly related to the HCWM to find the estimation of the generation rate of hospital waste and assessment on the HCWM activities in projected district hospitals for this report.

CHAPTER 1. HEALTHCARE WASTE MANAGEMENT AND LEGISLATIVE FRAMEWORK

1. 1 Introduction

Vietnam currently have 13483 healthcare hospitals including 956 state-owned ones and 859 regional policlinics, 51 rehabilitation centers, 10815 commune beds (GSO, 2007), 700 sector medial centers, 41 medical sites with the total bed number of bed 210800. The healthcare waste is estimated to be produced 70 tons/day and 80 tons/day due to the increase of healthcare establishments, beds, health services, population and urbanization and patients are day by day being more assess to health services.

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The Ministry of Health has been issued the Healthcare waste management (HCWM) Regulation on 30 November 2007, QD/43/2007QD-BYT. The HCW is the solid, liquid, gas wastes consist of 2 types: normal waste and hazardous waste. Healthcare waste should be separated and segregated right at source by using appropriate bags and tools, containers as stipulated in chapter III of the Regulation on HCWM of the Ministry of Health. Time for HCW storage at the healthcare establishments is maximum 48h. The HCW should be transported outside of the hospital by using specific tools matching the technical requirements of Circular No 12/2006/TT-BTNMT dated 26 December, 2006 on licensing the hazardous waste collection, transportation and destruction. Each medical center or healthcare establishments has to have the waste auditing notes, and the waste receipts regulated detail in the mentioned above Circular No 12/2006/TT-BTNMT. The suggestion of waste treatment models, treatment technology are more diversified compared to the old one. The liquid hospital waste treatments are more focused. The Decision No 43/2007/QD-BYT on HCWM has been issued since 2007 and together with the inspection and monitoring; the HCWM has been boosted and stepped by step put into orders. The HCWM basically has been separated at source and collected. However, at the projected district preventive medical centers (DPC) and district general hospitals (DGH), the HCWM has found in difficulties compared to the provincial and central level ones. The situation gets worse in the projected sites at the poor and difficult provinces in the Northern Central Provinces of Vietnam.

1.1.1 HCWM

Decision No. 43/2007/QD-BYT dated November 30, 2007, of the Minister of Health giving guidelines on healthcare waste management for implementations. Beside that, there are several documents on technical requirements for medical incinerator evaluation, technical standard for discharged hospital waste water as well as air emission from medical solid waste incinerator, radioactive management are based on the related Ministerial technical regulation. The documents, regulation related to HCWM is presented in Table 1.1. Table 1.1: The summary of the regulations relating to healthcare waste management at nation level

Name of regulation Date issued Main activities described All governmental ministries have to Constitution of SRV 1999 protect natural resources and environment Ministry of Health in charge of Environmental Law (revised one) Oct-05 environmental protection in healthcare sector MonDre on Hazardous waste Decision 23/2006 and Circular 12 on management and requirements for 2006 Hazardous waste management collection, transportation, treatment and auditing

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Guiding to implement Environmental Decree 80 of Government August, 2006 Law EIA requirement for development Decree 81 of Government Sep, 2006 project Guiding implementation of EIA and Circular 08 of MoNRE Sep, 2006 environmental protection commitment Decision 43/2007/QD-BYT Ministry of 30t November, Regulation on healthcare waste Health 2007 management Decision No 60/2002/QD-BKHCNMT by 07th August Issue on Technical guidelines on The Minister of Science, Technology and 2002 hazardous waste burying. Environment Decision No 67/2003/ND-CP by Fees for environment protection 13th June 2003 Government complied with waste water TCVN7382:2004 Water quality- Hospital National discharged standard for 2004 waste water – discharged standards hospital waste water

TCVN7381:2004. Healthcare solid waste Method for evaluating medical solid incinerator – Method of specification 2004 waste incinerator appraisement

TCVN7380:2004: Healthcare solid waste National technical requirement for 2004 incinerator- Technical requirement medical solid waste incinerator

Healthcare waste management regulation Decision on the enforcement of the 2007 QD43/2007/QD-BYT HWM regulation National technical regulation on QCVN 14:2008 2008 domestic water quality National technical regulation on surface QCVN 08-2008/BTNMT 2008 water quality National technical regulation on QCVN 09-2009/BTNMT 2008 underground water quality

1.1.2 Decision No. 43/2007/QD-BYT, November, 30 2007, of the Minister of Health on healthcare waste management.

This regulation has been regarded as the basic foundation for the healthcare waste management and for investing the infrastructure for treating of solid, liquid and gaseous wastes derived from health establishments.

This regulation makes concretely on classification, identification of healthcare waste and the process of healthcare solid waste collecting at heath establishments, regulations on on-site and off-site transportation of solid hazardous waste. Moreover, the HCWM Regulation also introduces some models, technology and measures for treatment and destruction of solid, liquid, gaseous wastes as well as the regulations for implementation.

1.1.3. Standards Solid waste:

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-The requirement on separation, collection, transportation, treatment of HCW is stipulated in QD43/2007/QD-BYT, November, 30,2007 of MoH. -Decision No23/2006/QD-BTNMT dated September 26, 2006 in which the Ministry of Natural Resource and Environment issued a list of hazardous wastes and the Circular No12/2006/TT-BTNMT dated December 26, 2006 giving the guideline on the condition, the procedures for application preparation, registration and license granting to practice and issuance pf the code for hazardous waste management. Landfill waste based on technical design TCXDVN 261:2001; Landfill of Hazardous waste based on technical design: TCXDVN 320-09-11-2004. General requirement of sanitation landfill: TCVN 6696:2000. Technical design TCXDVN 320:2004. Technical design requirement for the construction of radioactive works that causes damage for people has to follow designed technical regulation of the Decision No 32/2005/QD-BYT dated 31 October 2005 for designing the X-ray and related labs or departments.

Air pollution QCVN 02-2008/BTNMT – Technical requirement for air emission from medical incinerator Vietnamese standard TCVN 7380:2004 established standards and other requirements on Healthcare solid waste incinerator – Technical requirements. Vietnam standard TCVN 7381:2004: Method of specification appraisement for healthcare solid waste incinerator. Vibration and Seizing cause by the construction activities: Maximum vibration at the residential and public areas, TCVN 6962:2001. Technical requirement for equipment and machines working in the construction works TCVN 4087-1985. Vietnamese standards for air quality and surrounding air quality TCVN 5937:2005; TCVN 5938:2005 – Air quality – Limited maximum concentration of some poisonous chemical in the air, TCVN538-2005, TCVN 5939-2005 and TCVN 5940-2005) and safety and occupational environmental standards based on Decision QD3733/2002/Q -BYT dated 10 October, 2002 of the MoH. Water and waste water: QCVN12-2008: National technical requirement of domestic waste water discharges. QCVN 08-2008/BTNMT – National regulation of surface waste water quality QCVN 09-2009/BTNMT – National regulation of underground waste water quality

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Vietnam standard TCVN 7382:2004: Water quality – Hospital waste water – Discharge standards. Medical waste water after treatment has to reach the first level of the standard. TCVN 5945-2005 output standard of industrial waste water. 1.1.4. TCVN7380-2004 and TCVN7381-2004 on medical solid waste incinerator The main content of TCVN7380-2004 on medical incinerator is the regulation on having dual chambers: primary and secondary chambers. The temperature of primary has to reach over 800oC and the temperature at the secondary has to reach 1050oC, the retention time in the secondary has to over 1.5s. The temperature of discharged air from the chimney has to less than 2500C. The height of chimney should be higher than 8m and waste water from the incinerator should followed TCVN5945-1999; Detail methods of appraisal and evaluation regulated in TCVN7381-2004. The said above standard has been issued in order to limit the hazardous air emission to environment when the specific regulation QCVN02-2008 has not yet stipulated. At the provincial level, DONDRE has responsible to carry to environmental monitoring of the discharged air from medical incinerator. TCVN7380-2004 and TCVN7381-2004 have been considered as the technical requirement for selecting of incinerator, supplying to the hospitals. With the QCVN02-2008, the heavy metals, the toxic gas as well as the concentration of NOx have been paid more attention. Table 1.2 1.1.5 Review of requirement on HCWM practices in Vietnam and in the world The HCWM practices in Vietnam steps by step integrate with the international one. The identification of hazardous healthcare waste has been suited with practices and based on the practices of healthcare curative treatment so that the medical staff easy to practice. The method of hazardous healthcare waste treatment has diversified. The new method based on microwave, autoclaving or chemical neutralization have introduced and should have consistent technical standards to be chosen. - Non-combustible hazardous healthcare solid waste (explosive containers, waste with mercury...) should be awarded to practice. - Finding suitable solution for hazardous healthcare waste management and treatment in small scale of the district hospital and district preventive medical centers of the project areas. 1.2 Comparison with international standards HCWM regulation has introduced several manuals of specific type of waste as well as specific technical treatment and destruction methods. This is the basic regulation on collection technology and infrastructure investment in order to treat liquid and solid and air discharges from medical establishments. a) Priority on HCSW treatment:

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Designate major concerning categories of waste that require special handling and disposal precaution based on the most suitable to the existing facilities and pointed out the considered types of waste 1) infectious and microbiology laboratory waste 2) sharp and pointed items 3) bulk blood, blood products, blood, bloody body fluid specimen and items as well as pathology and anatomy waste, 4) drugs 5) Hazardous chemicals 6) Radio active waste 7) Heavy metal and non hazardous/recyclable waste and hazardous/non recyclable waste consistent with WHO regulation. b) The attention should be given to developing guideline: on how each waste category should be managed. It is needed to harmonize the new regulations on hospital waste treatment solution in to the revised HCWM Regulation. Treatment of Hz HCSW is now based on incineration technology and is associated with high capital investment and high operation costs. The destruction of infectious waste by incineration will be paid more attention on the types of waste that may have been disinfected with chlorine bearing chemicals and PVC plastic bags and materials in uncontrolled; small scale incinerators would results in emission of toxic gases such as dioxin and furan which are very hazardous pollutants. The technologies such as autoclaving and micro waving effectively treat waste as lower costs and safe manual has been introduced to apply according to Decision 43/2007/Qd- BYT. The new technological treatments and options should be introduced at the project areas especially at the poor medical establishments in Hue, Ha Tinh or Thanh Hoa and Nghe An of the North Central Provinces (NCPs). The field trip survey has revealed that many medical establishments have not updated yet. c. Pay more attention on the environmental friendly technology and sustainable operation. Reviewing technological selection of the methods as well as the facilities, integrated with the Vietnamese regulation and WHO guidelines for developing countries on HCWM towards most environmental friendly and sustainable manners. d. Technology standards for Regulated medical waste treatment based on disinfection, neutralization or chemical treatment as well as the cost effective solution for liquid waste treatment in order to facilitate the use of disinfection equipment or new model of waste water treatment to put in use and evaluate. e. Preparation of the standards design, technologies and operation in order to introduce to the HCWM legislation. Their permitting, monitoring, reporting requirements will be involved fully. The options of using incineration, autoclaving, microwaving, deep burial waste pit, landfills are will based on its characteristics compliance with the technology standards. The standards will be referred from the available one of the developed countries, developing countries and suitable with Vietnamese condition. f. Encourage the hospitals using the environmental company services or existing facilities if recognized the condition for Hz HCSW treatment is sufficient.

-14- Healthcare waste management plan - Central North Region Health Support Project g. Introducing of low cost model of HCW treatment with standard design, assessment and recommending appropriate technology for the poor provinces. h. Development of a guideline on occupational health and safety in health-care centers. 1.3 Air emission from Healthcare waste incinerators The bellowed table presents a comparison of Vietnam and European standards on air emission from healthcare solid waste incinerators. The results show that Vietnamese standards meet international standards. However, Vietnam has not got quick test or quick measuring equipment for detecting toxic gases as such dioxin and furans.

Table 1.2: Comparison of environment standards of medical waste incinerators TCVN7381 QCVN E.U. USA -2004 02:2008 2000 1997 On forced Temperature 120-250°C - - Dust (mg/m3) 100 115 10 115 CO (mg/m3) 100 100 NOx(mg/m3) 350 250 SO2 (mg/m3) 300 300 Total heavy metal 2 0.5 - (mg/m3) Cd(mg/m3) - 0.16 0.5 - Hg (mg/m3) 0,5 0.55 0.005 0.55 Pb (mg/m3) 1.2 HF (mg/m3) 2 2 1 - HCl (mg/m3) 100 100 - 100 Dioxin-furan (ng/m3) 1 2.3 0.1 2.3

In USA and EU regulations, threshold limit value for air emission from incinerators depends on type and capacity of incinerators. 1.4. Recommendations for strengthening the legislative framework - National guidelines on occupational health and safety in healthcare establishments should be developed. - Enhance the inspection mission as well as monitor the healthcare waste management from Central and local level. -Supplement the compulsory environment protection fee for enhancing the supervising, operating the management system, healthcare solid and liquid waste management. The contents need to be added to the HCWM regulation in Viet Nam Healthcare waste management in community and home individually Healthcare waste management in private health stations

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The technical standards and pilot’s demonstration for new method of safe healthcare waste destruction (autoclave, microware, chemical neutralization...) The responsibilities of private health stations (waste producer) and environmental agencies in waste collecting and transporting and treatment 1.5 Safeguard policies of WB on Environmental assessment Based on the Safeguard policies of WB for developing projects form loans or grants, the project has followed the Environmental assessment (OP4.01) and has been classified as project B. 1.6 Environmental assessments and building HCWM plan team The environmental assessment team and HCWM Plan consist of 1) Environmental specialist and colleagues (based on environmental assessment TOR) 2) Members of PMB at Central and provincial level 3) Medical establishments’ leaders 4) Chief of infectious control departments or Chief of waste management team 1.7 Methodology Methodology for environmental study and survey at DGH include some main methods. The firstly, information is collected, secondly, the measurement and analysis of HCW composition, thirdly, the observation HSW management. Deep interviews between consultants and people in charge of HCWM (Board management of DGHs, DPCs, Department of Health, Medical workers, sanitation staff, waste collectors, and other related people). Investment and assessment HCWM for received survey paper. Listing environmental date and components needed. Method of environmental description based on the collected data and dates. Method of environmental catalogues report writing, grouping of coordinated, the simple catalogues, listed environmental factors. The catalogue showed impact level to each environmental factor and the question formed catalogues (applied to assess the economy and social condition of the project area). Environmental impact assessment EIA matrix: Use the simple matrix and matrix method within direction followings all expert’s opinion. Comparison method: applied to assess the impact level from activities.

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CHAPTER 2: PROJECT SITES AND STATUS OF HCWM

2.1 Description of project sites and HCWM status

1) Project sites: Northern Central Provinces (NCPs) consist of 6 provinces: Thanh Hoa, Nghe An, Ha Tinh, Quang Bình, Quang Tri and Thua Thiên – Hue. Being one of 8 ecological zones of Vietnam, NMPs are popular with the characteristics of coastal provinces. The wide of provinces narrow, complicated topological figures and arid climate condition: high sunny hours, rains, floods, typhoons. The surface areas of NMP is accounting for 15.6% of the national wide, the population accounting for 12,6% of the total national population and just follows the Red Delta River and Mekong Delta River population. Many minorities such as Thai, Hmong, Muong, Kho mú, Tho, Chut, Du u, Bru- Vân Kieu live in NMP.

The socio-economical conditions: the projected areas are not well developed in term of economics, infrastructures and the ratio of poor families is high compared to the national wide.

Table 2.1: Information of socio-economical condition of 6 projected provinces Thanh Nghe Ha Quang Quang TT Information Total Hoa An Tinh Binh Tri Hue Area (Km2) 11.136 16.488 6.055 8.065 4.760 5.065 51.569 Population (1.000 3.702 3.122 1.290 854 639 1.144 10.751 people) Districts/town 27 20 12 7 10 9 85 Communities/wards 634 481 262 159 139 152 1.827 Poor village 135 94 166 30 73 27 15 405 Poor district/total 62 7 3 0 1 1 0 12 districts Ratio DTTS (%) 14,4 13,4 1% 10,5% Ratio of the poor 139 31% 29% 17% 28% 40% 12% (%) 26,16% (Source: Social assessment report)

The North Central Provinces possesses high ratio of the poor people compared to others provinces. The average income lowers the national level, especially high number of poor villages and sub poor villages. The Ha Tinh, Nghe An và Thanh Hoa have average income lower than the remote and mountainous provinces like Lai Châu (96.000 /ng i/tháng), i n Biên (114.000 /ng i/tháng). Main sources of income are come from the food processing and agricultural production, cultivations, sea products captures. Therefore, the project on “Healthcare support for North Central Provinces” with the targets of i) providing medical equipment, increasing healthcare services at district general hospitals, at the district preventive medical centers at the poor district areas. Beside that the Project has been designed to supply the equipment and training courses for regional healthcare training center likes one in Danang city. The list of 30 district general hospitals and others is presented

-17- Healthcare waste management plan - Central North Region Health Support Project in table 2.1. The list of 33 district preventive medical centers is presented in Table 2.2 and Table 2.3.

2) Description of healthcare services in project sites

There are 81 medical centers or healthcare establishments with 7484 beds are under the management of 6 Provincial Departments of Health (DoHs). The number of bed in policlinics is 1481 beds in 141 sites. Total number of nurseries and health communes are 1813 sites with above 8988 beds and the numbers of preventive medical centers equal to the number of district administration units belonging to the 6 NMPs. Table 2.2: List of 30 District general hospitals and one Quang Tri provincial GH having the equipment investment. NCPs DGH NCPs DGH Nh Xuân Nghi Xuân Hoàng Hóa Hà T nh c Th Ng c L c C m Xuyên T nh Gia K Anh Thanh Hóa Lang Chánh Minh Hóa Th ng Xuân Qu ng Bình Tuyên Hóa M ng Lát B Tr ch Qu Phong Krong T ng D ng Qu ng Tr Gio Linh K S n H i L ng BV K T nh QTr Nghi L c Phong i n Ngh An Yên Thành Phú Vang Thanh Ch ng Th a thiên Hu H ng Trà Nam àn Phú L c KV Tây Nam Hu City (Source: Project design document, September, 2009) The total projected beds is 3820 beds accounting for 51% of the total bed in the 6 NCPs (refer to Annex 2) As for infrastructure capital investment: Muong Lat and Ba Thuoc districts in Thanh Hoa Province and Minh Hoa – Quang Binh province are getting funded by local government’s state budget, and have requested the project investment to be targeted at 3 other district preventive centers, namely Cam Thuy and Hau Loc and Le Thuy who are mountainous districts with high poverty rates and high occurance of floods and diseases. The province’s objective is to ensure sufficient equipment for these 3 district preventive health centers after completion of administrative and technical buildings funded by the project. Table 2.3: List of 30 District preventive medical centers NCPs DPCs NCP DPCs

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Lang Chánh Qu Phong Thanh Th ng Xuân Ngh An T ng D ng Hoá Quan Hóa K S n Quan S n Ngh a àn M ng Lát (equipment) Qu nh L u H u L c (Construction) Nh Xuân Thanh Ch ng Bá Th c (equipment) Nam àn C m Thu (Construction) Nghi Xuân Minh Hóa (equipment) Hà T nh Qu ng Bình L Thu (Construction) K Anh Tuyên Hóa H ng S n B Tr ch H ng Khê Qu ng Tr ch Qu ng aKrông Th a Phong i n Tr Gio Linh Thiên-Hu Phú Vang H i L ng H ng Trà V nh Linh Phú L c (Source: Project design document, September, 2009)

The description on the project provinces as well as project districts is presented in Annex 1 and Annex 2 of this report. The most of the project medical establishments are located in the main towns of the districts where the access to the main roads, good electricity and water supply systems. Particularly, there are several medical establishments such as Tuyen Hoa, Que Phong, Ky Son are still using the dig well water. The project sites also located in the quiet zones, less population and traffic vehicle density, where have been planned for the medical services in the master plan of the district and district’s town approved by the Chairman of provincial people committee. There are several DPCs such as Tuyen Hoa, Bo Trac, Quang Trach, Le Thuy belonging to Quang Binh and Vinh Linh, Gio Linh, Hai Lang – Quang Tri province and Nghi Xuân, K Anh, H ng S n (Hà T nh) where the district towns still have lot of land for the developments, the District People Committee have approved the new land sites for construction of DPCs under the project of “Healthcare support for NCPs”. The new land sites of DPCs are located next or nearby to the existing DGHs.

The location of new DPCs that are preparing the construction are presented in Annex 2.

2) Description of the project healthcare services.

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The total district and provincial general hospitals in NPCs are 81 sites with 7484 beds in which the policlinic beds are 1481 beds in 141, nurseries and commune healthcare sites are 1813 sites with 8988 beds and the DPCs as much as the district administration units. Table 2.4: Healthcare indicators at the project provinces. Population

People/bed growth rate CBR (%o) CDR (%o) IMR (%o) (%o) Nation 596,3 17,4 5,3 11,62 16,00 NMP 476,6 17,6 6,2 11,51 20,00 Thanh Hoa 401,6 15,3 6,9 7,96 23,0 Nghe An 636,8 18,4 6,6 12,81 23,8 Ha Tinh 470,2 14,9 7,0 8,86 18,1 Quang Binh 561,2 17,2 5,5 11,22 18,0 Quang Tri 501,5 18,7 8,0 10,48 35,5 TT Hue 288,1 20,0 5,6 13,71 14,8 (Source: Annual healthcare statistics year book, MoH 2007)

The basic health indicators of 6 North central Provinces with children under 1 year old mortality and raw rate of infant mortality in 6 NCP are higher than the average rate of the nation wide show that the poor medical services in the region. Lacking of necessary consultation and curative equipment, old and out of date equipment is often meet in the 6 NCP. Several provinces do not have enough equipment to provide to the district hospitals.

The average number of bed per on district general hospital in NCP, typically in Thanh Hoa, Nghe An, Ha Tinh, Quang Binh are 110-120beds/per units in the moderate populated districts. The average number of bed of the Hue and Quang Tri provinces is about 70 beds/unit.

Table 2.5: Medical units, district, and commune sickbeds by region and in NCP Total Hospital Policlinics Nurseries Commune Region Sickbe Sickbe Sickbe Sickbe units units Sickbed units units units d d d d Nation wide 12258 103176 610 49022 790 8416 24 679 10834 45059 Thanh Hoa 684 6570 27 2749 23 491 0 0 634 3600 Nghe An 531 4500 19 1725 43 430 0 0 469 2345 Ha Tinh 294 2845 12 1330 20 205 0 0 262 1310 Quang Binh 172 1554 6 805 7 90 0 0 159 659 Quang Tri 155 1219 8 525 8 70 0 0 139 624 Thua Thien Hue 174 1280 9 620 14 195 1 15 150 450 6NCP 2222 17968 81 7484 115 1481 1 15 1813 8988 (Source: Annual healthcare statistics year book, MoH 2007)

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The average number of days of in-patient stay reflect the quality of treatment, the longer the stay is, the better quality the treatment is. The number of days during an average in-patient stay in North Central provinces is less than the national number. However, in poor provinces where health care quality is low, the short in-patient stay indicates the contrary finding (which can be read through higher rate of referrals than other areas). One reason of short stays is also due to the local family’s lack of condition in terms of food, accommodation and economic conditions, for sufficient stay till their health recovery; they have to work daily to earn their living. This can be considered typical feature of the poor areas with low quality of health care services.

Table 2.6: Rata % inpatients 2006 by the medical establishments Total Public Region Commune Policlinics Private Tradi.m Other (%) hospital National 100 78,1 14,0 5,0 1,6 0,3 0,9 Red Delta River 100 84,2 11 2,9 0,5 0,4 1,0 North East 100 74,3 17,3 6,6 0,4 0,3 1,1 North West 100 64,1 23,8 9,9 0,5 0,2 1,5 North Central 100 71,2 21,5 3,6 1,7 0,9 1,2 South-central 100 80,6 12,3 3,7 2,6 0,1 0,8 Tay Nguyen 100 75,3 12,6 6,1 4,4 0,3 1,3 South East 100 85,8 5,4 5,0 2,6 0,2 1,0 Mekong Delta 100 76,0 15,1 6,4 1,8 0,2 0,5 (Source: GSO household living standard survey 2006)

Although lacking of main medical equipment and human resources, the medical establishments of 6 NCP are trying their best to apply the HCMW regulation as stipulated in QD43/2007/QD-BYT. However, the results are far comparing to the requirement on HCWM and sanitation of the hospitals.

Table 2.7. Use of public hospitals in 6 project provinces

Times of using Out- Number of in-patients Average days in patient care / 1000 admission/ 1.000 Province hospital people people Thanh Hoa 6.9 416 120 Nghe An 6.6 380 114 Ha Tinh 6.9 611 143 Quang Binh 6.2 330 132 Quang Tri 5.4 26 133 Hue 6.8 217 53 Nation wide 6.72 284 108.7 (Source: Health Year Book of statistics 2007; Reports provided by Provincial Health Departments, 2008).

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The surveys on existing situation of HCWM in 6 NCP is presented in following.

3) Healthcare services at the project district general hospitals The district general hospitals of project areas and the policlinics have typical average beds of less than 150beds/hospital and accounting for 53% (17/32) and expand in the large areas of the North Central Land of the country. Main departments of the district general hospital are: Administration Department, Financial and planning Department, Nurse ring Department, Ultraviolet Consultations Department, Surgical Department, Maternity Department, R-H-M Department, Emergency Department, Recovering Department, Pediatric Department, Infectious Control, Traditional Medicine, Pharmaceutical Department, Pharmaceutical Department and Laboratories. In which, there are DGH such as Ky Anh, Cam Xuyen will be increased double up to the year 2020 to meet the industrialization process and development of the industrial – economical zone of the Province as well as to meet the high increasing requirement of the public health. Comparing to other areas of the country, the projected districts having medical centers (DGH and DPC) with small scale but have to serve the high population density areas in the country. In 6 NCPs, there were over 85% of the medical consultation for poor of the region. Annually, about 385 tons of infectious HCSW (HzHCSW) generated and need to be properly treated, in addition over 1.05 tons of HzHCSW generated from DPC, raising to over 386tons/day of HzHCSW that needs special treatment and management. The total HzHCSW have been generated in medical establishments of project areas is accounting for over 51% of the total waste generated in the whole NCP. The high HzHCSW generation province is Thanh Hoa, Nghe An, Ha Tinh and lowers in generation are Hue, Quang Tri, Quang Binh province. Solid waste in DGH: The major parts of HzHCSW are waste of group A and B. In the DGH that have more than 150bed with the Laboratory, the waste of group C and radio-active waste are declared with significant amount. 4) Healthcare service at project district preventive medical centers (DPC) The project DPCs have responsible on carrying the initial healthcare and preventive medicine programs such as anti malaria, anti tuberculosis, mums, melees, , HIV/AIDS control), food safety and productive healthcare. There are 6 or 7 departments in DPC: 1) HIV/AID prevention and control 2) Public health 3) Food safety 4) Laboratory 5) Public awareness raising 6) Initial healthcare 7) Productive healthcare. The medical staff in DPC is about 28-35 depends on the population of the district. Average annual medical consultation at DPC is about 12000 cases/year. Some DPCs have several inpatient beds mainly for the productive healthcare consultation. Solid waste in project DPC: The sharps and pointed items and cotton used in injection are main part of the solid waste generated from DPC. The infectious solid waste generate daily in small amount. Despite the fact that the total amount of HCSW is less than 5kg/day, but the pointed items such as needles, glasses having patient bloods are listed as the high risk and medical workers and waste officers could directly be infected by scratching and tearing and this type of waste should be managed strictly and properly.

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2.2. Survey and field trips to investigate the existing HCWM at the project healthcare establishments. 2.2.1 Questionnaires on HCWM The generation rate of HCSW depends on the scale of the DGH and its services. The higher rate is found in the DGH that have more than 120 beds with high quality medical doctors, specific department and modern medical equipment, comfortable services. The rate is smaller in the mountainous and remotes areas. One survey carried out by questionnaires has been designed to estimate and assess the generation rate of HzHCSW, Table 2.8, together with the field trip observation and assess this rate and situation of HCWM in the project healthcare establishments.

Table: 2.8: The questionnaire information

General information about DGH Type of the DH or Polyclinic, basic key factors (number of bed, inpatients, outpatients, number of medical consultation, surgery, number of medical staffs) Estimation of HCSW generation rate Clinical waste, specific waste (chemical, radioactive, pressurized containers,) domestic waste. The practice of segregation, Separation of the waste as well as the methods for collection, storage, transportation, segregation of sharp and pointed items. Use of color codes treatment and destruction of HCSW for waste collection and transportation means. Facilities for waste storage and the recycling or reuse of waste The perception of the Regulation on Availability of document/guideline on Regulation on HCWM HCWM and elaborating themselves the guidelines for separation and treatment of waste. Trained medical staff on HCSWM Is there any HCSWM team in DH Facilities for disposal/treatment of Final disposal (burying, open burning), existing hazardous HCSW incinerators, technical information about incinerators Expenses related to HCSWM All expenses from the generation point of waste to the final disposal

2.2.2 Assessment of waste generation rate at project healthcare establishments

The questionnaire has been designed to collect information on the healthcare services and HCWM for both solid waste and water supply and discharged water management. Based on data analysis, the generation rate of HzHCSW is about 0.19kg/bed/day in which the waste of group A: pointed items is 0.048kg/bed/day, Table 2.9, 2.10.

Table 2.9: Generation rate of HzHCSW in project DGHs

No Type of Investigated Total Average Standard Min Max waste beds amount rate deviation

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(n.DGH=21) (kg/day) kg/Bed/day 1 Infectious 2035 393.44 0.19 0.24 0.01 0.45 healthcare waste (Ngo Kim Chi, Survey on HCWM in project DGHs in NCPs, 2009)

2.2.3. Assessment of the type of waste/group of waste in practices The HCSW has been separated in almost DGHs. However the level of waste separation at source is different from one to others. The percentage 40.6% (13/32) of DGHs being asked give the reply that they follow QD43/2007/QD-BYT by separating waste into clinical waste with 4 types of waste A-D, Hazardous chemical wastes, radio active waste, pressured containers and have the receipt of generated waste in detail.

HzHCSW generates from DGH is mainly waste of group A, infectious waste of group B. Few DGHs have been separated waste from laboratories. This type of waste is often small amount. Almost of DGH answered that they carried out the waste disinfection before discharging waste. The tissues and body organs wastes are often smaller than the waste of group B. The chemicals, out of dated drugs have been identified. However, the discharging of this type of waste is not daily routine. The reported amount of waste is the waste discharged randomly. At the pharmaceutical departments, these wastes have been discharged periodically. The same to the pressured containers, this type of waste is not common daily waste, but discharged several times a year.

Based on the questionnaires, the radio active waste generates from project DGH is small amount. However, the monitoring this type of waste is not given in priority list and the data on the total amount of waste is often lacking and missing. Some recycling waste such as transfusion bottles, glucose plastic bottles, nitrogen solution bottles are recycling materials and have been disinfection before discharging for recycling purposes.

Table 2.10: Generation rate of infectious waste (group B) at project DGH No Type of Investigated Total Average Standard Min Max waste beds amount rate deviation (n.DGH=21) (kg/day) kg/Bed/day 1 Waste of 2035 97.6 0.048 0.007 0.003 0.125 group A (Ngo Kim Chi, Survey on HCWM in project DGHs in NCPs, 2009)

Table 2.11: Generation rate of waste of group C, D of project DGH

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No Type of Group Group Group Chem Radio Pressured Domes Total waste(kg/GB) B C D icals active containers tic waste waste HCSW 0.107 0.017 0.029 0.007 0.002 0.001 1.03 1.2 (Ngo Kim Chi, Survey on HCWM in project DGHs in NCPs, 2009)

2.2.4. Waste separation, collection, transportation, storage and treatment HzHCSW at project DGHs

HCSW has been separated and initial segregated at source. The infection chambers, chambers for changing materials for wound are the places that generate most of the infectious healthcare waste, more than other departments in the DGHs. The DGH has been paid attention on using color code bags and containers for waste collection and storage. However, this type of bags and containers are based on the local materials and improperly far from the HCWM regulation for examples lacking of symbols for type of waste, missing the printed line: “Do not over this line”. In addition, the containers for pointed items are diversified in most of the DGHs. Some DGH use plastic bottles, beer canes/drinking canes, local carton containers. Some DGHs use regulated “box for sharp and pointed items”, several DGHs utilize the small plastic box, bucket and bottles. There is 76.92% of carton boxes followed the yellow color for pointed items as regulation. The collection waste bins are small bucket or small common waste bins. Just only several DGHs that have been under the investment recently have opportunities of using the new design waste bins with lids and wheels.

Survey result at the district general hospitals (DGH). 76.92% of DGHs using the yellow-box to store sharp material or pointed end of transfusion tubes under the regulation of Ministry of Health, the left of 30.77% uses plastic bottles, of 15.38% use beer cans and of 15.38% use the carton boxes to store sharp materials. There are 92.13% of hospitals use color code for each kind of waste bin as regulated by MoH, the left of 7.69% of DGHs do not answer the survey question.. Transportation: There are 69.23% of hospitals use trolley carts to transport waste through the hospital, there are 23.08% of hospital use plastic-bin without wheel. Pretreatment of highly contagious waste are implemented by 84.62% of DGHs in order to treat infected waste before disposal, they use Chloramines B1: 1-2% or Raven 1-2% or CLDEX 28.1; 285, 145. Solid waste storage rooms: There are 69.23% of hospitals have the area to store solid waste, the others don’t have in which there are 53.85% of hospitals have the stored area without the roof, 61.54% of hospitals have the stored area without any fences, 46.15% of hospitals have both roof, main door and lock. There are 76.92% of hospitals separating hazardous waste from domestic waste and 61.54% of hospitals has got the hand-cleaning materials. Disposal methods of medical hazardous waste 46.15% of DGHs dumping waste at their hospital area, there are no cluster incinerator to burn hazardous waste for many DGHs in the area, 38.46% use the onsite incinerators, the local brick handicraft incinerator is 23.08 percent, therefore, there is about 15.38% (38.46-23.08%) of hospitals have got the model incinerator and 30.77% of hospital burning waste outdoor. Selling recyclable plastic/glass material to recycler: There are 69.23% of hospitals answered that they did not sell med-25-ical plastic material and glasses to recycler or crap iron dealer but they still have got the separation of drip feed, drip feed bottle, drip feed string, Healthcare waste management plan - Central North Region Health Support Project

Wrong use of color code plastic bags for HCSW, some DGH give wrong answers to the color code for radioactive waste and hazardous chemicals waste. Showing the fact that the radio active waste and hazardous waste are rare so that people do not pay attention on these type of wastes.

Most of DGH have been regulated the fixed places for waste collection bins. No observation of guideline for waste separation at source. Waste collection is done from most of the departments daily before 16h00. The waste plastic bags are picked by waste officers of each department to the gathering waste collection point in the hospitals. Several DGHs well equipped, the collection of waste is push and carried by HDPE containers or the carriers with the wheels. Some hospitals have the specific places for waste storage. But more often, the waste storage areas are the place in front of the incinerator’s room. The waste is putting in the plastic bag and tightly tied and gathered next or in front of the incinerators. Almost of DGHs’ incinerator have been operated 2times a weeks.

Most of DGHs have medical incinerators or step by step having onsite treatment incinerators. The new invested incinerators have dual chambers: primary and secondary chambers from branch names such as imported HOVAL incinerators (Austria), Medical Burn (USA) or the trade name of local manufacturers VHI, hay BDF-LDR10, 15i of Vietnam.

The incineration of waste is one of favorable final destruction of HCSW that the DGH like to have and use. Some hospitals do not have the appropriate and modern incinerators, use the simple brick incinerators (Vinh Linh, Gio Linh, Hai Lang and DGH of Hue and Ha Tinh). Some hospitals have broken or damaged incinerators, they change to use the brick simple incinerators. Using simple brick incinerators of open burning of waste are considered as prevention and alternative solution, example Nam Dan DGH.

The initial disinfection treatment of waste has been designed in order to safe disposal and to give the high priority for training course so that this method will be of considered as

-26- Healthcare waste management plan - Central North Region Health Support Project the accidental or the solution of discharge of waste, but in general the method is paid less attention in most of DGH. Ash of the incinerators is considered as hazardous waste but there is no specific solution: consolidation/solidification solution for proper management. The DGHs have the specific landfill site or pits of waste inside the DGH in cases the incinerators are under repairing or stopping.

The HCSWM is starting with the waste separation at source, waste collection, waste transportation and destruction inside the hospitals and carried out by DGH staff. The domestic common waste is collected daily by Environmental Company of the district town. The waste is then transport to the district landfill. 2.2.5. Assessment of HCWM team, internal guideline, training course in HCWM Most of DGHs have been stated that they have their own regulation and HCWM team consists of 2-5 people. However, information updating and disseminating the updated and renewed HCWM regulation has not been completely implemented to most of DGHs. Some DGH still use the old version of HCWM regulated since 1999. In most of investigated DGHs, there are not images/pictures or instruction of guiding waste separation at source by suitable materials. The appearances of the guiding images will be a good picture and examples to help medical workers thinking carefully when disposal of waste, and proper disposal of waste will help safety and limitation of risk from HCSW and limit the contamination of diseases from hospitals to the community.

Survey result at the district general hospitals (DGH)

There are 61.54% of DGHs have got the incinerators placed at their location, in which 20,83% have got two-combustion chambers, 46,15% have one-combustion chamber incinerator and none of them has the turning incinerator. Quan Hoa DGH has the local made incinerator of BDF-LDR 10i, 15i, with capacity of 5kg/day, installed in 2008, it still works well with frequency of 2times/week, petroleum consuming of 96l/month for 40 kg waste equal to 2.4 l petroleum per kg waste. The amount of 40kg of burning waste creates 12kg of ash coal. Salary cost for worker is vnd 600.000 per month. Lang Chanh district general hospital has installed the incinerator BDF LDR 10i at their location, with capacity of 10kg/burning time from 2007, includes two- combustion chamber, petroleum consuming of 130l/month, 4times/week, consuming petrol of about 0.8l/kg waste or 2 million vnd/month. Nam Dan, Thanh Chuong DGHs have dual chamber incinerator VHI-18B. Dakrong has got one combustion incinerator istalled in 1999, consuming petrol of 15l/month. Quang Tri general hospital has onsite MZ40 incinerator with the capacity of 400kg/batch, its temperature is from 850oC to 1100oC burned with frequency of 3times/week, installed in 2008. the created coal ash is about 60kg per month. Most of simple brick handicraft incinerators is burn waste in the temperature from 5000C to less than 1000oC. Of cause, the condition of incinerating not ensured for complete destruction of waste.

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Survey result at the district general hospitals (to be continue)

76.92% of DGHs using the yellow-box to store sharp material or pointed end of transfusion tubes under the regulation of Ministry of Health, the left of 30.77% uses plastic bottles, of 15.38% use beer cans and of 15.38% use the carton boxes to store sharp materials. There are 92.13% of hospitals use color code for each kind of wastebin as regulated by MoH, the left of 7.69% of DGHs do not answer the survey question.. Transportation: There are 69.23% of hospitals use trolley carts to transport waste through the hospital, there are 23.08% of hospital use plastic-bin without wheel. Pretreatment of highly contagious waste are implemented by 84.62% of DGHs in order to treat infected waste before disposal, they use Chloramines B1: 1-2% or Raven 1-2% or CLDEX 28.1; 285, 145. Solid waste storage rooms: There are 69.23% of hospitals have the area to store solid waste, the others don’t have in which there are 53.85% of hospitals have the stored area without the roof, 61.54% of hospitals have the stored area without any fences, 46.15% of hospitals have both roof, main door and lock. There are 76.92% of hospitals separating hazardous waste from domestic waste and 61.54% of hospitals has got the hand- cleaning materials. Disposal methods of medical hazardous waste 46.15% of DGHs dumping waste at their hospital area, there are no cluster incinerator to burn hazardous waste for manay DGHs in the area, 38.46% use the onsite incinerators, the local brick handicraft incinerator is 23.08 percent, therefore, there is about 15.38% (38.46-23.08%) of hospitals have got the model incinerator and 30.77% of hospital burning waste outdoor. Selling recyclble plastic/glass material to recycler: There are 69.23% of hospitals answered that they did not sell medical plastic material and glasses to recycler or crap iron dealer but they still have got the separation of drip feed, drip feed bottle, drip feed string, glass bottle like Que Phong DGH, Quang Tri PGH and Quan Hoa DGH. Quang Tri GH and Hai Lang DGH sell medical recycle material from hospital but without decontamination. Guideline document, regulation of solid waste management. In the answered questionnaires, there are 76.92 percent of hospitals have internal rule or guidelines or internal regulation for solid waste management. 76.92% hospitals have got the detail guideline for process of waste separation, collection, and transportation. 61.54% hospitals have got the specific group for waste collection, transportation and treatment, at least 4 to 35 people per group. More than 50% medical staff of hospitals is trained the waste management regulation

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Survey result on HCWM at the district preventive medical center (DPC)

Waste separation at source has been implemented in 91.67% of the total DPCs. Although they participated well into the waste separation, but the ration of mixing clinical waste with other waste are still high and 20.83% of the DPCs do not discharge clinical into the proper medical dustbin. Many DPCs use the QD47/2007 as their own internal rule/regulation and use it as the guideline. 66.67% of DPCs implemented HCWM, only 8.33% of which do not implement the regulation and carry out source separation. However, their implementation is not so strict, there is 29.17 percent answering that they do not use the collection plastic bag or box for sharp and pointed items or right dustbin in regulative. With 23 fulfilled questionnaires from DPCs there is only Que Phong and Vinh Linh DPCs don’t have the local rule of HCWM. The others have built their internal rules or use DQ43/2007 for guiding waste collection and source separation; it shows the good knowledge and awareness of the DPCs’ board management. There is 29.17 percent of DPCs said that they have their medical workers exposed with occupational diseases; Only 33.3% of DPCs have sent their staff to HCWM training course. Nhu Xuan, Que Phong and Quan Hoa have high number of trained staff (30 to 40 people)/year in the field of HCWM and disease control.

100 percent of DPCs separate sharp-pointed material out of other medical solid waste; it shows their good awareness of implicit danger from medical solid waste, especially from those stained with blood or body biological fluids, blood samples.

Waste store and disposal: at small DPCs limited human source and patient (only 3 checking in/out per day), the generation of hazardous solid waste is almost none. It also the reason for the treating cost of solid waste is very small, with only more than 30.000 vnd per month. With the questions on hazardous waste store and disposal, there is 37.50 percent strictly implemented, and 54.17% percent do not separately and separated stored hazardous waste, the same ratio disposed mixed hazardous waste and general waste and discharged to public dumping site. It shows that if the DPCs carried out the waste separation and stored they can return waste to manufacturers or safe storage to treat in the good quality incinerator. 50% of DPCs bring their clinical waste to co-burn in DGH’s incinerator. It is also a good sign of strict implementation of HCWM. In general, the separation of HCSW is quite high of 87.5 percent. Through the survey, third of centers has got specific staff in charge of medical waste collection. It shows the happy sign although their material condition is not very high.

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Survey result of HCWM at preventive medical center.

Through the survey, third of centers has got specific staff in charge of medical waste collection. It shows the happy sign although their material condition is not very high. However, it should to open more training class of medical solid waste management and increase communication as well as supporting more material, equipment for waste collection and store then they can satisfy and implement well the regulation of ministry of public health. Petition from preventive medical center : Although the Decision 32/BYT comes into force from the last year, 2007 but Most of the center hope Bac Trung Bo project support more the incinerator, train for medical waste manager staff ( Nhu Xuan, Huong Khe, Quan Hoa, Cam Thuy…). Some centers hope to have the waste water treatment at their centers. They mostly fell satisfy if their water treatment system is invested like the system for other polyclinics. When asking some centers which will be built next to polyclinic of the ability to co-use the incinerator and water treatment system with the polyclinic, their answers are depended on the leading of Medical service, and cause they have to pay money for polyclinic to co-run the equipment. Most of them said that infected waste water from preventive medical centers are treated following the regulation for medical waste water like polyclinic

2.2.6. Assessment of HCSW treatment Mostly, contagious waste is treated on site by incinerator. The existing medical solid waste incinerators using at the DGHs are the dual chambers and the temperature at the secondary chamber can reach to 10500C. The incinerators are working with the lowest running cost manual with batch running and operation. Burning cost is described in the appendix and field trip survey report. If district general hospitals don’t have the incinerator, it not to be encouraged of using the simple and handicraft incinerator made by local bricks or dumping waste without disinfection. It shouldn’t encourage outdoor burning of hazardous waste 2.2.7 HCWM assessment

Hospitals recognize the environmental and health threads from HCW so they have got efforts to follow HCWM regulation. The waste discharged volume is not much but highly contagious waste in group A and C should be the first priority. Besides, radioactive solid waste must be managed by the specific regulation 2.2.8 Assessment of local authorities’ and DPC leader’s proposals on HCWM

Most of the medical establishments recognize that it needs to train and improve HCWM knowledge for all medical staff. Besides, it needs to increase the disinfection by increasing onsite training, visiting and learning experiences from other hospitals, and providing/supplying equipment and tools for waste separation, collection and disinfection.

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2.2.9. Infectious liquid waste and waste water treatment (WWT) Status of infectious hospital waste water at the project sites. There are 32 project district general hospitals in which DGH in Hue and Quang Tri province do not have medical waste water treatment system or appropriate facilities. Meanwhile, the DGHs of Quang Binh province have just equipped additionally of hospital waste water treatment systems, and the others have carried out the construction survey, technical design and are waiting the investment form the state budget to build up. Most of the district general hospitals are under upgrading and or being implemented with the hospital infrastructure investment includes: waste water collection drainages and waste water treatment system, however the most of DGHs don’t have the suitable and enough cost for medical waste (solid and liquid waste) treatment. Contagious wastes and water, sample of blood, body biological fluid need to be disinfected before running to the collection ditches. Normally, surgery room, postoperative room, delivering room discharges directly their waste water to the outdoor environment because the broken drainage ditches. This ditch system needs to be tight.

Some district general hospitals (Yen Thanh DGH) have got the separated toilets and located out of the main hospital building. Such toilets are small, narrow, not enough area for patient to use and the septic tank there are not big to make the full or enough digestion process. 2.2.10 The needs of spread out regulation on safe discharges of medical waste water The discharge of waste waster needs to be considered and paid more attention especially at the testing labs due to the high risk of contamination and the diseases can be spread out and be come water born diseases to water environment. Discharging of blood, fluids, infectious liquid often pays the great concern of the guideline of EPA-US and CDC- US. The regulation on discharging of even a few milliliters of blood remaining after laboratory procedures, suction fluids or bulk blood can be inactivated in accordance with CDC and EPA approved treatment technology. The situation of liquid infectious in Vietnam is in opposite side.

Healthcare waste treatment of EPA in the US, there is the guideline of Center of Infectious Disease Control (CDC-US) on the discharge of blood fluid, body biological fluids, In Vietnam, such guideline is lacking and concerning to discharge contagious waste water is less, especially at the district general hospitals.

The discharge of blood liquid or body fluid and infectious liquid should be firstly inactivated by disinfection chemicals. After making the infectious liquid inactivated, the

-31- Healthcare waste management plan - Central North Region Health Support Project liquid waste will be diluted and discharge to the sewer system and then to septic tank system before final treatment at WWTF and discharging to the environment after treatment at the central WWT or gathering point of WWT. The properly designed and well functioned septic tank system is adequate for inactivating blood borne pathogen and pre- treating pollutants and contamination germs in hospital waste water before intensive treatment to meet the requirement of discharge effluents from the hospital waste treatment facilities regulated in Vietnamese standard TCVN7382- 2004. 2.2.11. Assessment of Healthcare waste water management

Treatment operation: The survey at the district general hospitals have the hospital waste water treatment facility/system invested by the provincial or state budgets showed the following results. It is the fact that, most of waste water treatment system is not sustainable running and the WWT system does not work at the survey time.

The operation diary and analytical results of treated waste water are the necessary documents, useful information and should be prepared with full information and dates and should be available to be provided to the public and to the management officers or authorities, but in fact that, they are not easy to access.

It is clearly declare on the Decision QD43/2007/QD-BYT that the investment for building up waste treatment system is the responsible of the governmental budget. And the operation and treatment expenses are defined as the responsible of medical establishment and based on the hospital financial source. But, operation and maintain cost of WWT seems not a small amount budget comparing to the hospital daily expenses for medical activities. The sustainable treatment technology (appropriate operation cost, reduce the material and human consuming) should be more concerned especially in the circumstances of poor provinces. Although, there are governmental regulation of environmental protection fee for waste water based on Governmental Decree ND67/2003/ND-CP and TCVN 7382-2004 discharge quality of hospital waste waster, and the medical establishments are the polluters have to respect environmental law and meet the requirement on reduction the pollutants from hospital waste water to meet the environment standard before discharging. Liquid infectious waste, especially products with blood should be disinfected by chemical reagent (CaOCl, chloramines B and other suitable disinfection chemicals) in the labs before discharging to the sewage system. Liquid infection waste from the patient wards flows to the septic tank of the departments/faculties of the main building. Such kind of wastewater often

-32- Healthcare waste management plan - Central North Region Health Support Project contains high pollutant BOD, COD, SS, T-N, T-P and total coli form and need to be treated in WWTF to meet the discharge standards.

Hospital waste water investment:

The depth interviews of person in charge of WWT in term of technology, equipment and the norm of capital investment per one treated cubic Metter of waste water, it is revealed that the appraisal of investment for building up one hospital WWT system should be improved toward give more priority to the environmental friendly hospital WWT technology as well ad sustainable running or durable operation and maintain to avoid from the waste of electricity, chemicals, spires part and eventually from the governmental budget consuming. 2.3. HCWM Budget

The almost district hospitals do not have sufficient funds for proper waste management. For example money to buy the container/box for sharp and pointed items, color coded plastic bag or plastic waste bin and waste trolleys and need destroyer/autoclave or construct the controlled deep burial pit as well as the simple solution for disinfections of liquid waste. It is easy to estimate the financial requirement for one district hospital to treat of HCW and treatment hospital waste water based on the price to incinerate 1 kg of waste and 1m3 of waste water and tools. The problem is that permitting hospital collect the fee based on inpatient bed or giving the subside cost to the DHs. Creating special budget line for HCWM is one key factor to make the implementation of HCWM success. 2.4 Risk associate with current HCWM practices and role of Provincial DOH in HCWM inspection

The most dangerous is scratching by sharp items and needles (group B wastes), HIV/AIDS waste of group C having blood is one source of direct contamination of the HIV/AIDS diseases as well as direct contact with the Hz HCW group A wastes containing blood, materials contacted with blood.. The next danger from HCSW is that if the HCSW is improper management and un safe disposal of contagious waste, so medical staff, waste collectors, waster transporters, patients and public can be impacted. The contamination can be transmitted through vector of disease, or waste water to air environment, to soil, to water surface and water body. Whilst these theoretical risks can be foreseen, health workers know little of the actual risks; waste workers/waste pickers and the trainees and ground water are exposed.

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CHAPTER 3: ENVIRONMENTAL IMPACTED SOURCES FROM MEDICAL WASTE AT THE PROJECT UNITS

3.1 Environmental impact caused by medical waste water

Project activities will attract more and more patients to project units, therefore will make the increase solid waste and waste water volume. Especially, it will make the high pressure to the hospital which did not have the waste treatment facilities. The waste water contains a big amount of bacterium, contamination germs. Besides, the lack of oxygen, excessive and overloading of organic substances and nutrients in waste water will create subtropical phenomenon of water environmental body. If there is not any treatment solutions to remove the pollutants in medical waste water especially the contamination germs, it will impact not only surface water in the lake, canal, river but also penetrate to the soil, accumulate to sediment and keep will affect the underground water.

3.1.1 Estimation of waste water volume from the preventative DGHs in project area.

Generation of waste water in DGHs Volume (m3/day) = number of beds x norm of water use per person per day(m3/bed/day). The daily water consuming at DGHs is surveyed about 35 to 60m3/day/unit for the DGH with less than 150beds. (Equivalent to 0.4-0.5m3/sickbed/day). DGH, if the capacity is double, the regular factor (k) is 1.25 then waste water volume generate will from 85-160m3/day. This waster water should be separated from rainfall and surface water and other normal waste water, then flows to the septic tank.

Generation of waste water in DPCs: The waste water is not high volume comparing to the DGH; the biggest is about 10m3/day. The above number is estimated from one DPC that has 37 officers, 50 patients going for the consultation per day. The water supply demand in generally is estimated about 120 l/person/day according to the norm of water use for domestic purpose. 3.1.2 Specific characteristics and components of healthcare waste water

Hospital waste water always contains BOD, COD, nitrogen and phosphorous and suspended substances and organism, virus, germ…. Depending on the hospital characteristic, capacity, the pollution characteristic can be different. For example, one hospital with the scale under 150 sickbeds, characteristic of waste water can displayed followings.

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Table 3.1: Characteristic of district general hospital/ preventive medical center Factor Standard Concentration* TCVN7382- Min Average Max 2004 pH 6.5-8.5 6.4 7.45 8.15 Suspendes substance, 50 150 160 220 mg/l

BOD5, mg/l 20 120 160 220 COD, mg/l 100 150 200 250 + NH4 , mg/l 10 15 22 54 - NO 3 mg/l 30 35 72 96 3- PO4 , mg/l 4 - - Total coliform, 1000 106 109 106-107 MPN/100ml (Date from the Environmental Impact Assessment for upgrading 3Ha Tinh DGHs) Recognizing that, if hospital has got its waste water treatment (WWT) station/facility, waste water after storing at the septic tank is discharged the ditch system then goes to the concentrated central treatment tank or central WWT or gathering point. The water is stored at the regulated tank then running outside also reduces pollutant volume. (Although that, the waste water treatment system does not run). However, to complete the treatment of hospital waste water to meet the requirement of Vietnamese standards TCVN 5783-2004, TCVN 1945-2005, especially to increase or make the quality of disinfection more effectively, then it is needed that the waste water should be treated by biological process to reduce or limit the pollutants and to eliminate almost the organic substances as well as the nutrients to the minimum level in order to create a good condition for the disinfection process. Therefore, the BOD concentration after treatment is encouraged to reach at least 20mg/l. And in order to meet the above requirement as well as QCVN 14: 2008, waste water treatment system needs to continuous and sustainable operation. If the DGH has got the waste waster treatment system, it should be checked the electricity and operation condition in order the WWT can have good condition to operate daily as much as possible for one sustainable treatment and then the disinfection will get high result and effectively. One thing should consider is that if waste water is well pretreated at the septic tank, the sedimentation tank, oxygen ditch, or ditch system, it will make the waste water treatment more effective and contribute to reduce the pollutants.

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3.2 Raising hospital waste is one environmental impact. 3.2.1 The discharge of medical solid waste from DGH/DPC in the project sites

The hazardous medical waste arising from the DGH, district general hospital is about 0.19-0.2kg/bed/day. It is very different depending on the hospital scale and their services. In which, there is a high ratio of medical waste volume doesn’t treat properly following the regulation.

Hospital waste has got the diversity components, low calorie, and low density from 0.13 to 1.15kg/m3, with the high moisture. The HCSW components is referenced and displayed as followings. Table 3.2: Solid medical waste components from hospital STT Hazardous medical waste Ratio (%) 1 Needles injection 14,6 2. Drip lines 17,54 3. Swabs and containers stained with swabs. 33,87 4. Medical waste products 5,53 5. Others 28,46 6. Total 100 (Source: master plan of medical waste management, 2002)

Table 3.3: Chemical characteristic of medical waste No Standard Unit Average Density Ton/m3 0,13 Moisture % 50 Ash volume % 10,3 Calorie Kcal/kg 2153 (Source: master plan of medical waste management, 2002)

With the low caloric medical waste, cost for burning waste on the location is always more than 0.6kg petrol/kg waste without calculating the other costs.

3.2.2 Objective, impacted scale of medical solid waste 1) Impact to public health

The HCSW can bear the dangerous disease like HIV/AIDS, B or C infected hepatitis, harpoon to medical workers, especially nurses, orderlies that are people who have the most highly infection potential because they contact to sharp materials or pointed ends of tubers. Hospital’s staff or waste officers who are in charge of medical waste management also have the significant potential in contacting with high risk waste (person in charge of waste cleaning, digging waste up). The potential of contamination from infected disease is higher if

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they contact directly and contact daily to medical waste without any safety protection tools. Some contagious diseases through fly, mouse…have created dangerous risks for public community and patients in the district general hospitals. HCSW and waste waster treatment containing contamination germs are the reason of increasing the water born diseases like diarrhea, enteritis, encephalitis, cholera, dysentery and the new diseases. Table 3.4: Contamination disease by touching with medical waste, and germ Contamination Germ Infecting way Digestion Groups of Enter bacteria: contamination Salmonella, Shigella spp.; Manure or vomit Vibrio cholera; worm, taenia Respiration Tuberculosis virus, rubella Phlegm, fluid contamination virus, Streptococcus neumonia Eye contamination Virus herpes Eye fluid Neisseria gonorrhea, Virus Genital fluid Genital contamination herpes Skinned contamination Streptococcus spp. Pus Substance from skin ( Anthrax Bacillus anthraces sweat, excreta) Meningitis Neisseria meningitis cerebrospinal fluid AIDS HIV Blood, genital excrete virus: Junin, Lassa, Ebola, All blood’s products and Hemorrhagic fever Marburg excrete Blood contained Blood Staphylococcus spp. staphylococcus Staphylococcus spp. Blood Blood bacterium Staphylococcus arueus; contamination (by Nitrobacteria; Enterococcus; different bacterium) Klebssiella; Steptococcus spp. Candida fungi Candida albican Blood A hepatitis Virus carrying hepatitis A Manure B and C hepatitis Virus carrying hepatitis B, C Blood, 2. Spreading ways from medical waste Table 3.5: Risk, disease spreading ways from medical waste at district general hospitals without proper management

Risk Spreading way Hazardous substance Cutting disease Direct/ Indirect Medical waste product, waste Contagiousness, touching through the contained germ, contagious waste middle organism causing disease by disease vector, especially at the dumping site. Direct touching Sharp and pointed material like Being skinned injection needles, broken glass

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pieces create the condition for disease penetrating the body, examples: carelessly use the injection needles Non effective Direct effect Use the expired medicine, treatment pharmaceutical products without doctor’s prescription Cancer Direct/ Indirect Radioactive waste, waste from X-ray touching, working room (most of the district general closely to it hospitals don’t manage waste properly) Scald, itch Direct/ Indirect Hazardous waste, radioactive waste touching, working closely to it To be injured Explosion gas Pressure container Underground/surface Direct/Indirect Virus, microorganism, hazardous water, air pollution touching to polluted waste, expired pharmaceutical water/ air. Waste high concentration of metal.

3) Air environment impact from improper incineration (outdoor burning, handicraft incinerator) Burning medical waste outdoor will create air pollution because of smoke, fly ash, coal ash and other pollutants. Because there are some other materials like plastic materials, rubbers and hazardous metals in the solid waste and when it is burned it will create the uncomfortable smell and hazardous un desirable pollutants, wastes such as dioxin, furan and some persistent substances if they are burned with the temperature under 8500C. The hazardous pollutants are also spreading to the wind then impact medical workers, patients and others. The people contact daily to fly ash, smokes from burning wastes can be exposed to respiratory disease. 3.3 Environmental impact when building the technical house for preventive medical center. 3.3.1 Impacts in the preparing and the implementing phase. Pollution source: -Clearing the ground: dust, gases -Dust from windy in the implementation process -Rainfall is mixed by sand, petroleum. -Constructive solid waste, domestic waste of worker, -Noise from implemented transports Dust pollution: In the construction process, air pollution mainly is dust from process of soil digging, clearing surface, transporting material, and mixing concrete. The dust from above activities doesn’t have the large size then it reduce the impact to the recent areas. The

-38- Healthcare waste management plan - Central North Region Health Support Project use of excavators, machines in the construction work will create dust, hazardous gases like

CO, SO2, SOx, NOx… with the light impact to air quality and air environment because the very large spreading areas and the machine also works and creates lightly impacts to the air quality. However, the construction work in the project sites will not include heavy activities and working volumes so the impact will be small. The construction time will not prolong for a long period, so the impact to air quality is not high in the project area. Air pollution: In the construction phase, air pollution can appear from the domestic waste burning of construction worker or from burning waste in simple brick incinerators or open burning wastes outdoors. But it can be limited by avoiding the outdoor waste burning and improperly incinerated waste in in appropriate medical solid waste incinerators. The increasing of transportation vehicles also can create the local pollution at the construction site but it not worth considering and will stop and the completing of the construction activities. Noise pollution, vibration pollution: The construction activities will make the noise pollution, vibration pollution in the construction implementation. The impacted scale is mainly in the working area, directly impact to construction worker and can impact to patients living in the hospitals during the construction period. Solid waste: Solid waste generated in the construction stage is mainly construction materials and domestic waste of the construction workers generated daily. The discharges just are the instant so it need to enhance the solid waste management. The domestic waste needs to be collected by environmental company daily to limit the bad impacts to environment. After the construction is completed, the recovering and rehabilitation activities should be carried out so no one could file the traces of the construction materials or hazardous wastes still remains in the construction sites, all the waste will be collected and cleaned by appropriate solutions. In general, most of the construction works can impact air environment in the residents’ area. However, these impacts are mainly locally and happen only during the working time. There are different impact levels will impact air quality at different levels but for the project construction work the level of impact will be small due to the small construction building in the small surface area. It can mitigate by applying the appropriate construction methods, use the construction standards and all of the impacts will remove after finishing the building.

3.3.2 Environmental impacts in the operation phase Like other medical units or healthcare establishments, in the operation phase, the preventive medical center can discharge HCSW and impacts on environment. However, this impact is not worth considering because there are have suitable treatment methods described in mentioned chapters above for waste water treatment and infectious solid waste treatment and destruction. They are described above (3.3 sections), therefore environmental impacts can be control properly.

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3.4. Integrated assessment of environmental impacts of the project

To make the integrated assessment of the development of environmental impacts during three phases of the project, it can apply environmental impact matrix. This method is following: Listing environmental impacts in the column, and listing the project activities in the rows, marking environmental impacts to the appropriated cells and scoring the impacts comparing to others. Environmental and social factors include:

- Natural environment: (climate, temperature, moisture, rainfall, wind velocity... water resource (underground water, surface water), and soil resource will be impacted. - Organism resource and ecosystem: include vegetation cover, aquatic system, and terrestrial animal will be impacted by the project activities. - Social environment: Life quality, public health, job, resident distribution, social economy, landscape, tourism and relaxation, land’s value. …land acquisition and compensation. Activities in implementing phase (planting trees, clearing the surface, preparing the platform of construction site, land acquisition, activities of worker, and equipments, machine installation…). Activities in the operating phase: Bring the medical equipment to operated, increase medical service and treatment quality.

In order to evaluate the EIA matrix, an application is designed to make the marking to show the quality and role of the impact. The detail level of marking scale depends on the document use for identifying and analysis the impact. The positive impact displayed by (+), the negative impact displayed by (-). The natural numbers show the importance of one impact to other impacts. In this report, we use scale 10, and 0 point to show that there is not any impact. The marking is implemented by team working, within the expert’s consultation and expert’s assistances. From the EIA matrix, we can see that when project goes to the operation, the project have a good impact to socio economy and environmental components. The bad impacts caused by the project will be minors and will be foreseeable and being treated or mitigated by properly mitigation solutions.

Table 3.6. Environmental impact matrix of the project

-40- Healthcare waste management plan - Central North Region Health Support Project , r e n e e e c o g e Activity t i n i r c i a t v a a h r a w

f h r c e r c b s a u i s e i s v m g d r e

Environmental a e h d t k t t h r s n n e c g l a impact g n a a g e s g a n i n o r n i y m c w i i m i l t d a i e t

l i e n l t p d h t d d u a s i l v s a a i l s t i i c i e t l l u a e t s s u o l u o o o i q c n M D S C B I e a W N p T d Social environment - Public health -0.5 0 0 0 0 0 -0.5 0 -1 - Economy condition +2 +3 +7 +5 -1 -1 -0.5 0.5 +14 Landscape, culture, history +1 +3 +2 0 0 0 0 0 +6 Natural environment

Quality of air environment -0.5 0 +5 0 0 0 -0.5 0 +4 Underground and surface - water quality 0 0.5 +3 0 -0.5 0 0 0 +2 Soil quality 0 0 0 0 0 -1 0 0 -1 Creative source, ecosystem 0 0 0 0 0 0 0 0 0 Sum 2 5.5 17 5 -1.5 -2 -1.5 0.5 +24

The project environmental impacts are mainly coming from HCSW and waste water at the operation stage of the DGHs/DPCs.

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CHAPTER 4: BUILDING ENVIRONMENTAL MANAGEMENT PLAN AND MITIGATION SOLUTION Medical establishments in the project areas are still poor, lacking of necessary conditions; their status HCWM can impact on medical service quality, on the safety health of medical workers working in the DGH, DPC as well as on communities’ heath in the project areas. Therefore, the preparation of an action plan for HCWM will create the key output points to guide daily activities as well as to give the guidance to the investment so that HCWM will have or be allocated enough budgets from credit loan or budget from provincial/state budget to improve HCWM at the project sites.

Purpose of HCWM plan: To improve practicing of HCWM in the district general hospital and district medical center and to make the planning HCWM followed sustainable manners as well as to fully respect to environmental standards and HCWM regulation of the MoH. To define mitigation methods to eliminating bad impacts to environment. To decrease unwanted impacts on community as well as to patients’ healthcare within the construction areas.

Scope: To improve practicing and making the planning of one environmental management plan (EMP), and to overcome environmental breakdowns and accidents

The basis contents: The new regulation under Decision number QD43/2007/QD-BYT of the Ministry of Health has updated the new methods for safe treatment of medical waste, preliminarily disinfecting methods for identified categorization of waste and making detail guidelines for waste destruction in the safest way especially to the high risk infectious and high considered waste. So, the action plan of HCWM and environmental management plan (EMP) for the mitigation of bad impacts of the Project “Healthcare support for North Central Provinces” focuses on the following: Increase the guideline of HCWM for project’s medical establishments Develop the regulation and human resource for HCWM of 6 provinces of central north area. Provide additionally financial resource (coordinated fun if it is possible) for medical equipment and tools for HCWM within the suitable technology, concern more t friendly environmental methods like disinfection.

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Design hospital waste water treatment station if it runs sustainable and environmentally friendly then expand a performing model for hospitals as well as preventive medical centers. Find the policy mechanism to create the specific fun for HCWM at project areas. 4.1 Decrease the impact of medical waste by increasing practices HCWM for medical establishments in the project areas. 4.1.1 Increase guideline of HCWM

To create a practical plan for HCWM and point out the detail guidelines of HCWM for separated hospitals to follow the national and international regulations. The followings will be developed base on the coordination between experiences, fun from and other supports from WHO. Base on the HCWM regulation of Health Ministry and other related documents, then making the detail guideline of HCWM practicing for each project provinces therefore HCWM will be implemented effectively and sustainable and ensured by the good organization, monitoring. It also necessary to make sure that the responsibilities of undertaken persons will appoint clearly in order to build suitable practicing methods for medical workers with the suitable budgets.

4.1.2 Regulative development, human resources for HCWM

Anti disinfected groups will be in charge of implementation, local monitoring of HCWM and medical disposal. The group leaders will monitor, train medical staff in medical waste identity, source separation, its disposal and other technical equipments. a. Assigning the responsibility: Assign clearly task to related officer. Leaders of anti- infectious department or group will be in charge of HCWM implementation at DGH/DPC and make the periodical report on HCWM includes reporting waste volume at each department to the medical establishment director. The managers of each department will be responsible of waste separation, waste collection at their department. The waste collectors are being in charge of waste transportation to the gathering points. b. HCWM training: Training HCWM for the board management leaders then they will reorganize the training courses to staff in charge of HCWM at each medical establishment. The training course contents will consist: 1) Practices of separation, collection, disposal of medical waste. 2) Management and making plan. It needs to have two training courses.

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The first course: for staff in charge of HCW, director of anti-disinfected group, head nurse (01/hospital), the focus point is the practicing of HCWM, then they will training its contents at their hospital or medical center. The second course: For board management of hospital and medical centers, relating to HCWM monitoring and assessing (02/ medical service). Additionally, it needs to have more budget for training courses that have been designed for management staff at the health commune as well as for preventive medical center staff and others medical units in the project areas.

Table 4.1 Detail description on training courses of HCWM practices.

Training Objectives Quantity Teacher Time Expected result contents HCWM staff in charge 64 units in Health 1 day Knowledge to good practicing of MW, the project Ministry implementation: medical director of anti- areas (Treatment waste identity in disinfected department) regulation, correct group, head expert separation, preliminary nurse treatment, disposal. Attain the requirement of HCWM plan. Monitoring- Hospital 64 medical Health 1 day Clearly understanding assessing director + units and Ministry, regulation of HCWM, HCWM provincial staff provincial (Treatment making plan and in charge of officer. department) monitoring the medical waste expert implementation (Medical Service)

4.1.3 Building up one specific HCWM Plan for projected district general hospitals

It is important to develop one specific HCWM Plan for project district general hospitals/preventive medical center. The HCWM plan includes methods for separation, collection, transportation, and disposal of medical waste; and running cost, function, duties for all related officers. Selecting pollution mitigation methods as well as to have the EMP. The EMP has to be designed well in order to invest and to improve equipment for medical waste treatment. This plan needs to be approved by each medical establishment’s director and then will put under the control and monitoring of Provincial Department of Health. - Objective: Before implementing the Project, district general hospitals and preventive medical centers will develop and complete their own HCWM plan to reduce waste, to prevent

-44- Healthcare waste management plan - Central North Region Health Support Project pollution and to improve environment quality at district general hospitals and DPCs of 6 project provinces, where generates more than 51% of hazardous medical waste of the total medical waste from North Central area. - Principles: 1) Source separation- reduces and recycles waste under the regulation 2) Safe disposal – select the friendly environmental methods for waste disposal

3) Policy discussion and finding fun for HCWM witch is now very limited 4.2 HCWM plan and environment impacts mitigation for district general hospitals in the project area.

4.2.1 Waste separation at source by group of waste based on HCWM Regulation of HCWM- Q 43/2007/QD-BYT. Communication, training for collection and isolating hazardous waste at source: 1. contagious waste, 2. hazardous chemicals, 3. radioactive waste, 4. pressure container, 5. general waste Contagious waste is paid attention on the most high risk group of waste from A to D group of infectious waste. The leader of each department has to stipulate the place of department waste collection and have the waste bin at the waste generation sources and have to have the guideline for waste separation at source. A) Sharp and pointed waste (Waste of group A or Type A): injection needles, sharp and pointed ends of transfusion tubes, scalpesl, nail and saws, injection ampoules, broken glass pieces and other sharp and pointed instruments used in medical activities. B) Non-sharp and non- pointed contagious waste (Waste of group or Type B) are those stained with blood or biological fluids and wastes from isolation wards. C) Highly contagious waste (Waste of group C or Type C) are those generated at laboratories such as swabs and containers stained with swabs. D) Surgery waste (Waste of group B or Type D), which include human tissues, organs, body parts, placentas, fetuses and tested animal carcasses. Hazardous chemical wastes: a) expired or poor-quality pharmaceuticals which are no longer usable. b ) Hazardous chemical used in medical activities, tissue toxicant including drug bottles and pots, instruments stained, c) tissue intoxicants or substances secreted from patients treated with chemical. d) Waste containing heavy metals: mercury (from thermometers, blood pressure meters, wastes from dental treatment), cadmium (Cd (from batteries, accumulated batteries), lead (from lead-coated boards or materials used to prevent X-rays from image diagnosis or X-ray treatment rooms)

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Radioactive waste: include solid, liquid and gaseous ones, which are generated from diagnostic, therapeutic, research and production activities. Pressure containers: include oxygen, CO2 or gas cylinders, prone to cause fires and explosion when put on the fire. General domestic waste are those which do not contain contagious elements, hazardous chemicals, radioactive substances, inflammable or explosive elements, including garbage from patient’s room (excluding isolation wards); b) wastes generated from medical activities such as glass bottles and pots, serum bottles, plastic materials, assorted plasters for broken bone cast, which are not stained with blood, biological fluids and hazardous chemicals) papers, newspapers, documents, packing materials, cardboard boxes, plastic bags and film bags. 4.2.2 Color coding for waste bag, stored bin, waste bin.

1. Yellow PP or PE bag for storing contagious waste (A-D); 2. Black bag for storing hazardous chemicals and radioactive waste; 3. Blue bag storing normal domestic waste and pressure container of small capacity; 4. White bag storing recycles waste. Medical establishments have to support enough PP plastic bags for all departments. Stored equipment storing sharp and pointed waste: Sharp and pointed Waste containers must suit the final destructive methods, satisfy the following standards: Their wall and bottoms are hard enough so as not to be punctured. They can resist infiltration. They have proper sizes. They have lids which are easy to open and close. Their mouths are big enough for putting sharp and pointed objects without push. They are printed with the phrase “ CHI DUNG CHAT THAI SAC NHON” (FOR SHARP AND POINTED WASTES ONLY) and a line at the ¾ height and the phrase “ KHONG DUOC DUNG QUA VACH NAY” (NOT CONTAINED ABOVE THIS LINE). The re-used box has to be clean, disinfected. Waste bins: Use the waste bin with lids, and easy to open within the carrying rope. Following the color coding. The bin’s outside must be printed with a signal line at the ¾ height and with the phrase “ KHONG DUOC DUNG QUA VACH NAY” (NOT CONTAINED ABOVE THIS LINE). To be clean the waste bin everyday.

Encouraged use trolley, specific vehicles to transport waste in the hospitals. 4.2.3 Responsibility of waste collection, transportation in the medical units.

Waste collection: Nurse’s aide/ sanitation staff collect waste at all departments (before 16h) from the source to the concentrated waste station of the department then bring to the waste gathering place regulated in the DGH/DPC.

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Waste transportation: The transport of waste through patients’ area, and other clean zones should be avoided. When transporting in side DGH/DPC, it is avoided waste falling to the floors. Waste store: Hazardous waste, re-use waste, recycle water are separately stored. (The stored house depends on the hospital’s regulation, it should be far from their restaurant, working room, public area; and have the rope, protected wall, clock door, suitable area, hand-cleaning area, protected equipment, disinfected chemical, water drainage, good air ventilation. The stored time of medical waste is lower than 48 hours in the general condition. Waste should be treated at the moment. If the medical center with the waste volume lowers than 5kg per day, its collection, treatment is two times per week.

Transport to the treatment: Person in charge of MW management transported surgery waste to dump every day. To district medical center/ preventive medical center propose that they bring their waste to the next hospital which has got the equipment to treat medical waste properly. Medical waste of district hospital or medical center, before being transported to destruction places, must be packed in bins to avoid cracks or breaks on route, must label first, and take note of waste transportation and respective disposal 4.2.4 HCW treatment plan of medical units in the project area.

1) Temporary disinfection for all high contagious waste (C, A, B group) 1. Highly contagious waste can be initially treated at the source by one of the following methods a). Chemical disinfection: soaking medical waste in 1-2% Chloramines B, 1-2% Javen, for at least 30 minutes (or other disinfected chemicals under the use instructions of producers and regulation of the Health Ministry). b ). Hot- steam disinfection: Highly infectious waste is put into disinfection steamers which are operated under producer’s instructions. C) Non- stop boiling for at least 15 minutes. 2) Highly contagious waste after being preliminary treated, can be buried or wrapped in yellow plastic bags for mixture with contagious wastes. If these waste are initially treated by autoclave or microwave methods or other modern technology up to prescribed standards, they can be later treated like general waste and be recycled. 3) If the hospital is equipped incinerator, sanitation dumping is just applied like a temporary method and it can discover the difficult condition at the mountainous areas. 4. Hygienic burial: being surrounded by fences, at least 100m away from water wells and residential houses; their bottoms are at least 1.5m below the surface water level, their mouth are above the ground and temporarily roofs against rain water, each waste layer must be covered by an earth layer of 10-25cm thick and the final earth layer must be 0.5mthick. Contagious waste must not be buried together with general wastes. Contagious wastes must be disinfected before being buried.

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2) Final treatment for all kinds of waste 1) Treatment of sharp and pointed waste: a) Incineration in special furnaces together with other contagious waste b) Direct burial in cement hole exclusively used for burial of sharp and pointed objects: The holes are built with concrete bottoms, walls and lids. 2) Treatment of surgery waste: a) the contagious waste treatment and destruction methods like treatment of contagious waste at incinerator. b) They are wrapped in two yellow bags, packed in cases and buried in cemeteries. c) Burial in concrete pits with tight bottoms and lids. 3) Chemical waste treatment and destruction methods: a) Returning them to supplier under contracts b) Incinerating them in high blast furnaces c) Destroying them by method of alkali neutralization or hydrolysis. d) Pre-burial winterization: mixing waste with cement and number of other materials in order to fasten hazardous substance in waste. The mixture ratios will be as follow: 65% pharmaceutical, chemical waste, 15% lime, 15% cement, 5% water. After an unique block is created, it is transported for burial. Pharmaceutical waste: a) returning them to the supplier under the contracts. b) Incinerating them in high blast furnaces. C) Inert able - then burying them at hazardous waste burial sites. Treatment and destruction of waste Contain heavy metal: a) returning them to producer for recovery of heavy metals. b) Destroying them at places for safe destruction of industrial waste. C) If these two methods cannot be applied, the method of packing wastes tight in metal or high density polyethylene cans or boxes, then adding fastening substances (cement, lime, sand), letting them dry and packing them tight, then discharging them to waste duping site. 5) Treatment and destruction of tissue-intoxicating waste: a) incinerating them in high- temperature furnaces. b) Initially, the infectious waste has been disinfected and then burial at concentrated waste burial sites. c) Using a number of oxides such as KMnO2, H2SO4, etc. degrading tissue intoxicants into non hazardous compounds.

6) Radioactive waste treatment and destruction: Medical establishments using radioactive substances and radioactive substance- related instruments or equipment must comply with current legal provisions on radiation safety. 7) Treatment and destruction of pressure cylinder: a) Returning them to the producer under the contracts; b) Re-using them. c) Burying them like pressure cylinder of small capacity. 8) General solid waste treatment and destruction: 1) Recycling, reuse general waste must no contain contagious elements and hazardous chemicals. Waster allowed for recycling and reuse are only supplied to organization or individuals licensed for such operation and having function of recycling waste. Medical establishment assign one unit to organize, inspect and

-48- Healthcare waste management plan - Central North Region Health Support Project strictly supervise the treatment of general wastes according to regulation for recycling and re- use. 2) Treatment and destruction: Burial at local waste burial sites. 9) Treatment of waste water: Each hospital must have a synchronous waste water collection and treatment system. That hospital, which does not have waste water treatment system, must build complex waste water treatment system. Separating medical waste water, domestic waste water and rainfall. Applying the disinfection methods at the source of infected waster, water containing blood or cell sap or saline…; This is good if the waste water is locally treated before running to the collection waster water treatment system. Output domestic waste water has to follow QCVN 14:2008. Output medical waste water has to follow TCVN 7382-2004 (standard for hospital waste water) and TCVN 5945-2005 (applied to the left components not under TCVN 7382-2004). Monitoring output water quality every year, at least 2 times per year) 10) Treatment of gaseous waste: 1) Laboratories, chemicals or pharmaceutical storehouses must be constructed with air ventilation systems and toxic gas-gathering cabinets up to the prescribed standards. 2) Gas discharged from solid medical waste incinerators must be treated up to Vietnam’s environmental standards with frequency of two times per year. Regular maintain of incinerators. 4.2.5. Impact mitigation from radioactive waste

The construction, arrangement of radioactive able equipment caused human impact has to follow strictly the designed standard base on decision number 32/2005/ QD-BYT in October, 31 of 2005 on designed stand on image prediction diagnosis. Use X- ray equipment, CT- Scanner, MRI with the clear origin (machine code, where and when make it). This equipment is checked regularly one time per year, checking process bases on the DVVN 41:1999 To X-ray room, its design has to followed construction standard of number 365/2007 (minimum room area is 12m2, window and main door of X- ray room has to preventive effect of X-ray Fully equip of laboratory equipment for machine operation, suitable prevention equipment such as prevention for thyroid gland. Person in charge of A-ray machine has to be equipped with personal safety and has to exam personal health regularly.

4.2.6 Mitigation method of epidemic diseases It is necessary to ban food products, materials, foods, drinking can be contaminated with epidemic diseases.

Limiting patients are being treated at epidemic diseases departments living outside the hospital to eliminate the disease contamination to the community.

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Disinfection based on doing sanitation activities at the DGH/DPC.

Limiting to bring people and equipment living in the restrict areas of the DGH/DPC place to place aiming at reduction of disease spreading; in a special situation it needs to equip fully protection instruments and tools and to obey and follow the instruction of the Ministry of Health on epidemic control and prevention.

Proposals to cut the pathway of contamination: Eliminate direct contact between people and hazardous HCSW by: providing personal protective equipment e.g. heavy duty gloves, safety glasses, thick clothes; Restricting access to healthcare waste dumping site; Improving awareness of dangers of contamination from HCW.

Eliminate indirect contact between people and hazardous healthcare waste by Applying vector control methods e.g. covering waste; Protecting water supplies from contamination; Implementing good hygiene practices when dealing with waste by hand washing;

Hazard reduction: Encouraging the use alternative solution for safe disposal of clinical such as autoclave/chemicals to initial disinfection of clinical waste before safe disposal of waste in separate sanitary burial pit/cell at disposal site. In case use the incineration method, the good designed and qualified incinerator should be used.

4.2.7 Other mitigation methods Public awareness rising: It needs to build guideline of waste management apply for whole project life. The guideline can be printed by A4 paper, divided into 4 parts (fourfold), includes contents: I- Definition of medical waste and how to recognize it; II- Impacts of medical waste within expert reflection and other assessment on impacts of bad situation of HCWM or the disease contamination when contact with high risk infectious waste; III-Guideline of medical solid waste separation, description by color picture of waste bin all kind, nylon bag all kind; IV- Commitment of strictly follow HCWM regulation of MoH.

Implementing of medical waste separation at source by following the Regulation of MoH is committed.

It needs to improve human capacity on HCWM, open the professional training course as well as the technique of HCW treatments for medical staff. Onsite trains and awareness are given to everyone from sanitation officer to the medical manager. Prevailing mitigation methods and other related solution to concerned people aiming at increasing awareness in the project area Encourage and communicate to the private medical units to strictly follow the regulation of medical solid waste separation. Besides, environmental policeman needs to strictly keep a close watch of medical waste treatment situation. Strictly punishing will be delivered to organizations due to illegally dumping infectious medical waste. Green belt should be created in the hospitals by planting trees and creating the beautiful landscape, against dust, noise, gas.

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Protection of waste workers, medical staff that have to contact daily with HzHCW and organizing the healthcare checking periodically to check the infection respiration systems, skin diseases… 4.2.8 Preventive and deal with environmental breakdown

To build the water container, fire-fighting equipment followed TCVN 3254-1989 of fire fighting regulation Safety internal rule is issued as regulated. Having anti –fire foaming bottle to protect from fire as regulated. To train for medical staff of method and equipment in case of incident To prevent lightning problem, medical centers have to equip of lightning-prevention, follow the regulation of 76/VT on March 2, 1983, by Ministry of Construction. Training the methods and activities in emergency cases to control accidents based on the safety laboring principles. Medical workers are protected by safety toolkits. Anti thunderstruck by installing appropriate tools as regulated Make sure that the pits of waste as mentioned Were prepared in cases of emergency and having accidents with medical incinerators. In most of cases, the infectious has to initially disinfect by mentioned above safe solutions (autoclave, boiling, microware, disinfection using chemicals). 4.2.9 Increasingly monitoring the information of hazardous medical waste

HCWM plan needs to be approved and monitored its implementation from the waste’s arising to the disposal Taking the note of waste volume Checking regular disposal standard and condition. 4.2.10. Increasing individual responsibility of HCWM

Dean/chief of department: in charge of HCWM from waste generation source, initial disinfection, collection of waste to proper place, assigning tasks for checking, monitoring and writing the discharged waste within the department. 2. Medical staff/ sanitation staff: transportation, treatment and applying final way of medical waste disposal. 3. Board management of hospital: approving the HCWM plan and building investment project, improving infrastructure for HCWM of the units. Enough supply of specific equipment for HCWM. To coordinate to specific institute who will monitor the disposal, to check environmental quality at least two times per year.

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4.2.11. Preparing specific financial source for HCWM

Being priority to chose the low cost technology for HCSW treatment. The minimum cost for medical waste incineration is about 10,000 d per kg of infected waste. The expenses for treatment of medical waste water are about 1800d/m3. These expenses should be available and paid by the DGH/DPCs. 4.2.12 Preparing to build treat HCWM based on the assessment and selection of suitable technology for project DGH/DPC.

If the DGH has got its financial source and has planned to build HCW treatment system by financial budget of other donors (buying the incinerator, building the waste water treatment system/station), it needs to assess existing waste water treatment systems operate in the whole country in tern of technical design and operation and maintain) to have the basic conduction for choosing suitable technology that will be used for 6 project provinces. It is needed that the selection of two DGHs to demonstrate and to perform the suitable medical waste treatment models (WWT and HCS treatment facility). The two DGH are looking for is DGH Que Phong- Thanh Hoa and DGH Phu Loc – Hue to introduce the cost effective treatment solution and environment friendly operate and maintain of medical waste (liquid and solid). If DH or preventive medical center doesn’t have their expense and any waste treatment facilities or has not have planed incinerator, they should be supplied disinfected equipments like autoclave, disinfected chemical for safe disposal of waste and the initiation disinfection of infectious waste should be priority to apply.

The infected waste is safe after separating and be disinfected in autoclave at least 15 minutes, or soaking and boil in hot water 1000C about 30 minutes before dumping it at specific/separate pit of waste or in waste concrete tank onsite the hospital. Sharp material (within or without the point of needle) is soaked disinfected chemical or consolidation/solidification, and then dumped in the concrete tank or in safe pit of waste.

Low cost of HCW treatment technology/facility that can treat the waste at national environmental standard should be introduced. The mentioned technology based on the following principles:

+ Collecting waste water at the regular tank for primary bio treatment, there is solid waste screening to remove the raw or coarse solid waste with big sizes to avoid from damaging pump and obstacle of the drainage system. In addition, the primary treatment will make the biological process and treatment easier and quicker). The biological treatment will implement in concrete tank that designed as septic tank or intensive septic tank with bastab (partition wall with the up flow direction wall). After that, waste water is then pumped or flowed gravity to bio-treatment tank to implement further treatment there.

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+ Bio-treatment (aeration or SBR Sequence Batch Reactor treatment): Medical waste water can be biologically treat at 1) Aeration tank with sedimentation partition and sludge and sediment gathering cell. There are two operation section in the tank with the appropriate partition wall, the treatment includes several process: fully pumping waste water to the treatment tank, oxygen/air flowering for nitrification, de nitrification, purification to remove pollutant substances, checking input parameters DO, BOD, COD, N,P, oxygen scouring intensity to create favorite condition (temperature, pH, DO...) to effectively remove suspended substances and pollutants in the next sedimentation phase. 2) Trickling filter system: Waste water is sprayed regularly in the bio-filter by water- distribution pipes or canals. When waste water down flows through biomaterials (make up gravel, coarse sand, plastic buffers…), the liquid membranes is created along the materials and the pollutants contact directly with air from one to two side when getting in touch with bio membrane in the other. Then substances, oxygen will diffuse to bio-layers and be decomposed by microbiological process. There is integrate treatments: aerobic, anaerobic, anoxic in the bio-membrane at filter materials, oxygen is naturally provided continuously through the pores of filter materials, then waste water is purified and cleaned. Under the filter material is the water collection drainage which enough for air circulation. Treated water can be circulated and mix with raw water to reduce its concentration before spraying it to filter- material, it also help controlling the water power. When surface layer is thick enough, substance is difficult to inter then the microorganisms will die, the die membrane follow the water running to make the sediment. Dry sludge appears normally very small. Bio-system can treat organic pollutant, nitrogen, bio-phosphor by the transformation among aerobic, anaerobic ... in the tank through changing the oxygen supply demand at filter-membrane structure; arrangement of water running order. Trickling filter is now the popular technology with the trend that it increases the filtering times, and uses plastic filter material instead of biomaterial. 2) Trickling filter system structure: 1) the bottom. It collect filtered water and sediment in the bottom, air goes into filter by the main door. It is made by block, hole-bored concrete, glass-reinforced composite place in the concrete layer to support the filter material. The bottom’s slope is from 1 to 5 percent toward the water collected door. minimum velocity of running water in the water collected ditch is 0.6m/s to ensure that sludge is not be stagnated and water does not block the air interring. 2) Filter material: requirement of the big surface (m2/m3), big empty volume, light, strong, low cost. However, the plastic material is popular day by day because it satisfies the above requirement and high treatment effectiveness. In the other hand, it is light so that filters tower can be higher then reduce the surface area. 3) The secondary sediment uses just for heavy sludge collection, it not need to press sludge therefore the requirement is not complicated. + Sediment deposit: After bio-treatment, waste water is deposited, maximum deposited time is 2hours.

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+ Decontamination: After bio-treatment, most of the organic pollutant reaches the permitted standard, effective treatment of organism, bacterium and coli form. Waste water is run to decontamination tank, and decontamination chemical should be ozone or hypochlorite... Sludge let out: Sludge is transported to the sludge stored tank It needs to priority select the waste treatment system of sustainable working, to train and remain well. Waste water treatment station can primarily treats at the latrine or sediment tank then applies trickling filter and final decontamination, will reach the environmental standard of nitrogen, organic compound, coli form, decreasing output sludge, and output water reaches the TCVN 7382:2004.

4.2.13 Implementing, building and treating medical waste for medical units with different source of capital Cost for medical waste treatment bases on the additional supply for the units which have never invested following the medical scale.

Mixing finance plan (from provincial source, governmental debenture) to ensure that medical waste of the project units are controlled and monitored following environmental standard in the implemented time.

4.2.14 Making and creating appropriate budget and encouraging medical waste treatment Following the HCWM Decision 43/2007/QD-BYT of MoH, medical waste treatment cost is self-paid by hospitals. However, the most of the project districts are very poor district, which serve the poor, its finance is limited then it needs to have the specific policy and support from province in term of financial assistance for HCWM.

4.3 Mitigation of environmental pollution in the construction phase of the preventive medical center. 4.3.1 Mitigation method when preparing construction Ensure to design works follow the technical design requirement for district general hospital or preventive medical center. The diagnosing and treatment rooms, test labor, medical storage area have to use the window system, air ventilation system and are designed to ensure the input of natural fresh air and air exchange according to specific design standard. Monitoring and requiring the construction designer to make the separation of waste water stream so that the waste water can be managed separately. The scheme of waste water stream for preventive medical center will be organized and be checked with the following principles: a. System 1: Rainfall. This system includes ditches; closed drainage ditches with the coarse waste screening .

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It is built by concretes and steel rods. It will collect rainfall from the house roof and direct to inlet system along to the local collection inlet pipes of the hospital or preventive medical center. The rainfall at the yard will run to rainy collection pit hole and then running to general inlet of rainfall and going to the commune’s system. b. System 2: Domestic waste water This is from medical workers’ rooms and patient, member of the patient’s family use. The domestic waste water is divided into two small orders. The first stream: The waste water from washing clothes, having washes, cleaning the medical rooms... of medical staff, patient. Normally, the pollutant concentration is not high then it can discharge after decontamination. The second stream: The waste water from septic tank with high concentration of pollutants, inspections pollutants, therefore, it should to be treated effectively. Nowadays, there are many methods of treating gray waste water, depending on the waste water volume, characteristic, and terrain of WWT to choose it as better as possible. One of them is three-partition septic tank. The well designed and functioned septic tank includes sedimentation tank and decomposing sedimentation tank. The organic maters and the sediments in the septic tank will be decomposed, partly created gas and other dissolvent inorganic. After running through the first deposition section, the waste water will continue run to the second and the third section then go out to the environment after disinfecting treated waste water at the gathering point. The detail diagram is follows:

Domestic waste water Partition1 Partition Partition 2 3 Output Regulate Deposit Deposit - Deposit sediment sediment sediment Biodecompose Biodecompose

Picture 4.1. Model of three-compartment septic tank The sedimentation or sludge are keep in the tank from 6 to 8 months, under the impact of anaerobic organism, organics are decomposed, partly create gas, partly transferred to dissolvent inorganic. The waste water is deposited in the deposit tank then going to the total waste water processing system then discharging to received environment

Septic tank volume depends on characteristic of each department, building, being suitable to number of direct and indirect medical staff, patient and medical service. Calculation for building latrine

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Septic tank includes two parts: water stored and deposit sediment stored + Volume of the deposit sediment tank W1 = a*N*T1/1000;W2 = b*N*T2/1000 + a: Waste water standard per person per day, select a = 20 l/day night + N: Number of people + T1: Detention time of waste water in the latrine (20 days) +b Sediment standard in the latrine per person per day, select b =0.08 l/day + T2: Minimum interval of 365 day between each removal of the solid waste accumulated in the latrine. Total volume of the septic tank: W = W1 + W2 c. The system 3: Waste water from testing process, is divided into 2 different waste water stream. Steam 1: Waste water from treatment process (example: reproductive health care, putting in a coil, gynecology treatment), waste water in the toilet. This waste water should collect to latrine before going to the water inlet and waste water treatment area. Steam 2: Water from labs. It has to collect and locally treat before running into the latrine. Before discharging to the outside, waste water need to be treated at slowly bio-filter system to kill microorganism, reduce organic pollution level, prevent unsolved matter and get rid of bacterium to ensure environment standard. The final is the tank to make the purifying waste water.

Initial disinfection waste water Disinfection Waste water from at Labs Biological treatment Output all department Collect Septic tank

Remove of Landfill sludge Note Waste water order Sludge Picture 4.2: Local waste water treatment system Local treatment: Waste water from testing lab is decontaminated initially, collect to the store, then run to the general latrine. Waste water is pumped through the inlet to the chemical mixing tank. Sludge in the latrine and the sludge from the bio-treatment tank are removed regularly then bring to landfill. d. The preventive medical center places in the hospital area According to the legislation, district hospitals of 50 patient beds have to make the environmental impact assessment when build the new one, make environment protection project when improve itself and have to clearly explanation of hospital waste water treatment system and medical solid waste management. Waste water from septic tank flows to the regulatory tank or waste water collection tank of the preventive medical center have to connect to the general treatment system of the district hospital. And medical waste water has to reach level I, TCVN 7382-2004. Some destructive hospitals, general waste water treatment systems are being designed simply. It needs to note that medical waste water has the same characteristic with domestic waste water because organic pollutants is in average level, is not difficult to treat, but if the

-56- Healthcare waste management plan - Central North Region Health Support Project bio-treatment is not effective then organic pollution level is still high therefore the last decontamination phase will be not effective and lost of decontaminate chemical. So, it needs to encourage technology for medical waste water treatment at a district hospital should be followings: Bio-technology treatment of Aeration coordinates with deposit in batch or slow bio- filter and decontamination by friendly environment chemical, the treatment technology is described following:

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Waste water from WC Septic tank

Waste water from treating, washing, eating room

Screening

Regularory tank

Oxigen blower Aerobic tank+ SBR/ or bio-filter (without oxygen scouring) Sludge collection Decontaminate Disinfection substance

Lanfill Output, level I TCVN Picture 4.3: waste water treatment for hospital7382 or- preventive2004 medical center 4.3.2 Mitigation impacts when preparing the building platform Preparing the building area includes: clearance of the ground, removing the old building, cutting trees, cleaning the bramble bush, digging the house foundation, mixing the constructive material and constructive progress. These activities are implemented next to district hospital then impact the diagnosing and treating diseases; therefore constructive activities impact not only worker but also medical staff and patient of the district general hospital. Besides, there are some impacts to residents and their property. These impacts will be calculated based on the comparative prices in the market. The same to the land acquisition for the construction of the DPC building or the land surrounds the DPC. So, it is needed to have the surveys to make the prediction of the impacts to the residents and people next to the project sites. To make sure that if the impacts are un significant or having appropriate solutions/compensations, complains and worries come from the residents are small and negligible. 4.3.3. Air pollution mitigation in the construction phase It needs to fully protect the vehicles for transporting sandy and stone, packing and locking the door to the DGH. All constructors must have appropriate solution to ensure the constructive legislation. Construction material transportation does not permit in the rest time, in the treatment area. If the land use is available it should to have a private path to transport material It needs to ensure mechanical and constructive standard of TCVN 4087-1985. Do not use the old car or machine to transport material and implement works, equipments also need

-58- Healthcare waste management plan - Central North Region Health Support Project to check regularly for safe work and environmental standards such as air, noise, and shaking level. In other hand, petrol, lubricant also leak in the implementation process then impact air environment as well as worker health. In other hand, petrol, lubricant also leak in the implementation process then impact air environment as well as worker health. Spraying water to make the moisture air, reducing dust distribution in works especially in the hot weather The new construction will be built first and separate with the diagnosing and treating disease by wall and canvas sheet in the area which is much more dust. Taking full advantage of the old building to treat and diagnose patient. After the new construction finishes totally, gradually moves the present medical rooms to the new ones then repairing and altering the left. It need to strictly ordinate between project owner and constructor to properly build and mitigate of dust, hazardous gas, noise, shaking level and the impacts to surrounded environment. 4.3.4 Mitigation of water pollution in the construction phase Project owner orders contractor do not place the construction material near the water source or water reservoir, and manage the petrol, lubricant and hazardous material from transportation and construction activities. It needs to have the concentrative cistern to collect all the water of workers, to avoid the freely running of waste water in the area. After leveling a road surface, the soil and stone ...are collected and transported to the regulative area, to avoid the flood situation and impact the construction activities as well as diagnosing and treating diseases. It needs to collect regularly construction waste to limit the solid waste falling into the drinking water source. With the special terrain area like the project sites in the North Central Provinces, the weather is usually irregular, a great amount of rainfall each year, therefore the constructors should build the temporary sewerage and septic tank to primary treat the over running rainfall 4.3.5 Mitigation of solid waste in the construction phase Limit the solid waste arising from implementing process by suitable using materials, training and reminding worker of material saving to reduce the solid waste. Good implementation of solid separation, regularly cleaning the construction areas. Then, there are the suitable treatment methods. + Construction waste, which is inert and not harmful for environment, can be reused for leveling the road surface such as soil, concrete, stone. + Recycle material, like steel, wrapping, bottle can bring to recycle + Domestic solid waste is collected at proper area for treatment. Training worker collect waste at the construction work and transport waste to the collection points. Construction owners have to plan for worker cleaning the construction work everyday. Besides, waste of patients and medical staff are still collected and treat by their own way by the present equipment. The non hazardous and infective waste are collected and transported to the treatment location.

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4.3.6 Safety in construction implementation and protection Most of the preventive medical center located or be built located and built next to the district general hospital so that the construction owner needs to build the internal principle and regulation and at the construction site for workers and related people to be implemented: + The construction and working time follows the regulation to avoid impact on rest and relax time of patients in the DGH. + Checking regularly and require constructors of preventing from dusting by way spraying to limit the dust and suspended substances. Preventing from flying objects comes from higher stores. Preventing from noise and vibration to ensure the environmental quality is in the acceptable level. + In the construction work, impacted implementation areas are protected by road- block, pitch the notice board. In the implemented areas, street traffic alarms should have to provide with night - lighting system at the nigh time when digging in the road. + Board managements have to require and regularly check the implementation of said above solutions and work safety, fire fighting in the construction works during the implementation phase. 4.4. Air pollution mitigation in the operation of newly built DPC 4.4.1. Air pollution mitigation Regularly clean the preventive medical center/DGH, spray the antiseptics in the rooms that operate with patients’ bloods, surgery units, infectious departments .., WC. Alter the damaged or broken manhole cover or lids, regularly clean and dig and evacuate the drainage ditches, and limit the sludge and bad smell generation. Arrange and design enough window system, air system and ventilation in the diagnosing and treatment rooms, testing labs, medical stores to ensure fresh air exchange according to technical design requirement of DPC building. Use the biological products to treat and limit the strange and annoying smell. The biological products such as Enchoice, EM... are easy found in the market. These biological directly spray to the polluted sources, to waste collection points to keep general sanitation of the areas. Regularly check and repair and maintain cars, properly use the petrol according to machine design. 4.4.2 Water pollution mitigation Collect general domestic waste water to the regular tank designed as advanced and intensive septic tank for primary treatment. Creating good condition for bio-treatment with oxygen blower (at aerobic tank or SBR tank) or facilitating bio- trickling filter process in the construction tank (without blower) as described in said above mentioned technical description of biological process in waste water treatment. 4.4.3. Mitigaiton method for healthcare solid waste (HCSW) Good implementation of waste separation at source, it allows good implementation of the Decision QD 43-2007-BYT of the Ministry of Health, to ensure good separation at source. Not only medical doctors, but also nurseries, orderlies, waste workers have to be trained of healthcare waste separation, they should know how to distinguish HzHCSW, which kind of

-60- Healthcare waste management plan - Central North Region Health Support Project bag color for each type of waste, what is the right waste bin for clinical wastes, knowing the safety of provided protective equipment and tools. Workers also need to have knowledge of medical separation to meet the requirement. Approval and implementation of HCWM plan at DGH and preventive medical center. HCWM plan for preventive medical center is likely to district general hospital but the waste volume generated in DPC is not high as in DGH and not diversified. The maximum amount of HzHCSW comes from DPC is ranged from 2kg to 5kg per day. The waste of A, B, C groups and hazardous substances are the main daily waste. HCW Treatment plan: 1) Implementing well the initial disinfection process for the highly infected wastes. 2) Discharge whole injection needles, discharging to the “box and boxes for sharp and pointed items”, pour to waste pits or concrete tank and dumping, or separate the pointed needles, put in “box for sharp and pointed items”, then making the pointed items in solidification form, or landfill in separate concrete tank. The remained plastic cylinders are then disinfected by disinfection chemicals or soaked in the boiling water and boil in 30 minute. The disinfected plastic cylinders then could be disposed or recycled. The other hazardous wastes could be solid or concreted by cements and dumped in the concrete tank or at specific pit of waste. The prior treatment is the incineration in the available medical solid incinerators or the planned district or provincial incinerator at the DGH or in the project area. Absolutely, the transportation of HzHCSW outside of the DPC is followed the strict rule on labeling and packaging as well as storing in the proper container and use the specific vehicle just for carrying the HzHCSW. The mitigation of HzHCSW discharging, step by step makes the alternatives for hazardous wastes. Using less hazardous or none hazardous materials (example: do not use PVC plastic materials or bags, limitation of using mercury thermometers…)

4.4.4 Sum up the method of MW treatment of preventive medical center

Table 4: Summaries of HCW treatment method in preventive medical center District MSW WW WW MSW treatment treatment treatment treatment Lang Chanh C XDCB Que Phong C Thanh Hoa Thuong Xuan C XDCB Nghe An Tuong Duong C* Quan Hoa C XDCB Ky Son C Quan Son C XDCB Nghia Dan C* Muong Lat (TB) C XDCB Quynh Luu C Hau Loc (XD) C XDCB Nhu Xuan C XDCB Thanh Chuong C Ba Thuoc (TB) C XDCB Nam Dan C Cam Thuy (XD) C XDCB

Nghi Xuan KK or C* XDCB Minh Hoa(TB) C

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Ha Tinh XDCB QBinh Le Thuy XD C Ky Anh KK or C* XDCB Tuyen Hoa C H ng S n KK or C* XDCB Bo Trach C Huong Khe KK or C* XDCB Quang Trach C

Quang Tri aKrông C XDCB Hue Phong Dien KK+C* Gio Linh C* XDCB Phu Vang KK+C* Hai Lang C* XDCB Huong Tra KK+C* Vinh Linh C* XDCB Phu Loc KK +C* C: Burning solid waste in DGH by incinerator; KK+C*: priority for disinfection and central treatment at incinerators to be invested at DGH, XDCB: building septic tank and intensive biotreatment tank (such as trickling filter tank).

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CHAPTER V: INVIRONMENTAL MANGEMENT AND MONITORING PROGRAM

5.1. Environmental management and monitoring program Environmental management and monitoring ensure environmental methods in environmental impacted assessment to be implemented 5.1.1 Environnemental management plan (EMP)

When the project is implemented, project owner will implement the environmental management program includes To build the environmental management plan and program in the project area To point out the environmental monitoring programs To build the progress to ensure urgently of environmental accidents To have the deployment and the appropriate environmental management plans for all project phases: implementation and operation

Management of solid waste, waste water and poisonous gas in the implementation phase as well as operational phase. The HCWM has been designed to implement when the project is carrying, at least there is one staff working full time or part time at the Central PMB. The project management officers will have to trained on environemental law, requirements and the regulations to put in to practice on environmental monitoring and finding the imitation sollutions as well as inspection and reporting so that the project will run by the most environmental friendly manuals.

Most of projected provinces have been strongly committed to the Central PMB and the Provincial and District Department of Natural Resource and Environment on carrying the environmental protection solutions, they will cooperarte with the environmental consultant and World Bank Team in the project preparation, project appraisal and participating in the building up the HCWM plan as well as the EMP of the project.

The Environmental management scheme and the responsible of the stalkeholders presented as following:

Environmental management units/engineers

Environmental managers Responsibility Note

Environmental expert or Designing of EMP, supervising, Environmental expert and

-63- Healthcare waste management plan - Central North Region Health Support Project monitoring station environmental management PMB has to implement the during construction inspection of EMP Directly involve in applying Hiring environmental to Staff of Central PMB and solutions mentioned in EMP in assist Provincial PMB the construction phase and operation phase Directly involve in Constructor has to hire environmental protection at the engineer for that kind of Constructor/environmental site during construction. purposes. engineer Implementing requirements of the project owners on EMP

Inspection of the Provincial Department of Health and Natural Resource and Environment and others related

Responsible 1. Inspection of the implementation of LoE and EMP DoNDRE 2. Coordinate in EMP implementation 3. Checking, guidance, and appraisal of mitigation solutions 1.Inspection PMB 2. Checking the DGH/DPC on implemetation of HCWM of MoH Project owners in Checking the building up EMP for HCWM at hospitals, using provinces and refer to this report to develop detail HCWM at the hospital and put in to practices.

Environmental monitoring program Purposes, contents and methods of the environmental monitoring programs Purpose: Environmental monitoring plan/program has been designed for monitoring environmental quality of DGH and DPC aiming at controlling the environmental quality exchange in the operation phase, therefore explore in time the bad impacts and remedy methods, mitigation methods, to ensure environmental standards at the project sites

Contents: Air environmental monitoring. Monitoring domestic waste water, general water. Monitoring of collection, management of solid waste, mostly for hazardous solid waste

Method: Monitoring program has to design to reach the representative data and focus on specific pictures, comprehensive data. -Air monitoring management plans includes the monitors of air quality from the pollution source and air quality of surrounding environment. The waste water monitoring

-64- Healthcare waste management plan - Central North Region Health Support Project includes sampling domestic water supply in the project site and discharged water from the project sites to the water body, to the river system. - Solid waste monitoring: DGH and DPC have to always implement the environmental monitoring plans and make regular report with the period of 2 times per year to their district environment and natural resource authority at their project site. The regulation of Decision No 05/2008/TT-BTNMT with the minimum frequency of 6 months is applied. More details as following:

5.2 Air environment monitoring Table 5.1 . The air components to be monitored No Dust CO SO2 NO2

Location mg/m3 mg/m3 mg/m3 mg/m3 NH3 H2S CO2 Location Dust CO SO2 NO2 mg/m3 mg/m3 mg/m3 mg/m3 mg/m3 mg/m3 mg/m3 District hospital are or preventive medical center

1 Center area x x x x x x x

Incinerator are x x x x x x x 2 Surrounding area Head wind x x x x x x x End of wind x x x x x x x 3 Output of the chimney x x x x x x x Frequency: 2 times per year Equipment and analysis method: Standard equipment and methods Comparison standards: TCVN of air environment (TCVN 5937-2005, 5938-2005, 5939-2005, 5940-2005) and sanitation and labor regulation of 3733/2002/Q -BYT dated on 10/10/2002 of Ministry of Publish health and QCVN 02-2008: Technical requirement and regulation for air emission from medical incinerator Table 5.2. Environmental monitoring of micro climate

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Temperatur Wind No Location Moisture e velocity Surrounding are Head wind x x x End of wind x x x District general hospital or preventive medical center area Center area in the hospital x x x Incinerator area x x x 5.3 Waste water monitoring Water in general: pH, SS, BOD5, S2-, NH4-, NO3, animal oil, PO43-, total coli forms, intestine-diseased bacterium, and total radioactive activityβ. Location: In the output of the hospital waste water treatment system (WWTS), output at each department.... Number of sample: depending on location and requirement. Frequency: 2 times per year Equipment and analysis method: Standard methods and condition Comparison standard: TCVN 5945-2005 (column) and TCVN 7382:2004 level I Waste water: pH, NO3-, Cl-, N total, P total, SS, BOD5, COD, Coliform Location: In the output of hospital WWTS, at drains of medical waste water, output at each department.... Number of sample: depending on location and requirement. Frequency: 2 times per year Comparison standard: QCVN 08-2008/BTNMT – National technical regulation on surface water threshold and QCVN 09-2009/BTNMT- National technical regulation on underground water threshold and QCVN 14-2008/BTNMT- National technical regulation on domestic waste water threshold. 5.4 Solid waste monitoring In the operational phase, project owners have to monitor solid with the followed conditions Solid waste separation + Infected medical solid waste + Hazardous chemical waste + Radioactive waste + Gas or container + Domestic solid waste 2. Solid waste collection 3. Solid waste store 4. Monitoring frequency: 2 time per year Separation, collection and store of medical waste has to followed regulations of ministry of publish health on regulation of 43/2007—Q BYT on November, 30, 2007 Hazardous solid waste monitoring has to follow the regulation number 12/2006/Q - BTNMT on December, 26, 2006 and decide number 23/2006/QD-BTNMT of Ministry of natural and resource

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Monitoring cost: at least two time per year, in charge of the owner medical unit Analysis price of all components for environmental monitoring is following the price of Ministry of Finance in the regulation number 83/2002/TT-BTC on 25/9/2002

5.5 Monitoring the sanitation condition of working environment

The working environmental and sanitation condition will be monitored at the places, which are most impacted by disadvantage factors to human health include temperature, humanity, noise, light density, radioactive dose, poisonous gas. The monitoring places are some where in the departments, rooms, surgery area, and x-ray room.

Yearly, DGH and district preventive medical center will work with professional institute/organization to take samples, analysis samples, measure the pollution factors, and assess the necessary factors to be mitigated. All the data and environmental analysis results will be stored as the basical data to know environmental status of the medical establishment.

Otherwise, medical establishment needs to have the periodical health checking for medical workers. It is an important way to discover occupational diseases on time then to treat and recover health of their medical staff.

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CHAPTER 6: ACTION PLANS AND COST OF MWM IN NORTH CENTRAL PROVINCES

6.1 Cost estimation

Table 6.1: Estimated cost for MW treatment plan in north central coast base on the low cost methods Cost discription Note Price $ Co-ordinate to

Making a guideline of MWM other project Making the guideline of MWM for north central coast The guideline will be the document for the training courses. The guideline must be clear and 1 5.000 understandable for all medical staffs know clearly

separation methods; and discriminate and use correctly the collection materials, disinfection methods; and follow safety work to avoid the carrier disease

Ability and Institutional development by training 30.000 activities 2.1 Organizing 02 training causes for 6 provinces: + The first training for person in charge of MWM + The second training for Board Management of Medical Service and General Hospital, Preventive Medical Center to assess their MWM.

Total cost: 60$/person (accommodation, transportation, document) x 150 persons 2 Cost to rent the training places, prepare the tea break... 2 day * 60$/day + Additional cost and other reserved ones 2.2 Material and communication cost for 6 provinces Cost from the _ Communicating the waste separation and waste communication 12.000 treatment program _ Communicating to increase public awareness Total cost 50.000 6.2 Co-ordinate cost estimation for the supplying of MW treating equipment

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Table 6.2. Co-ordinate cost estimation for MW treating plans in north central coast MWM, medical waste treatment (solid waste and waste water) Implemented Plan discription Cost ($) methods Preparation and approval the detail plan for MWM at 1 Implemented units medical units Assessment the suitably treating equipment for the project provinces (under the detail MW treating plans for each Boad management, 2 5000 province) consultants

3.1 Buying of the waste collection and transportation materials of district hospitals Implemented by (cost for nylon, collection material…$15/kg medical 3 hospitals waste)

3.2 Buying MW treating equipments (incinerator/ Project board alternative equipment) for two performing location Hue management + Thanh Hoa (Que Phong + Phu Loc) Designing the sample, experiment model, and deploying of the medical waste water (MWW)treatment 4 4.1 Designing the two experiment models of medical waste water treatment with capacity of 150m3/day 4.2 Building two experiment models of medical waste Project board 200,000 water treatment at two project provinces. management 5000 4.3.Workshop: Assessment the operation, management cost.

4.4.Deploying and expending the MWW treatment Local budget Local budget Building the MWM fun includes provincial 1).Cost for solid waste treatment(3820 sickbed x 0.19 kg budget, base MW/day x 0.6 kg DO/kg MW x vnd 15000d/ l DO) is on the 2,384 vnd billion/year/ for the general hospitals and (33 x number of 3kg MW/day x 0.6kg DO/kg MW x vnd 15000/l DO) sickbed and 5 0,33 vnd billion/year for the preventive medical centers waste 2).Cost for waste water treatment: (3820 sickbed x volume per 0.5m3/sickbed/day x 1800 d/m3) 1,05 vnd billion/ year for hospital or general hospitals and (33 preventive medical center x preventive 10m3/day x 1800 d/m3) 0,216 vnd billion/year medical center 6 Total PBM 210.000 Table 6.3: Estimated cost for environmental monitoring Environmental monitoring for Total Implemented way DGH PMC one district Cost ($) Monitoring of the air, waste 1 water, solid waste, and Self implemented 31000 32000 63000 working environment 2 Reserved cost (10%) Self implemented 3100 3200 6300

Total monitoring cost/ year Self implemented 69300

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6.3 Implementation Schedule In the first stage, project has to support training courses for person in charge of MWM and complete MWM plan. The main job of this stage is to develop guidelines for the implementation of MWM, open training courses of HCWM, and start doing the HCWM plan at the project hospitals The next stage, project will consider the supporting of MW treating equipments, they are the more friendly technologies with the low running cost. After the testing period, this equipment will be expended for all project units. The project will be in charge of the testing cost. Provincial budget will be in charge of the expansion cost, it will ensure all medical units in the project areas have got the methods for MW treatment. Timetable of HCWM plan is displayed in the following diagram Table 6.4: Planed timetable for action plans of MWM at project area. Action plans Gi i pháp 1st 2nd 3th 4th 5th Development, To train, 2 guideline, develop the and training plan of MWM Select the disinfected equipment and To select the 3 the design and the experiment model designs for equipment waste water treatment Performing, taking 4 Performing experiment and Expending expansion that models Building fun Petition of 5 fee recover for MW and subsidy to treatment MW treatment

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Chapter 7: Recommendations to strengthen HCWM at North Central Provinces. The project impacts are foreseeable during the construction and operation phase and the impacts of HCW still prolong in long term with the problems with the increasing the amount of HCS and hospital waste water. However, with the EMP and mitigation solutions if they are well implemented as mentioned in Section 4 of this reports the project impacts is minimum and controllable. Some of the key points of the successful implementation of the project EMP on HCWM are the following: 7.1 Increase training, wide spreading, practicing HCWM based on QD43/2007 of MoH and other legal regulations.

To develop the guidelines of HCWM at North Central Provinces and organize training course, updating newer document of waste separation, collection and disposal. Updating environmental standards, documents, guideline on HCWM at NCP are included, popularizing the legal documents and policies at the HCWM training course. To carry out the training course of HCWM and practicing the discharging medical waste and safety working for each Infectious Control Team/Department, to choice the key factor of district general hospital to increase the practicing skill and local self-monitoring. 7.2 Building HCWM plan and environmental impact mitigation

(Detail information in plan for medical waste management and pollution mitigation) 7.3 Increase the proper monitoring at the province, increase human ability of HCWM assessment for Medical Service.

Increase the assessment capacity on HCWM for Provincial Department of Health and related authorities as well as to open training course on HCWM to , the directors or the leaders of district general hospital, specific officers in charge of medical waste management. These training courses are belonging to the responsibility of Department of disease treatment- Health Ministry. They have to ensure to implement it. 7.4 Increase equipment and tools for medical waste collection and disposal

The separation tools, collection tools and suitable equipment for personal safety protection are planed to provide to district general hospital by hospital budgets or support from project based on the optimum selection equipment/tools to district general hospitals

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7.5 Increase testing suitable equipment for medical waste treatment; operating, collecting experiment from operation and management.

Increasing testing, evaluating the existing and new design equipment, increasing assessment of suitable technologies for medical waste treatment based on the monitoring, the investment cost, reparation cost, operation cost as well as environmental standard are important works in the project’s timetable. It will create the information and data to all medical units when they has to make the decision on which kind of waste treatment facilities to be selected for the DGH or DPC in the project areas. 7.6 Step by step creating specific financial source for HCWM (solid waste and waste water treatment and management) In the project area and scale, the hospitals need to coordinate with related district or provincial authorities concerning to environmental inspection such as the provincial Department of Health, Department of Natural Resource and Environment to get the guidance and proposals to have the appropriate budget from the provincial level as well as to unity the method for management, operation of Healthcare waste treatment based on environmental standards and the regulations.

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References 1. Project document, 2004 2. Statistics Healthcare Year Book 2001 3. Hospital Waste Management in the Philippines - Two Case studies in Metro Manila’ UWEP Case Study Report. 4. Lessons from India in Solid Waste Management’ WEDC, Loughborough, UK 5. Regulation on HCSW management, Ministry of Health, 1999 6. Guideline on HCSW Management Practices, Ministry of Health, 2000 7. Thai N., T .,K., Proposed measures to treat medical waste in Hanoi. Hospital Waste Management – Workshop Proceeding, 6/1998 8. Chi N., K., Evaluation of implementation of Regulation on Healthcare Waste Management of Ministry of Health. Report of the Nation Project on Master Plan on Health care solid waste management. 5/2002 9. State of Environmental Status 2002, Ministry of Natural Resources and Environment. 10. Thuy Tran Thu et all (1998), Result the survey on Healthcare solid waste in 24 hospitals, Ministry of Health, Joint project between Ministry of Health & World Health Organization, 5/1998 11. Thuy Tran Thu et all (1998), Result of the survey on Healthcare solid waste in 80 hospitals, Ministry of Health - Joint project between Ministry of Health & World Health Organization, 5/1998 12. Chi N., K., Healthcare Waste Management survey in Phu Tho Province, May-2003 13. Chi N.,K., Healthcare Waste Management for HIV/AIDS prevention control in Vietnam, World bank project, 2005. 14 Project document, 2009. 15. Statistics Healthcare Year Book 2001 16 Hospital Waste Management in the Philippines - Two Case studies in Metro Manila' UWEP Case Study Report. 17. Lessons from India in Solid Waste Management' WEDC, Loughborough, UK 18. Chi N., K., Evaluation of implementation of Regulation on Healthcare Waste Management of Ministry of Health. Report of the Nation Project on Master Plan on Health care solid waste management. 5/2002 19. State of Environmental Status 2002, Ministry of Natural Resources and Environment. 20. Chi N., K., Healthcare Waste Management survey in Phu Tho Province, May-2003 21. Chi N.,K., Healthcare Waste Management for HIV/AIDS prevention control in Vietnam, World bank project, 2005.

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APPENDIX 1. SOCIAL- ECONOMY INFORMATION OF 6 NCP THANH HOA PROVINCE Thanh Hoa has got area of 11.136 km2, population of 3,7 million people, there are 27 districts and 634 communes; from Thanh Hoa centrel area to Muong Lat district is 300km, there are 12 mountainous districts, 7 districts in the list of 62 poorest districts. Appendix 1. Table 1. Social-economy status of project districts in Thanh Hoa province. Area Populate Density Total Medical Sickbe Medical District (km2) (person) (per/m2) communes units ds staff Muong Lat 808,7 30.784 38 8 10 83 44 Quan Hoa 996,5 43549 44 18 21 220 76 Ba Thuoc 777,2 103.189 133 23 26 225 128 Quan Son 931,1 34.311 37 12 15 165 44 Lang Chanh 586,3 45.702 78 11 13 180 78 Cam Thuy 424,1 112.484 265 20 23 205 130 Thuong Xuan 1105,1 88.369 80 20 24 203 116 Hau Loc 143,6 187.766 1.308 27 65 288 130 Nhu Xuan 717,4 60.648 85 18 21 191 96 (Source: Static general directorate, social economy date of 671 districts/urban district, tows, city, 2006) NGHE AN PROVINCE Nghe An province is one has got the biggest area of central north area, with natural area of 16448,45km2 , population of 3122405 people. There are 20 administrative units of district, city and tows, 481 units of communes. In which, there are 10 mountainous districts (244 mountainous communes). From Vinh city to the fairest district like Ky Son is 300km, Que Phong is 250km. Table 2. Social- economy status of project districts Medical Population, Medical District Area km2 people/km2 Communes Beds staff persons units (people) Que Phong 1.895,4 60.398 32 13 16 135 301 Ky Son 2.094,8 63.895 31 21 25 180 118 Tuong Duong 2.806,4 74.313 26 21 26 190 257 Nghia an 737,7 190.580 258 32 35 365 338 Quynh Luu 607,1 358.906 591 43 48 375 276 Yen Thanh 546,9 269.129 492 37 41 387 322 Thanh Chuong 1.127,6 232.812 206 38 45 365 260 Nghi Loc 379,1 216.881 572 34 39 330 255 Nam an 293,9 158.872 541 24 28 226 208 (Source: Statistical general directorate, social economy date of 671 districts/urban district, tows, city, 2006) HA TINH PROVINCE There is natural area of 6.055,7 km2 , population of 1.227.554 people(population survey on April, 1, 2009), and account for 1.7% of national population. Population density is 203 persons/km2. The main ethnic groups are Kinh and Chut people, there are about some thousands of people living in the mountainous area. Ha Tinh province has got one small city,

-74- Healthcare waste management plan - Central North Region Health Support Project one town and 10 districts, 262 communes, and small town with 4 districts and 1 town locate in the mountainous area. Ha Tinh province has got the complicated terrain, difficult transportation, mostly mountainous area. The low economy, and Ha T nh is one of the poorest province of Vietnam. Main economy structure is agriculture- forestry and seafood (42.5%), industrial and constructive sectors just gain 21.5%. Infrastructure does not develop, total output revenue just support enough for 25% of input revenue. People living is still difficult, the average earning is the lowest in the central –north provinces.

Appendix1. Table 3. Social- economy status of project districts Medic Populat Total al Area peopl Medical Sickb Distri District ion, commune staff km2 e/km2 units eds ct persons s (peopl e) Nghi 220 99.478 452 Kinh 19 22 225 316 Xuan Huong 1101 127.830 116 Kinh 32 35 280 347 Son uc 203 117.930 581 Kinh 28 30 300 304 Tho Cam 636 154.562 243 Kinh 27 30 275 355 Xuyen Huong Kinh, 1299 108.010 83 22 26 260 300 Khe Ch t Ky 1.058 170.351 161 Kinh 33 37 315 291 Anh (Source: Static general directorate, social economy date of 671 districts/urban district, tows, city, 2006)

QUANG BINH PROVINCE Quang Binh province has got the natural area of 8065km2. The terrain is narrow and decreasing the high from west to east. 85 percent of natural area total is mountainous land and is strongly separated. Most of the west is High Mountain of 1000 to 1500m, in which Phi Co Pi is the highest of 2017m, next is the low mountain. There is small and narrow delta. The final is the costal sandy area of sickle-shape or fan-shape. Quang Binh terrain is small and narrow, in the tropical are then always impacted by climate of the north and the south, therefore food and storm happen often. According to the survey result on April, 1, 2009, Quang Binh population is 846.924 people, mostly are Kinh people. The ethnic groups are Chut ( includes local groups like Ruc, Sach, May, Arem…) and Bru- Van Kieu (includes local groups like Khua, Ma Lieng, Van Kieu), mainly living at the west communes of Bo Trach district, Quang Ninh district, Le Thuy district and Minh Hoa, Tuyen Hoa mountainous district. There are 7 districts and 159 communes, the poor rate is about 28 percent, is advantage of 139/2008 decision, the vicinity- poor rate is about 24.3 percent.

Appendix 1, Table 4. Social- economy status of project districts

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Medic Popul Total al Area ation, peopl Medical Sickb Distri District commune staff km2 perso e/km2 units eds ct s (peopl ns e) Minh Chut, 1410 43841 31 16 18 128 147 Haa Kinh Tuyen 79.46 Chut, 1149 69 20 23 167 168 Hoa 5 Kinh Kinh, Quang 200.4 612 328 Bru- Van 34 35 337 282 Trach 59 Kieu Bo 172.6 2123 81 Kinh 30 32 260 254 Trach 16 Kinh, Le 144.5 1411 102 Bru- Van 28 29 250 247 Thuy 43 Kieu (Source: Statis general directorate, social economy date of 671 districts/urban district, tows, city, 2006) Quang Tri province

Quang Tri has got area of 4745,7km2, according to survey result on April, 1,2009, they has got 597.985 people. Quang Tri contains 1 city, 1 bit town and 8 districts, 139 communes, the populaton density is 104 people/km2. The main is Kinh people, beside that there are Bru- Van Kieu group, Ta Oi group living in Dakrong, Huong Hoa, Gio Linh and Cam Lo district. Provincipal administrative central is Dong Ha is 598km in the south of Hanoi and 1.112km in the north of Ho Chi Minh. Quang Tri climate is very harsh, hot and dry southwest wind from Lao. Stom season of Quang Tri is from July to November, in which there are most stoms in September and October. Following the analysis date of 98 years, there are 75 storm entering Binh Tri Thien area, averagely 0.8 storm/year, directly impact to Quang Tri, rainfall from each stom is about from 300 to 400mm, even to 1000mm. The poor rate is 16 percent in 2008, the close poor rate is 7.85 percent.

Appendix 1 Table 5. Social- economy status of project districts Medic Popul Total al Area ation, peopl Medical Sickb Distri District commune staff km2 perso e/km2 units eds ct s (peopl ns e) Vinh 90.69 626,4 145 Kinh 22 25 245 178 Linh 5 Gio 76.33 Kinh, Bru 473 161 20 22 136 143 Linh 6 – Vân

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Ki u Bru- Vân Dak 1223, 32.61 27 Ki u, Tà 14 17 77 96 Krong 3 5 Ôi Kinh, Hai 102.2 489,5 209 Bru- Vân 21 24 144 131 Lang 81 Ki u (Source: Statis general directorate, social economy date of 671 districts/urban district, tows, city, 2006)

THUA THIEN HUE Thua Thien Hue is a key province of central area of Vietnam. Thua Thien Hue locates in the life-line of transportation from the north to the south. ( 1A national road, Ho Chi Minh road, national railway) and economy west-east corridor connect Thai Lan, Lao and Vietnam. Hue has the potential of tourism, sipirit and non spirit culture maintenance and protection. Thua Thien Hue has got the natural area of 5053,99km2, 9 districts and 152 communes. It has population of 1087579 people (April, 1, 2009), population density is 215 people/km2. There are many ethnic group includes Co tu, Bru- Van Kieu, Ta oi living in A Luoi, Nam Dung district. About administrative organization, Thua Thien Hue has got 8 districts, 150 communes, and towns.

Thua Thien Hue is normally impacted by natural disaster, flood and strongly destroyed both material and people. Disease prevention and health care after flood are alsway the burden for medical service of Thua Thien Hue province. But, infrastructure, medical equipment are still weakness and shortcoming, health care service quality is still low especially to the mountainous districts. It is also the only province do not have the principal hospital. Appendix 1. Table 6. Social- economy status of project districts Medic Populati Total al Area peopl Medical Sickb Distri District on, commune staff km2 e/km2 units eds ct persons s (peopl e) Phong 953,8 105.134 110 Kinh 16 20 128 146 ien Phu Vang 280,3 180.059 642 Kinh 20 25 170 180 Kinh, Tà Huong Tra 520,9 116.066 223 16 20 148 160 Ôi Phu Loc 728,1 149.875 206 Kinh 18 23 179 179 Hue city 71 321.498 4.529 Kinh 25 43 2404 1990 (Source: Static general directorate, social economy date of 671 districts/urban district, tows, city, 2006)

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APPENDIX 2. INFORMATION OF PROJECT DISTRICTS I. THANH HOA PROVINCE 1. LANG CHANH DISTRICT Lang Chanh has got total natural land of 61.658ha, total population of 51.469 people including some main ethnic groups like Kinh, Thai, and Muong Forrest cover density of Lang Chanh district is 58% in 2001 and 72% in 2006. Poor ratio of the district is 46.77% in 2001 and 27% in 2005. Private secretary: Le Quang Tich, Tel: 3874010 Vice of private secretary: Le Minh Hanh, Tel: 3874010 Chairman: Ha Chi Phan, Tel: 3874518 Vice of chairman: Lê V n C ; Tel: 3874116 Vice of chairman: Ph m Th Thi t; Tel: 3874119

2. NH XUÂN DISTRICT The district has got total natural land of 70.532,80 ha, population total of 63.161 people including some main ethnic groups like Kinh, Thai, Muong and Tho.

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3. MUONG LAT DISTRICT The district has got natural land total of 84.558,03ha, population total of 27.823 people including some main ethnic groups like Kinh, Mong, Dao and Kho Mu.

4. BA THUOC DISTRICT

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The district has got natural land total of 74.740ha, population total of 107.365 people including some main ethnic groups like Kinh, Thai and Muong.

5. QUAN HOA DISTRICT The district has got natural land total of 104.350,89 ha, population of 45.940 people including some main ethnic groups like Kinh, Thai, Muong, and Mong. Private Secretary: Hà M nh Hùng; Tel: 3875027 Vice of Private Secretary: Cao Minh Nguy t; Tel: 3875809 Chairman: L ng V n T ng; Tel: 3875035 Vice of chairman: Cao Anh Tr i; Tel: 3875034 Vice of chairman: L ng Th L ng; Tel: 3875043

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6. QUAN SON DISTRICT The district has got natural land total of 86.528,85ha, population total of 32.519 people including some main ethnic groups like Kinh, Muong, Mong and Thai. Private secretary: Ph m Bá Di m; Tel: 3590020 Vice of private secretary: Hà Chí Nông; Tel: 3590021 Chairman: Lò ình Múi; Tel: 3590016 Vice of chairman: Ph m Phú Hào; Tel: 3590017 Vice of chairman: L ng Th Ngoan; Tel: 3590026

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7. THUONG XUAN DISTRICT The district has got natural land total of 111.040ha, population total of 86.633 people including some main ethnic groups like Thai and Muong. Private Secretary: L c ng Khoa; Tel: 3873040 Vice of private secretary: Xuân Nam; Tel: 3873039 Chairman: Vi Hoài Kham; Tel: 3873036 Vice of chairman: C m Bá Xuân; Tel: 3873555 Vice of chairman: Lang c Bông; Tel: 3873037

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II. NGHE AN PROVINCE 1. TUONG DUONG DISTRICT Tuong Duong is a mountainous district, in the southwest of Nghe An province, 200km far from Vinh city, 90km far from Nam Can border gate, The district has got 280.636,41ha (account of 17% of land total), population total of 75.993 people including 6 ethnic groups like Thai, Mong, Taypoong, O du, Kinh, Kho Mu and others. The average density is 27 people/km2 Medical center are supported and completely equipped, 100 percents of communes has got medical center. Some usual diseases are: diarrhea, dysentery, gynecology, having sore eyes, marsh fever. The district has got 18 communes and 1 town: Hoa Binh town, Tam Quang, Tam ình, Tam Thái, Tam H p, Th ch Giám, Xá L ng, L u Ki n, L ng Minh, H u Khuông, Nhôn Mai, Mai S n, Yên na, Yên T nh, Yên Hòa, Yên Th ng, Nga My, Xiêng My. 2. QUE PHONG DISTRICT Que Phong is a mountainous district of Nghe An province, 180 km far from Vinh city. The district has population of 59000 people, area total of 1.895km2, including some ethnic groups like Thai, Kinh, Kho Mu, H’ Mong and Tho The district has got 14 administrative units: Qu S n, Ti n Phong, N m Gi i, N m Nhoóng, Tri L , Thông Th , Quang Phong, C m Mu n, M ng No c, ng V n, H nh D ch, Châu Thôn, Châu Kim và th tr n Kim S n.

3. KY SON DISTRICT Ky Son district has got area total of 2.095km2, population total of 62.300 people including some main ethnic groups like Thai, Muong, Kho Mu, Mong, Hoa and Kinh. The district has the great potentiality of forest economy development. The district owns 59.000 ha of forest, gains 28% of natural area and there are many valuable flora and fauna here. Scientist discovers 12 family floras including 150 kinds of trees have the high economy value including ironwood, bassia, teak wood. There are more valuable mineral here like coal in Nam Can, Cu in Phuxanbu. 4. NGHIA AN DISTRICT Nghia Dan is a mountainous district of Nghe An, 90km far from Vinh, next to Quynh Lu, Quy Chau,Yen Thanh, Tan Ky, Que Phong and Nghia Dan district, natural area of 75.578ha and population of 129.159 people. Natural source here are very popular. They has got forest source of valuable wood with high volume, forestry lands are 22.203ha (2005). Mineral source are plentiful too, 100-150 million cubic meter of bazan pumice stone, 1 million cubic meter of granite, 6-7 million cubic meter of clay and brick, Viet Thai and Nghia Hieu coal mine. Surface water are supported from Hieu river, Dinh river and more than 50 small rivers and 100 other reservoirs

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5. QUYNH LUU DISTRICT Quynh Lu district is next to Tinh Gia district of Thanh Hoa province in the north, next to Dien Chau and Yen Thanh in the south and southwest. Next to Nghia Dan district in the West, nearby East China Sea in the East. Addiminatrive center is Cau Giat, 50km far from Vinh city. Quynh Luu has natural area of 58.507ha, agriculture area of 15.427ha and population of 345.000 people. The district includes 2 towns and 41 communes. 6. THANH CHUONG DISTRICT Thanh Chuong is a mountainous district of southwest of Nghe An province. It is next to Bolikhamzai province, Lao in the southwest, next to Do Luong and Nam Dan district in the East, next to Anh Son district in the northwest, it is 50km far from Vinh city. The district has got area total of 1128.311km2, population of 252.459 people including some ethnic groups like Kinh, Thai, Mong, Dan Lai living in 40 communes and towns. 7. NAM AN DISTRICT Nam Dan is next to Hung Nguyen and Nghi Loc district in the East, next to Thanh Chuong district in the West, next to Do Luong district in the North and next to Huong Son and Duc Tho in the south. They have got area total of 293.9km2, population total of 159.433 people, only Kinh group living here. Agricultural land of district gains 48%; the others are forestry and pond.

III. HA TINH PROVINCE 1. NGHI XUAN DISTRICT The district is next to Hong Linh town in the West, next to Can Loc and Loc Ha district in the south, next to Cua Lo town and Nghi Loc district in the North, and next to Hung Nguyen district and Vinh city in the Northwest. The district is 310km far from Hanoi city in the south. Nghi Xuan has got area total of 218km2 , population of 100.300 people. Nghi Xuan district includes Xuan Anh town, Nghi Xuan town and other communes: Xuan Hoi, Xuan Truong, Xuan Dan, Xuan Pho, Xuan Hai, Xuan Yen, Tien Dien,Xuan Giang, Xuan My, Xuan Thanh, Xuan Hong, Xuan Vien, Xuan Lam, Xuan Linh, Xuan Lien, Co Dam and Cuong Gian. 2. KY ANH DISTRICT The district has got area total of 1.053 km2, population of 162.100 people, density of 154 people/km2, and there is only King people living here. The district includes Ky Anh town and 31 other communes: Ky Bac, Ky Tien, Ky Xuan, Ky Giang, Ky Phu, Ky Phong, Ky Son, Ky Tay, Ky Hop, Ky Lam, Ky Khang, Ky Van, Ky Lac, Ky Ha, Ky Hung, Ky Hai, Ky Chau, Ky Tan, Ky Hoa, Ky Thu, Ky Tho, Ky Phuong, Ky Loi,

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Ky Lien, Ky Ninh, Ky Dong, Ky Long, Ky Trinh, Ky Thinh, Ky Thuong, Ky Nam, Ky Trung. 3. HUONG SON DISTRICT Huong Son has area total of 950.2km2, population total of 119.240 people, and only Kinh people living here. Main agricultural activities are: deer, buffalo and cattle breeding, planting water rice and farm producer Main forestry activities: forestation, seafood manufacturing Main commerce activates are doing business with Lao through Cau Treo border gate. Tourism and service activities are developing at Nuoc Sot resort of Kim Son commune. 4. HUONG KHE DISTRICT Huong Khe is next to Lao in the West, next to Quang Binh province in the south, Cam Xuyen district and Thach Ha district in the East, next to Vu Quang and Can Loc district in the North. Huong Khe has got area total of 1278.0909km2, population of 107.996 people (2009) includes Tho, Thai, Kinh, Chut ethnic groups, in wich, King people are most popular. There are 22 administrative units including Huong Trach, Phuc Trach, Huong Do, Huong Tra, Huong Lien, Huong Lam, Loc Yen, Huong Xuan, Phu Phong, Huong Vinh, Phu Gia, Huong Long, Gia Pho, Huong Giang, Huong Thuy, Huong Binh, Phuc Dong, Hoa Hai, Ha Linh, Phuong Dien, Phuong My.

IV. QUANG BINH PROVINCE 1. MINH HOA DISTRICT Minh Hoa is a mountainous district in the Northwest of Quang Binh province, next to Lao in the West, next to Tuyen Hoa in the North, next to Bo Trach district in the East and Southeast. King people are popular in Minh Hoa, and Van Kieu people, Chut people live near boder communes.

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Minh Hoa has got area total of 1410km2, population of 45.013 people, 15 communes and one town. Labors work in economy sector are 22.372 people.

Medical center includes 1 hospital, 1 treating disease room and 16 medical centers.

2. TUYEN HOA DISTRICT

Address Group 2 - ong Le town- Tuyen Hoa district

Tell (052) 3684002 Fax: (052) 3684276 Email: [email protected]

Tuyen Hoa district is a mountainous one in the northwest of Quang Binh province; it is next to Huong Khe and Ky Anh district in the north, next to Minh Hoa district and Lao in the west, next to Bo Trach in the south and next to Quang Trach district in the East.

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The district has the population of 80.653 people, area total of 1.149km2, includes 20 town and communes. The producing value of agriculture sector is Vietnam dong million 127.902 The producing value of forestry sector is Vietnam dong million 14.954 3. BO TRACH DISTRICT Bo Trach district has got 24 km of coastal areaa and 40km of borderline between Vietnam and Lao. The district has got the 1A national road, two branh of Ho Chi Minh road, national railway, 15A national road, 2, 2B, 3 and 20 provincial roads, Ka Roong- Noong Ma border gate. Especially, there is national park here: Phong Nha- Ke Bang and tourism seaside resort of Da Nhay.

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The district has the population of 174.984 people, area total of 2.123km2, includes 9 mountainous communes and 2 highland communes. There are 85.755 people working in economy sector. The producing value of agriculture sector are Vietnam dong million 416.104 The producing value of forestry sector are Vietnam dong million 56.637 The producing value of industrial sector are vienamdong million 211.490 There are more than 4.950 business unit of commerce, tourism and hotel. 4. QUANG TRACH DISTRICT

Address Street 1- Ba on town - Quang Trach district

Tell: (052) 3512406

Fax: (052) 3515895 Email: [email protected] Quang Trach district is a big district in the north of Quang Binh province; it is next to Ha Tinh province in the north, next to Bo Trach in the south, next to Tuyen Hoa district in the West, and next to Asia China Sea in the East. Although, Quang Trach is a lowland district but they also have got both forest and sea. The lowland is small but the traffic, river systems are ensured to develop economy. The district has got two main rivers are Giang River and Song Roon river. The district has the area total of 612km2, population of 203.320 people, and includes 34 communes and town.

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The producing value of agriculture sector are Vietnam dong 324.183 The producing value of forestry sector are Vietnam dong 21.231 The industrial produce value in the area are Vietnam dong 624.177 There are more than 3.990 business units in the district. V. QUANG TRI PROVINCE 1. DAKRÔNG DISTRICT Dakrong is highland mountainous district in the southwest of Quang Tri province, are total of 123.332 ha, population of 25.917 people. There are now 34.160 people include Van Kieu people, Pa Ko and Kinh people; and 14 administrative units. It is next to Gio Linh district in the north, next to Thua Thien Hue and Lao in the south, next to Trieu Phong and Hai Lang district in the East and next to Huong Hoa district in the West. Dakrong terrain is higher in the East- Southeast and lower in the West- Northwest. The highest is Kovaladut Mountain with the high of 1251m; the lowest is Ba Long alluvial ground with the high of 25m. The mountain concentrates in the Southeast of the district.

2. GIO LINH DISTRICT Gio Linh is a small district of Quang Tri province; it is next to Vinh Linh district in the north, next to China Asia Sea in the East, next to Dong Ha town, Trieu Phong and Can Lo district in the south and next to Huong Hoa and Dakrong district in the West. This is the south side of 17 parallel which separated Vietnam. The district has the population of 72.100 people and the area total of 473km2. It has got two towns are Gio Linh and Cua Viet town, the others are communes include Gio Chau, Trung Hai, Trung Giang, Trung Son, Gio My, Gio Phong, Gio An, Gio Binh, Gio Hai, Gio Son, Gio Hoa, Linh Hai, Gio Viet, Vinh Truong, Hai Thai, Gio Mai, Gio Quang, Linh Thuong, Gio Thanh, both of them are Kinh people. 1A national road runs along the district. Quang Tri airpot project will be built in Gio Quang commune, in the south of district. 3. HAI LANG DISTRICT Hai Lang district is belonged to Quang Tri province; it is next to China Asia Sea in the East, next to Dakarong district in the West, next to Thua Thien Hue province in the south, next to

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Quang Tri town and Trieu Phong district in the North. It is 20km far from Dong Ha town in the north, 40km far from Thua Thien Hue. Hai Lang district has got area total of 42. 36,8,12 ha, population of 99.429 people, includes 20 administrative units: Hai Lam, Hai An, Hai Ba, Hai Xuan, Hai Quy, Hai Que, Hai Vinh, Hai Phu, Hai Thuong, Hai Duong, Hai Thien, Hai Thanh, Hai Hoa, Hai Tan, Hai Truong, Hai Tho, Hai Son, Hai Chanh, Hai Khe and Hai Lang town. There is My Thuy seaport of USD million 150, make the economy corridor from My Thuy seaport and Lao Bao border gate. 4. VINH LINH DISTRICT The district has the natural area of 620km2, with 91.000 people includes Kinh people and 1000 people of Bru- Van Kieu people. Vinh Linh is an agricultural district; economy sector includes 51% of agriculture, 28% of industrial- small scale industry, and 21% of commercial- tourism. VI. THUA THIEN –HUE PROVINCE 1. PHONG IEN DISTRICT Phong Dien is in the north of Hue city, is surrounded by Bo river and O Lau river. Phong Dien includes 3 kinds of terrain of mountain, hill and lowland with the plentiful natural source. Phong Dien is developing weekly by opened policies and regulation. Phong Dien has got 16 administrative units, includes 1 town and 15 communes: Dien Huong, Dien Mon, Phong Binh, Dien Hoa, Phong Chuong, Phong Hai, Dien Hai, Phong Hoa, Phong Thu, Phong Hien, Phong My, Phong An, Phong Xuan, Phong Son, and Phong Dien town. 2. PHU VANG DISTRICT Phu Vang is coastal lowland district of Thua Thien Hue. It is next to China Asia Sea in the North, next to Huong Tra district in the West, next to Huong Thuy district in the South, and next to Phu Loc district in the East. The district has natural area total of 280,83km2, includes 1 town and 19 communes: Phu Thuan, Phu Duong, Phu Mau, Phu An, Phu Hai, Phu Xuan, Phu Dien, Phu Thanh, Phu Thuong, Phu Ho, Vinh Xuan, Phu Luong, Phu Da, Vinh THanh, Vinh An, Vinh Phu, Vinh Thai, Vinh Ha and Thuan An town. Phu Vang has the potentiality of fishery with the sealine of 35km, Thuan An seaport, beautiful Thuan An seaside resort. There are 49 national road, 10B, 10C, 10A provincial road running along district area. It is very good for transportation and economy development. 3. HUONG TRA DISTRICT Huong Tra is a lowland district of Thua Thien Hue province, it locates in1A national road, is a north gateway of Hue city. In the district area, there are a sea line of 7km, 1A national road of 12km in long is parallel to the North- South railway, and 49A national road of 25km in long connect to coastal communes, 8A, 8B, 4 provincial road, army-economy road. There are also two big rivers: Bo river of 25km in long, Huong river of 20km in long, Tam Giang area of 700ha in width.

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The district has got 16 administrative units includes 1 town and 15 communes: H i D ng, H ng Phong, H ng Toàn, H ng Vân, H ng V n, H ng Vinh, H ng Xuân, H ng Ch , H ng An, H ng H , H ng Th , Bình i n, H ng Ti n, Bình Thành and Tu Ha. 4. PHU LOC DISTRICT Phu Loc is a south district of Thua Thien Hue province, it is next to Huong Thuy in the north, next to Da Nang in the south, next to sea in the East, and next to Nam Dong district in the West. It runs along to 1A national road, national railway. There are 18 administrative units in the district include: Vinh My, Vinh Hung, Vinh Hai, Vinh Giang, Vinh Hien, Loc Bon, Loc Son, Loc Binh, Loc Vinh, Loc An, Loc Dien, Loc Thuy, Loc Tri, Loc Tien, Loc Hoa, Xuan Loc, Phu Loc town and Lang Co town. APENDIX 2. STATUS OF WASTE MANAGEMENT AT DGH/DPC

Survey result at the district hospital Report on medical waste management in the project units. Quang Binh province District general hospital and preventive medical center of Minh Hoa, Tuyen Hoa, Bo Trach, Quang Trach and Le Th y district are on the project areas. Le Thuy, Bo Trach, Quang Trach, Tuyen Hoa district general hospital has got 170, 200 and 70 sickbeds respectfully. Most of the district general hospitals have just equipped waste water treatment station and new incinerators. Waste separation is implemented in most of the district general hospitals and preventive medial centers. Especially, district general hospitals are equipped dustbin, waste collection hand-put at each department followed regulation and color code for medical waste, white dustbin for recycle waste, green-black dustbin for domestic waste and yellow dustbin for infected medical waste. However, most of the hospitals don’t have the medical waste stored area. This waste is stored at the door of the incinerator house. In the project area, district general hospitals will facilitate preventive medical center to treat generally medical waste, as well as they will help to treat the medical waste and sharp material like injection needle weekly. Although, the medical waste at each preventive medical center is just 2-3 kg per week, but the board management of each district should lead and direct the preventive medical center about its treatment. Quang Tri province Quang Tri has got one policlinic of the province and four others in Dakrong, Vinh Linh, Gio Linh and Hai Lang district

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Land of 600m2 for building preventive medical center is available in Dakrong district. Three other preventive medical centers haven’t got the stable head office, working house is temporally rent or lives with hospitals. Three preventive medical predict will build the new head office next to hospital or 600m to 700m far from the hospital. In the standard schedule for preventive medical center, Gio Linh, Vinh Linh, Hai Lang preventive medical center has got 2000m2, 2500m2 and 5790m2 and most of them is placed in the town center or in the main road or in the master plan of the district Most of the preventive medical center has got its technical design, total area draw, methods for water supply and waste water treatment. When investment project improvement is implemented, preventive medical centers need to do the commitment to protect environment, to treat waste water and solid waste. At the provincial policlinic, there are 500 sickbeds has got waste water treatment system and Hoval incinerator of 400kg/batch. The incinerator also received waste from other private medical units, waste separation is good, there is the regular check of water quality and gases from the incinerator with the frequency of 2 times per year. 8 district hospitals has incinerator basically, only Vinh Linh district has got the handicraft. Hospital scale for the district of Quang Tri is from 50 to 80 sickbeds. There are 25 office staffs in Vinh Linh preventive medical center, regular cost is about 1.5 billion per year and about 500 million from national objective program. Medical waste mainly is injection needles, cotton, and the amount is small so that they incinerate 2 times per month. Thanh Hoa province Most of the hospitals in the project area are equipped the incinerator of 25kg/h. Hospital discharges averagely about 30-35kg of clinical waste (200kg to 300kg of domestic waste), incinerators are operated each time for 2 days, minimum cost of 25l petrol per one incineration. (After good separation of medical waste, have to incinerate to reduce the waste volume) Waste separation has to well implement at the source. However, the first decontamination methods have not applied for medical waste disposal at every department except test department. District hospitals discharge averagely 35 to 45 m3 of medical waste water per day. Now, there are not medical waste water treatment systems following the bio-technology- an environmental friendly technology. The waste water treatment now is just applied to ditch or drain after latrine. In the hospital improvement diagram, they propose the treatment method is very simple: just addition of 1 sediment tank and connect drains. Treatment cost is a quite important matter and should discuss among managers of hospitals and manager of medical service. Leader of medical service want hospitals self pay for there waste water treatment or incinerators but most of the hospitals are limited in economy while the income is limited and most of the project units place in the poor are of the province.

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Nghe An province There are 7 district hospitals and one polyclinic and 7 preventive medical centers belong to Nghe An medical service, in the project area. Medical waste separation is implemented in most of the district hospitals. .All incinerators are implemented in about 3 year nearby, District general hospital of Tay Nam doesn’t has the incinerator but infected waste is transported to provincial district general hospital to treat in the Hoval incinerator. In the room of injection or changing the dressing, there is a hard box to store the sharp injection needle, and infected material is separately stored. Infected medical waste is stored nearby the incinerator. Incinerator work 2 to 3 times per day. Cost per working time is from 17 to 25 l of petrol. In Nam Dan hospital, we recognize that incinerator was equipped but not entered working; instead that hospital is still use the handcraft incinerator building by block. Hospitals do not monitor the environment yearly. Cost date for incinerator operation is just repot to medical service in the report of medical waste test and cross test yearly (in the content of medical waste assessment) In other hospitals (Que Phong, Tuong Duong, Nghi Loc), infected medical waste is separated and handcraft incinerated in the landfill site in the hospital area. Waste-dumped pit is uncovered and without the fence. In the regulation, hospital with more than 50 sickbeds have to make environmental assessment report, includes the chapter of environment protection commitment but only hospitals, which are prepared to improve have already got the approved environmental assessment report. The hospitals are Thanh Chuong, Nam Dan, Yen Thanh hospitals but mitigation methods of medical waste are very simple and limited. Other hospitals don’t have the incinerators, they are designing incinerator investment project with the price of Vietnam dong million 300 per incinerator. Most of 9 district hospitals don’t have the medical waste water treatment system. Money for medical waste treatment is from government debenture. Medical waste water treatment system is being invested from Vietnam dong billion 1.4 to 3 depending on the capacity scale and number of sickbed.

Medical waste at preventive medical center of Nam Dan and Thanh Chuong district is normally limited and mainly from the injection needle rooms. Presently, preventive medical centers have got the comprehensive plan of building surface for preventive medical centers. Present environmental protection commitment of Nam Dan preventive medical center do not show clearly the methods of isolation and final treatment of medical waste or present clearly the first disinfection methods from the test department and the new requirement after waste water treatment in latrine. Other preventive medical centers like Thanh Chuong are guided to make the environmental commitment.

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Most of the district general hospitals and preventive medical center have demands of medical solid waste management and infection prevention in the hospital.

Ha Tinh province There are 120, 130, 130, 151 sickbeds in Cam Xuyen, Duc Tho, Ky Anh and Nghi Xuan hospital, Ky Anh hospital will increase the number of sickbed to 250 ones. Preventive medical center of Ky Anh, Huong Son, Huong Khe and Nghi Xuan district receive the support from the project. Most of the medical units implemented source separation and primary disinfection. Infection waste is dumped and incinerated in the hospital area, domestic waste is urban environmental company collected and transported to the dumping site. There is the contract to dump the medical waste tissue with the landfill town. Small tissue like afterbirth is incinerated in the hospital area. Hazardous waste like out of date chemical is also dumped in the hospital area. Most of waste is stored in the nylon bag but they do not follow strictly the legislation of color code. Two popular colors are applied is yellow and green color. Early disinfection of highly infected waste from test department with disinfection chemical is applied popularly in the hospitals and preventive medical center. Medical waste water of DGH is about 50m3 per day and predicted double when district hospital is improved and increases the number of sickbeds. There are 4 districts general hospitals have got the environmental assessment reports and improved investment project for hospital in which medical waste is separated like an investment item. District hospitals are equipped one incinerator of 25kg/h and waste water treatment system. Investment scale for all items of all hospitals in Ha Tinh province is 5 billion vnd but it is about Vietnam dong billion 1 in other province. Most of the waste treatment technologies confirm to satisfy the environmental standard. District medical centers are designed 1.5km far from the hospital and placed in the master plan zone of the district. However, they have not built the general ditches of the town HCWM Hue Hue Medical Service manages 4 provincial general hospitals, 9 district general hospitals, and 4 private units. In the master plan, district preventive medical centers are built next to the district general hospitals, the medical solid waste will be treated to gather at the incinerators, which will be equipped for hospitals. Most of the medical waste and waste water of the hospitals are treated at the location with thee simplest method. There is only Hue center general hospital has got the waste water treatment system and is equipped HOVAL incinerators with capacity of 400kg per batch. Now, this hospital received medical solid waste from two nearby preventive medical centers for waste incinerating.

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Waste separation at source is reported that it was not completed. Besides, preliminarily disinfection work has not been reminded and strictly implemented following Decision QD43/2007. At district general hospital, medical solid waste is generated in the brick and handicraft incinerator, worker pouring petrol then burning and smoldering for some hours later. Therefore nearby people complain about the black ash. Domestic waste is collected daily by urban environmental company Most of the district hospitals don’t have the waste water treatment system, the present ditch systems are damageable, toilet were built temporally and over used then be downgraded And there are not treatment methods following the normal methods for latrine. In the hospital improved project, Huong Tra, Phong Dien, Phu Vang and Phu Loc also propose and be accepted to construct the small scale incinerator with the investment cost of Vietnam dong million 300. However, because of capital lack, then there are only two hospitals are equipped incinerators in the next time. Waste water treatment systems for all hospital districts were proposed but it is just designed like the simple sediment tank to save money for other building items. There is not general plan for drainage in hospital as well as in preventive medical center and the entire town doesn’t have the general plan for drainage.

Appendix 3: Results of HCWM evaluated based on questionnaires

Appendix 3. Table 1. General information of district general hospital and medical waste generation Hue Code Nghe An Code PHONG DIEN DGH A1 PHU LOC DGH-HUE A2 QUE PHONG DGH A18 HUONG TRA A3 TUONG DUONG A19 PHU VANG A4 KY SON A20 HUE DGH- HUE A5 NGHI LOC DGH A21 Quang Tri THANH CHUONG DGH A22 DAKRONG A6 NAM DAN DGH A23 HAI LANG DGH A7 YEN THANH DGH A24 GIO LINH A8 POLICLINIC SOUTH WEST A25 PGH QUANG TRI A9 Thanh Hoa Quang Binh A10 LANG CHANH DGH A26 TUYEN HOA DGH A11 THUONG XUAN DGH A27 BO TRACH DGH A12 NGOC LAC A28 MINH HOA A13 TINH GIA A29 MUONG LAT A30 Ha Tinh NHU XUAN A31 CAM XUYEN A14 HOANG HOA A32 DUC THO A15 A33 KY ANH A16 QUAN SON A34 NGHI XUAN A17 Ba thuoc A35

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PL3, Table 3: Healthcare services and HCWM No Gas Domes Total No of No of No of No of No of Total Sharp Che cont tic solid Full Name of actual inpatient outpa consulta surgery No of HzHCSW items mic Radio aine s.waste waste Incinerato Hospital beds s tients tions acts Bed Oc staff (kg/d) A B C D als Actives r (kg/d) (kg/d) r? 1 Hue 2 PHONG DIEN 60 62 50 20 3 103.33 30 15 4 15 30 Y 3 PHU LOC 85 67 27 181 2.26 146.3 100 2.1 0.5 1 0.1 0.5 10 12.1 N 4 HUONG TRA 70 N 5 PHU VANG 70 144 7 533 3 130 84 15 3.8 40 55 Y HUE 80 C 6 Quang Tri 7 DAKRONG 50 40 36 80 1 80 59 5 1.5 1.5 1 1 55 60 Y 8 HAI LANG 100 101 10 123 1.5 101 107 13 2 91 104 Y 9 GIO LINH Y QUANG TRI 500 415 9 429 10 83 354 105 5 95 2 3 1800 1905 2010 Y 10 Quang Binh 11 TUYEN HOA 70 144 7 533 3 130 84 15 3.8 40 55 Y 12 BO TRACH 160 162 22 334 4 101.25 153 31.84 6.7 250 281.8 Y MINH HOA 75 144 7 533 3 125 84 16.5 3.8 58 74.5 Y Ha Tinh 13 CAM XUYEN 120 129 156 250 1.2 130 125 14.5 4 4.5 1 2 1.5 1 0.5 75 89.5 N 14 DUC THO 120 78 340 340 2.1 120 165 30.5 9 19 0.5 2 0.5 0.3 125 155.5 N 15 KY ANH 120 190 410 450 2 124.5 146 50 15 25 5 10 5 135 185 N 16 NGHI XUAN 100 148 178 182 1.2 151 118 23.5 8.4 9.6 0.4 4.2 0.6 48.8 72.3 N 17 QUE PHONG 85 72.288 150 104.73 1.3123 111 87 11.5 3.5 3.4 1.5 0.6 0.5 1 1 145 156.5 N 18 TUONG DUONG 75 78 N 19 KY SON 90 75 130 150 1 104 94 15 2.5 9.5 0.5 2 0.5 45 60 Y 20 NGHI LOC 135 140 2 131 4 103.7 181 35 3.8 100 135 N 21 THANH CHUONG 140 130 0 182 0.7 92.857 141 25 7.1 200 225 Y

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22 NAM DAN DH 80 80 320 1.5 100 102 36 3 18 10 5 200 236 Y 23 YEN THANH 135 145 18 0 107.41 181 32 4.2 120 152 Y 24 POLICLINIC Y 25 LANG CHANH 80 80 5 90 2 100 88 150 150 Y THUONG 26 XUAN 90 108 133 152 2.5 109 101 4.6 0.3 0.5 0.5 3 0.3 0.4 150 154.6 Y 27 NGOC LAC 400 217 Y 28 TINH GIA 300 Y 29 MUONG LAT 150 Y 30 NHU XUAN 80 89 105 145 2 110 122 30 90 120 Y 31 HOANG HOA 200 Y Projected beds 3820 QUAN SON 50 5.1 BA THUOC 100 13 Y QUAN HOA 70 12.5 8.7 3.5 0.3 35 47.5 N

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Apendix2, Table 3: Code of activities on HCSWM questionnaires

Code Content Method Method C1 Hazardous medical waste is separated from source domestic waste C9 Waster stored area C2 Sharp material is collected and separated C9,1 Waste stored area within roof C2,1 Color box following regulation C9,2 Waste stored area within surrounded wall C2,2 Plastic bottle C9,3 Waste stored area within lock and door C2,3 Container, beer can C9,4 Separate hazardous medical waste from domestic waste C2,4 Carton C9,5 There is material to clean hand such as soap C2,5 Others C10,1 Bring waste to the general dumping site C3 Use nylon to collect waste C10,2 Dumping waste in the hospital area C4,1 Clinical waste stored in the yellow nylon C10,3 General incinerating waste in the incinerator for hospital groups C4,2 Radioactive waste stored in the black nylon C10,4 Burning waste at the hospitals C4,3 Chemical waste stored in the black nylon C10,5 Burning waste at the handicraft C4,4 Gas container or pressure container stored in the blue nylon C10,6 Burning waste outdoor C4,5 Domestic waste stored in the blue nylon C10,7 Others C5,1 Plastic dustbin C11 Plastic and glass sell for recycler C5,2 Wastebasket C11,1 Drip feed bottle , kg/month C5,3 Carton box C11,2 Drip feed line, kg/month C5,4 Others C11,3 Old injection needle , kg/month C6 Use color code for waste stored dustbin following MoH C11,4 Glass bottle, kg/month C7,1 Trolley C11,5 Others, kg/month C7,2 Plastic bucket within wheel C11,6 Decontamination or not C7,3 Others D1 D1, guideline, management regulation C8 Treating infected waste D2 D2, Building detail process: separation, collection, transportation from source E1,1 E1,1 Discarding solid waste at the dumping site D3 D3, Creating the collection, transportation and treatment groups E1,2 E,1,2 Discarding solid waste at the hospital land D4 D4, Number of staff in charge of solid waste treatment E1,3 E,1,3 Discarding solid waste in the incinerator of other hospital D5 D5. Staffs are trained regulation, solid waste process E1,4 E,1,4 Disarding solid waste at the waste incinerating enterprise D6 D6, Hiring other company to transport/ disposal of solid waste. E1,5 E,1,5 Discarding SW in incinerator places at the hospital E2,6 Secondary gas jet E1,6 E,1,6 Waste outside burning E2,7 Temperature of the incinerator E1,7 E,1,7 Others E2,8 Hospital burning waste for other hospital too, or not E2 Incinerator places in the hospital land E2,9 It work well now or not E2,1 Two combustion chamber incinerator E2,10 Installed time E2,2 One combustion chamber incinerator E2,11 Working Frequency per week E2,3 Reverted furnace E3 E3, fuel consuming E2,4 Trade mark, E2,5: Capacity F F Cost for waste management per month

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Apendix 2, Table 4, survey result on solid waste management status at the hospital C1 C2 C2,1 C2,2 C2,3 C2,4 C2,5 C3 C4,1 C4,2 C4,3 C4,4 C4,5 C5,1 C5,2 C5,3 C5,4 C6 A1 1 1 1 0 0 0 0 1 1 1 x X 1 1 0 0 0 1 A6 1 1 x X X x x 1 1 1 1 1 1 1 0 0 0 1 A8 1 1 1 0 0 0 0 1 1 1 1 X 1 1 0 0 0 1 A10 1 1 x X x x x 1 1 x x X 1 1 0 0 0 1 A14 1 1 1 0 0 0 0 1 1 1 1 1 1 1 1 0 0 1 A16 1 1 1 1 1 1 0 1 1 1 1 1 1 0 0 0 1 A17 1 1 1 1 0 0 0 1 1 1 1 1 1 1 0 0 0 1 A18 1 1 0 1 0 0 0 1 0 1 1 1 0 1 1 0 0 1 A22 1 1 1 0 0 0 0 1 1 x x X 1 1 0 0 0 1 A23 1 1 1 0 0 0 0 1 1 x x X 1 1 0 0 0 1 A26 1 1 1 0 0 0 0 1 1 1 x X 1 1 0 0 0 1 A33 1 1 1 1 1 1 0 1 1 No No No 1 1 1 0 0 1 A35 1 1 1 0 0 0 0 0 0 1 0 X x bin 1 0 0 x 1 13 13 10 4 2 2 0 12 11 9 6 4 11 12 4 0 0 12 0 0 0 1 7 9 9 11 1 2 0 1 0 1 0 9 13 13 0 %,1 100 100 77 31 15 15 0 92 85 69 46 31 85 92 31 0 0 92 %,0 0 0 7,7 54 69 69 85 7,7 15 0 7,7 0 7,7 0 69 100 100 0 %, no answer 0 0 15 15 15 15 15 0 0 31 46 69 7,7 7,7 0 0 0 7,7

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Appendix 2, Table 5, Survey result on solid waste management status at the hospital C7,1 C7,2 C7,3 C8 Method C9 C9,1 C9,2 C9,3 C9,4 C9,5 C10,1 C10,2 C10,3 C10,4 C10,5 C10,6 C10,7 A1 1 1 1 Decontamination 1 1 1 1 1 0 0 0 0 1 0 0 A6 0 1 0 1 Decontamination 1 1 1 1 1 1 0 0 0 1 0 0 0 A8 1 0 0 1 Decontamination 1 1 1 0 1 0 0 0 0 0 1 0 0 A10 1 0 0 1 Decontamination 1 1 0 0 1 1 0 0 0 1 0 0 0 A14 1 0 0 1 Decontamination 1 1 1 1 1 1 0 0 0 0 0 1 0 Plastic A16 1 0 bin 1 Chloramines 1 0 1 0 1 1 0 1 0 0 0 0 0 A17 1 0 0 1 Decontamination 1 x x x x 1 0 1 0 0 0 1 0 Hand A18 0 0 bin 1 0 0 0 0 1 0 0 1 0 0 A22 1 0 0 xx 0 0 0 0 0 0 x x x A23 1 0 0 1 Decontamination 0 0 1 1 1 1 0 1 0 0 0 0 0 A26 1 0 0 1 soak with antiseptic 1 1 1 1 1 0 0 1 0 1 0 0 0 A33 0 1 0 1 Decontamination 1 0 0 0 1 1 0 0 0 1 0 1 0 A35 1 0 0 1 Decontamination 0 1 1 1 1 1 0 1 0 1 0 1 0 1 10 3 0 12 9 7 8 6 10 8 0 6 0 5 3 4 0 0 3 10 10 0 4 5 4 5 1 3 12 6 12 7 9 8 12 %,1 77 23 0 92 69 54 62 46 77 0 46 0 38 23 31 0 %,0 23 77 77 0 31 38 31 38 7,7 23 92 46 92 54 69 62 92 %,NA 0 0 23 7,7 0 7,7 7,7 15 15 7,7 7,7 7,7 7,7 7,7 7,7 7,7

Appednix 3, Table 6. Survey result on solid waste management status at the hospital

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C11,1 C11,2 C11,3 C11,4 C11,5 C11,6 D1 D2 D3 D4 D5 D6 A1 1 1 6 35 1 1 A6 1 1 1 5 56 1 A8 1 0 0 0 x 0 1 1 1 4 69 0 A10 15 x x x x 0 1 x 1 4 5, 100% 0 A14 x x x x x x 1, 1 1 14 14 1 A16 1 1 1 12 x 0 A17 1 1 0 14 72 1 A18 52 1,8 21 36 0 x 1 1 1 8 45, 54% 0 A23 x x x x x 1 1 1 6 4 0 A26 x x x x x x 0 0 0 4 0 0 A33 1 1 0 4 0 0 Glass bottle, syringe A35 7kg/ month 5kg/month 1kg/month 4 kg/month 33kg/month 1 1 1 1 8 7/8;87,5% 0 1 1 10 10 8 0 4 0 2 1 1 3 0 8 %,1 7,7 77 77 62 0 31 %,0 15 7,7 7,7 23 0 62 %, No answer 77 15 15 15 100 7,7

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Appendix 3, Table 7. Survey result of solid waste management status at the hospitals E1,1 E1,2 E1,3 E1,4 E1,5 E1,6 E1,7 E2 E2,1 E2,2 E2,3 E2,4 A1 0 0 0 0 1 0 0 1 0 1 0 A6 1 0 0 0 1 0 0 1 0 1 0 Handicraft Be transfered by MSF A8 0 0 0 0 1 0 0 1 0 1 0 model A10 0 0 0 0 1 0 0 1 1 0 0 HOVAL-MZ4 A14 0 1 0 0 0 1 1 0 x x x A16 0 1 0 0 0 0 0 x x x x X A17 0 1 0 1 0 1 0 0 A18 0 1 0 0 1 0 0 1 0 1 0 Handicraft by concrete A23 0 1 1 0 1 1 0 1 1 0 0 A26 0 1 0 0 1 0 0 1 1 0 0 BDF-LDR10i A33 0 1 0 0 1 1 0 0 0 1 0 X A35 0 1 0 0 1 0 0 1 0 1 0 BDF-LDR 10i,15i 1 1 8 1 1 9 4 1 8 3 6 0 0 11 4 11 11 3 8 11 3 6 3 9 %,1 7,7 62 7,7 7,7 69 31 7,7 62 23 46 0 %,0 85 31 85 85 23 62 85 23 46 23 69 %,Ko TL 7,7 7,7 7,7 7,7 7,7 7,7 7,7 15 31 31 31

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Appendix 3, Table 8. Survey result on solid waste managemetn status at hospitals E2,5 E2,6 E2,7 E2,8 E2,9 E2,10 E2,11 A1 3kg/ day 1/9/1997 3 l n/tu n A6 100kg/day 0 x 0 x 9/1999 x A8 100kg/day 0 500o C 0 x 12/1999 A10 400 kg/day x 850-1200 1 1 20/11/2008 3 times/ week A16 X x x x x x X A18 X 0 0 x X A23 1 A26 10kg/time 1 x 0 x 3/2007 4

A33 X X x 0 1 2009 1 times/ week

A35 5kg/day X 1100o C 0 1 2/2008 2 times/ week

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Appendix 3, Table 9. E3 F A1 30l diezel/ month, 20kg coal ash/ month 15l petroleum/month, 10kg lime/ month, 150 kg coal ash/ month to Vnd 500,000 of consuming equipment, transportation, vnd 200,000 of gas/ petroleum; A6 the duping site vnd100,000 of sanitation cost for environmental company Vnd 10,000,000 of salary , vnd 1000,000 of transportation and consuming equipment; vnd 1,500,000 of electricity; vnd 100,000 of petroleum ;vnd vnd 150,000 for hiring A8 5 l petroleum/month environmental company Vnd 2,331,000 of salary; vnd 3,600,000 of transportation and consuming equipment; vnd 50,000 of electricity money; vnd 16,000,000 gas/ petroleum;vnd 4,995,000 of sanitation A10 60 kg coal ash/ month cost for environmental companying, total money of vnd 26,976,000 100kg of coal ash/ month, white smoke, vnd 1500000 of labor cost ,vnd 1800,000 of transportation and consuming equipment; vnd 1,950,000 of consuming gas or petroleum; A18 150 l petroleum/ month total money of vnd 5,250,000 Vnd 12,000,000 of salary ,vnd900,000 of labor cost, vnd 1000,000 of electricity cost; vnd A26 130 l petroleum/month 2000,000 of petroleum; total cost of vnd 15,900,000 A33 10 l petroleum / month Vnd 600,000 of salary / month 96l petroleum/ month, use three- 12,5kg generated waste/month, disposal at the waste treatment area of the hospital, there is A35 phase current white smoke

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WASTE WATER OF THE HOSPITAL Appendix 3, table 10 code for contents Code Contents 1 source, m3/day 2 There is the rainy drainages, surface water and underground water or not. 3 Waste water is treated or not 4 What is the applied technology 5 Hypochlorite decontamination or not 6 Chloramines decontamination or not 7 Decontamination by lime or not 8 Decontamination by ozone or not 9 Other decontamination 10 Testing the waste water quality electricity, KW/day Treatment cost of medical waste water system salary/month Chemical/month

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Appendix 3, Table 11, Survey result on waste water management at the hospitals 1 2 3 4 5 6 7 A1 5 0 0 0 X x x A6 10 1 1 Bio-treatment 0 1 0 A8 9 1 x Bio-treatment 0 1 0 Waste water station built by concrete and steel rod, between sink and float (pressure pump + A10 200 1 1 self-running) 0 1 1 A14 30 1 1 Decontamination 0 1 1 A16 30 0 0 0 0 1 1 A17 1 1 Collect to the latrine 0 1 0 A18 15 0 x Discharge to the hospital’s pond 0 1 1 A22 35 0 A23 20 1 0 0 0 1 1 A26 15 1 0 0 x x x A33 5 1 x decontamination, deposition 0 0 0 A35 x 0 1 8 4 0 8 5 0 TB 3 4 9 1 4 1,% 34 61,54 30,77 0 61,54 38,46 0,% 23,08 30,77 69,23 7,69 30,77 No answer 15,38 38,46 30,77 30,77 30,77

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Appedix 3, Table 12. Survey result on waste water management at the hospitals 8 9 10 electricity, KW/day salary/month Chemical/Month A1 x x 0 A6 0 0 0 2 100000 85000 A8 0 0 1 4,5 425000 A10 1 0 1 50 2469000 600000 A14 0 0 0 A16 0 0 0 x A17 0 0 0 x A18 0 0 0 x A23 0 0 0 Vnd 10 million / month A26 x x 0 X A33 0 prerepsep, 2h 0 X A35 1 1 0 2 0 8 8 9 %,1 7,69 0 15,4 %,0 61,5 61,5 69,2 %, KTL 30,8 38,5 15,4

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PREVENTIVE MEDICAL CE.TER Appendix 3. Table 13. General information of the preventive medical center beds Number Testing Domestic Trained No DPC area Population Density Departments 2010 of staff times HCSW waste Cost staff (km2) (people) Person/day Kg/day kg/day Vnd/month 1 Hau Loc 143,6 187,8 1308 5 departments, 2 rooms 36 50 5 10 1000000 30 2 Thuong Xuan 1105,1 88,37 80 5 departments, 2 rooms 20 33 32,88 5 10 Budget to collect, treat 0 3 Nh Xuân 717,4 60,65 85 5 departments, 1room 40 0,5 3 200000d/ month 4 C m Th y 424,1 112,5 265 5 departments, 2 rooms 35 16 2 6 20000000d/year 44 5 Quan S n 931,1 34,31 37 5 departments, 2 rooms 28 4 2 5 300000 0 6 Quan Hoa 996,5 43549 44 5 departments, 1 room 31 56 8 15 X 0 7 Le Thuy 1411 144,5 102 5 departments, 2 rooms 36 82 5 30 DGH subsidizes DPC 30 epidemic, food safety, 8 Huong Khe 1299 108 83 productive health 20 33 15 25 400000 0 9 Que Phong 1895,4 60,4 32 3 department, 1 room 34 3151 1 1 33333 0 10 Phong Dien 953,8 105,1 110 Emer. deapartemnt 60 89 15 30 2000000 35 11 Gio Linh 473 76,34 161 No Lab 12 Vinh Linh 626,4 90,7 145 No Lab 13 Tuyen Hoa 19 34 14 Bo Trach 2123 172,6 81 15 30-35 15 Ky Anh 17 31 35 3 8 0 16 Nghi Xuan 220 99,48 452 30 40 37 3 15 3 17 Huong Son 1101 127,8 116 20 28 35 1 10 15 18 Nam Dan 293,9 158,9 541 14 35 30 2 11 10 19 Thanh Chuong 1127,6 232,8 206 22 40 50 2 18 25 20 Tuong Duong 2806,4 74,31 26 7Departs. 32/38 5 10 1000000 0 21 Lang Chánh 586,3 45,7 78 7 departments, rooms 90 beds 40 43 Provincial budget 0 22 Bá Th c 777,2 103,2 133 7Dept. 35 79,3 5 10 HCSWM materials 0 23 Phu Loc 728,1 149,9 206 7Departs. 85beds 100 180 10 30 2000000 0 Thuong Xuan: có các phòng khoa g m: phòng hành chính t ng h p, phòng truy n thông và giáo d c s c kh e, khoa ki m soát d ch b nh HIV/AIDS, khoa y t công c ng, khoa v sinh an toàn th c ph m, khoa ch m sóc s c kh e sinh s n, khoa xét nghi m,

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Appendix 3, table 14. Information on solid waste management at the preventive medical center 3.6 Is 3.2 there 2.4.2 3.1 Collection medical 2.1 2.2.1 2.2.2 2.3 2.4.1 HzSW Medical stored 3.3. 3.4 3.5 Is staff MSW is Discharge Discharge Sharp Hazardous discharges waste bin, Medical Person in there impacted Traning of separated in the fixedly to material is to the separation dustbin waste is charge of local rule by MS Preventive at source yellow other is separately dumping follows by burning in waste for MW medical management medical center or not nilon waste separated stored site regulation regulation incinerator collection collection waste or not H u L c 1 1 0 1 1 0 1 1 1 1 1 0 1 Thuong Xuan 1 1 0 1 0 1 1 1 x 0 1 1 0 Nh Xuân 1 1 0 1 1 0 1 1 1 1 1 0 x C m Th y 1 1 0 1 1 x 1 1 1 1 1 0 1 Quan S n 0 0 1 1 0 1 0 0 0 0 1 0 0 Quan Hóa 1 1 1 1 0 1 1 0 0 0 1 1 0 Le Thuy 1 1 0 1 0 1 1 1 1 1 0 1 Huong Khe x x 0 1 x 0 1 x 0 1 1 0 0 Que Phong 1 1 0 1 0 1 1 1 0 0 0 0 0 T ngd ng 1 1 0 1 0 1 1 0 0 1 1 0 Phong i n 1 0 1 1 0 1 1 1 1 1 1 0 1 Gio Linh 0 1 0 1 1 1 1 1 1 1 1 0 1 Vinh Linh 1 0 0 1 0 0 1 1 1 1 0 0 1 Tuyen Hoa 1 1 0 1 1 0 1 1 1 1 1 0 1 Bo Trach 1 1 0 1 0 0 1 1 0 0 1 1 1 Ky Anh 1 1 0 1 0 1 0 0 0 0 1 1 0 Nghi Xuan 1 1 0 1 0 1 1 0 1 1 1 1 0 Huong Son 1 0 1 1 1 1 1 0 1 0 1 1 0 Nam Dan 1 1 0 1 1 1 1 1 0 0 1 0 0 ThanhCh ng 1 0 0 1 0 1 1 1 0 1 1 0 0 T ngD ng 1 1 0 1 0 1 1 0 0 1 1 1 0 Lang Chánh 1 1 0 1 1 0 1 1 1 1 1 0 0 Bá Th c 1 1 0 1 1 0 1 1 0 1 1 0 0 Phu Loc 1 1 0 1 x 0 1 1 t TC 1 0 0

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Appendix 3. Table 15. Synthetic result of MSMS at preventive medical centers.

2.4.2 3.6 Is Hazardou 3.2 there s waste 3.1 Collection 3.3. medical 2.1 2.2.1 2.2.2 2.3 2.4.1 discharges Medical bag, Medical 3.4 Is there 3.5 Is staff MSW is Discharge Discharge Sharp Hazardou to the waste stored bin, waste is person in there impacted separated in the mixed to material s is general separation dustbin burning in charge of local rule by Preventive at source yellow other is separately dumping follows follow the waste for MW medical Training medical center or not nilon waste separated stored site regulation regulation incinerator collection collection waste HCWM? Implemented 8,33 20,83 83,33 0,00 54,17 37,50 8,33 29,17 45,83 33,33 8,33 66,67 62,50 rate, % Note implemented 87,50 75,00 16,67 100,00 37,50 54,17 87,50 66,67 50,00 62,50 91,67 29,17 33,33 rate, % No answer 4,17 4,17 0,00 0,00 8,33 8,33 4,17 4,17 4,17 4,17 0,00 4,17 4,17 rate, %

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Appendix 3. Table 16. Petition of HCWM at preventive medical centers. preventive medical centers Petition Nh Xuân Invest medical incinerator, training for staff who manages medical waste The preventive medical center do not relate to the DPC, no land acquisition. C m Th y Having WWT and incinerator at DGH Quan S n To be built the waste water system Quan Hóa Supported the suitable waste treatment, built the incinerator Huong Khe Need financial support for training staff in charge of HCSM Ky Anh HCWM to be trained Nghi Xuan HCWM to be trained Huong Son To be trained Nam Dan To be trained Thanh Chuong To be trained Tuong Duong Supported cost for management and treating waste of center. Project board management should support technical assistance for project Bá Th c preparation. To be trained. To be supported incinerator. Phu Loc HCWM to be trained

Appendix 4. Information of new buiding area and improved areas of preventive medical centers. Appendix 4: Table 1. Information on preventive medical center and medical waste treatment DPC Building scale and location SW treatment WW treatment Thanh Hoá Nh xuân Next to the district hospital DH’s incinerator Basically building Quan Hoa Next to the district hospital DH’s incinerator Basically building Quan Son Next to the district hospital DH’s incinerator Basically building Cam Thuy Next to the district hospital DH’s incinerator Basically building Ba Thuoc Next to the district hospital DH’s incinerator Basically building Thuong Xuan Next to the district hospital DH’s incinerator Basically building

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Muong Lat Next to the district hospital DH’s incinerator Basically building H u L c Next to the district hospital DH’s incinerator Basically building Nghe An Que Phong Building in area of 1000m2 of DGH Decontaminaztion+safe dumping Basically building Tuong Duong Building in area of 2000m2 of DGH Decontamization + safe dumping Basically building Ky Son Building in area of 1000m2 of DGH, next to DH DH’s incinerator Basically building Nghia Dan Building in area of 1200m2 of DGH Decontamization + safe dumping Basically building Quynh Luu Building in area of 1500m2 of DGH DH’s incinerator Basically building Thanh Chuong Building in area of 4500m2 of DGH DH’s incinerator Basically building Nam Dan Next to the district hospital DH’s incinerator Basically building Basically building Ha Tinh Nghi Xuan 3000m2 of new land , 2km far from DGH. Decontamization + safe dumping Basically building 3000m2 of new land in district’s master plan, 1km Decontamization + safe dumping Basically building Huong Son far from DGH. Huong Khe There is area in the town’s master plan Decontamization + safe dumping Basically building Ky Anh 3700m2 in the master plan of DH Decontamization + safe dumping Basically building Quang Binh Minh Hoa (TBB) It doen’t need to built DH’s incinerator Basically building - L Thu DH’s incinerator Basically building (XDCB) 3000m2 in the town’ master plan, 0.8km far from DH’s incinerator Basically building Tuyen Hoa (TB) the DH Bo Trach They have already had the suitable land DH’s incinerator Basically building Quang Trach DH’s incinerator Basically building Quang Tri Krông They have already had the suitable land Gio Linh 2000m2 of new land in the district’s master plan, Decontamization + safe dumping Basically building 1 5km far from the district hospital

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1.5km far from the district hospital. 5790m2 of new land in the district’s master plan, Decontamization + safe dumping Basically building Hai Lang 1.5km far from DGH. 3500m2 of new land in the district’s master plan, Decontamization + safe dumping Basically building Vinh Linh 1.5km far from DGH. Hue Phong Dien Decontamization + safe dumping Basically building Phu Vang Decontamization + safe dumping Basically building Huong Tra DH’s incinerator Basically building Phu Loc Decontamization + safe dumping Basically building

Note: Disinfection testing waste C, B and sanitation dumping. Sharp material, injection needles: separate the sharp part or not then concretion, the plastic material after separating out the sharp part can disinfect by broiling water, chemical disinfection then bring to the recycle. Basically building: Temparary disinfection of blood solution, solution. Treatment in the latrine, or biotreatment: trickling filter.

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Appendix 4. Table 2. Information of DH in the project districts. DH WW treatment SW treatment Thanh Hoá Nh Xuân Had got project treated MWW District’s incinerator Hoàng Hóa Had got project treated MWW District’s incinerator Ng c L c Had got project treated MWW District’s incinerator T nh Gia Had got project treated MWW District’s incinerator Lang Chánh Had got project treated MWW District’s incinerator Thuong Xuan Had got project treated MWW District’s incinerator Muong Lat Had got project treated MWW District’s incinerator

Nghe An Que Phong Decontamination + safe dumping Tuong Duong Decontamination + safe dumping Ky Son Decontamination + safe dumping Nghi Loc Yen Thanh WW treatment station DH’s incinerator Thanh Chuong WW treatment station DH’s incinerator Nam Dan WW treatment station DH’s incinerator PKDK Tây Nam XDCB DH’s incinerator Ha Tinh Nghi Xuan Had got project treated MWW Decontamination + safe dumping Duc Tho Had got project treated MWW Decontamination + safe dumping Cam Xuyen Had got project treated MWW Decontamination + safe dumping

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Ky Anh Had got project treated MWW Decontamination + safe dumping Quang Binh Minh Hoa WW treatment station DGH incinerator Tuyen Hoa WW treatment station DH’s incinerator

Bo Trach WW treatment station DH’s incinerator Quang Tri Krong Had got project treated MWW Decontamization + safe dumping Gio Linh Had got project treated MWW Decontamization + safe dumping Hai Lang Had got project treated MWW Decontamization + safe dumping Quang Tri provincipal Had got project treated MWW Decontamization + safe dumping general hospital Hue Phong Dien Had got project treated MWW Decontamination + safe dumping Phu Vang Had got project treated MWW Decontamination + safe dumping Huong Tra Had got project treated MWW DH’s incinerator Phu Loc Had got project treated MWW Decontamination + safe dumping TP, Hue Had got project treated MWW DH’s incinerator

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

Appendix 5: Picture of Guiding of separation and treatment of needs and syringes

Guiding of separation and treatment of needs and syringes

Report on “Building up the plan for HCWM and treatment” 117 HCWM Plan:“Healthcare for the Poor in 7 Northern Mountainous Provinces”

Appendix 6: List of organization and Individuals participated in HCWM Plan

STT Name Organisation Time n v n c 1. ¤. Nguy General Department of Environment T9/2009 TS. Hoàng Minh o Kh c Hi u 2. ThS V Center for Technological Transfer- T9/2009 ThS Nguy n Lê Nam GDE 3. T.S. Lª Hoµng Lan Hanoi Urenco T9/2009 Th.S. L ng Mai H ng 4. ¤. Hoµng §¹i TuÊn Vietnam Academy of Science & 8/2009 T.S. Ph¹m Hång H¶i Technology 5. T.S. Lª V¨n C¸t Institute of Chemistry, VAST 8/2009 T.S. NguyÔn Mai Ph­¬ng TS. Tr nh V n Tuyên 6. Institute of Environmental T8/2009 TS. Phan Hùng Technology, VAST TS. Nguy n Th Hu T.S, NguyÔn Anh TuÊn National of Hygiene and Epidemic T8/2009 7. 8. BQL d án 6t nh BTB 6 Vice Director of Department of T8/2009 Health Institute of Polytechnique 9. T.S. §Æng Kim Chi 8/2009

Appendix 7: Picture report at from the practical observation 1. QUANG BINH PROVINCE

Incinerator- Bo Trach district polyclinic. Waste water container- Bo Trach district polyclinic

Waste water treatment station - Bo Trach district Preventive medical center of Tuyen Hoa district polyclinic

Report on “Building up the plan for HCWM and treatment” 118 HCWM Plan:“Healthcare for the Poor in 7 Northern Mountainous Provinces”

Waste water treatment station (100m3/day and night)- Incinerator (5kg/h), Tuyen Hoa district polyclinic Tuyen Hoa DGH

Medical separation at source of Tuyen Hoa district All kinds of dustbin followed the color code legislation polyclinic

2. QUANG TRI PROVINCE

Quang Tri provincial polyclinic Preventive medical center of Vinh Linh district

Visiting the area, where will build the new preventive There are many perennial trees in the area, where will build medical center of Gio Linh district the new preventive medical center of Vinh Linh district, is provided by Vinh Linh district polyclinic because the polyclinic landuse is now overcrowded.

3. THANH HOA PROVINCE

4. NGH AN PROVINCE

Report on “Building up the plan for HCWM and treatment” 119 HCWM Plan:“Healthcare for the Poor in 7 Northern Mountainous Provinces”

Working with polyclinic and preventive medical center Working with director of Yen Thanh hospital of Nam Dan district

Injection room of Nam Dan district polyclinic. The Waste dumped site of Nam Dan district polyclinic source separation is not very good but can be accepted.

Dumped site of afterbirth- Nam Dan district polyclinic Bathroom- Nam Dan district polyclinic

Black ash at handicraft incinerator Nam Dan DGH. VHI-18B incinerator- Nam Dan district polyclinic. They normally used this incinerator instead of VHI-18B

Report on “Building up the plan for HCWM and treatment” 120 HCWM Plan:“Healthcare for the Poor in 7 Northern Mountainous Provinces”

Incinerator of polycinic and preventive medical center Water supply system- Nam Dan district polyclinic of Thanh Chuong district. It located very very far from the hospital are.

Medical equippment-stored room of Thanh Chuong Working with polyclinic and preventive medical center district polyclinic. of Thanh Chuong district

Incinerator of Yen Thanh district polyclinic. New works Old and damageable water supply system- Yen Thanh, are building surrounding the incinerator. be improved to have enough water

5. HA TINH PROVINCE

Path to the area of new preventive medical center of Preventive medical center of Cam Xuyen district. Ky Anh district

Report on “Building up the plan for HCWM and treatment” 121 HCWM Plan:“Healthcare for the Poor in 7 Northern Mountainous Provinces”

Preventive medical center of Duc Tho district. They Preventive medical center of Huong Son district. The are going to build the new waste water treatment new preventive medical center will build in the planed station area of the district

Working in with the boad management of Nghi Xuan Working at Ha Tinh medical service preventive medical center

Annex 8: Environmental standards and related documents

Report on “Building up the plan for HCWM and treatment” 122 HCWM Plan:“Healthcare for the Poor in 7 Northern Mountainous Provinces”

Report on “Building up the plan for HCWM and treatment” 123