WP/2008IDHP/IO Report series number: RS/2008/GEIl7(MOG)
English only
REPORT WORKSHOP ON HEALTH CARE WASTE MANAGEMENT PLANNING AND IMPLEMENTATION
Convened by: World Health Organization Regional Office for the Western Pacific
Ulaanbaatar, Mongolia 6-8 May 2008
Not for sale Printed and distributed by: World Health Organization Regional Office for the Western Pacific Manila, Philippines June 2008
WHO/WPRO LIBRARY
MANILA. PlULlPl'lNES
2 7 APR 2009
NOTE The views expressed in this report are those of the participants in the Workshop on Health Care Waste Management: Planning and Implementation, and do not necessarily reflect the polIcIes of the World Health Organization.
This report has been prepared by the World Health Organization Regional Office for the Western Pacific for governments of Member States in the Region and for those who participated in the Workshop on Health Care Waste Management: Planning and Implementation, which was held in Ulaanbaatar, Mongolia, from 6 to 8 May 2008.
SUMMARY
The Workshop on Health Care Waste Management: Planning and Implementation was conducted in Ulaanbaatar, Mongolia, from 6 to 8 May 2008 by the World Health Organization Regional Office for the Western Pacific. The objectives of the workshop were: (1) to review the progress of the participating countries towards development and implementation of national policies and plans for integrated management of health care waste; (2) to learn about WHO tools and technical guidelines on health care waste management planning and costing; and (3) to formulate country-specific national action plans for health care waste management and identify actions needed to establish or strengthen implementation of national action plans for health care waste management. The workshop was attended by 32 participants, including 17 representatives from Cambodia, the Lao People's Democratic Republic, Mongolia and Viet Nam; two resource persons, six observers and seven WHO staff members representing Headquarters, the Regional Office for the Western Pacific and various country officers. The proceedings comprised presentation of country reports by participants and working papers by the WHO expert and staff members summarizing the situation in each country with respect to health care waste management and relevant programmes and activities undertaken by countries and WHO. An overview of policy for mercury in health care was presented by an expert from WHO Headquarters. A presentation was made by the temporary adviser from Viet Nam on the Global Environment Facility (GEF) project related to mercury management. Two field trips were conducted to the National Centre for Communicable Diseases in Ulaanbaatar and a health care station in a rural area. The participants conducted a group discussion session, setting up an outline of a national action plan for health care waste management for each country. The workshop participants arrived at the following conclusions: (I)
National policy and plans for integrated management of health care waste • Legislation and policy frameworks are not in place in most countries and should be considered urgent priorities. All countries are requested to take appropriate measures to finalize their national HCWM policies, strategies and plans by the end of 2008. The national plans should address short-, medium- and long-term actions, and should be based on detailed assessment and cost estimation measures. After finalization of national action plans for HCWM, governments should support provinces in developing and implementing provincial HCWM action plans.
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HCWM needs to be integrated within the broader context of safety, quality of medical care and infection control. Donor-driven technologies should be avoided. Selection and choice of technologies should be strongly directed towards the objective of protecting the environment and the health of medical staff and the community. Health care facility practices for segregation, collection, transportation, storage, treatment and disposal of health care waste need to be standardized. All health care facilities should focus on waste minimization and risk reduction. All collection of health care wastes, from public to private hospitals, needs to be improved.
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WHO tools and guidelines on health care waste management planning and costing
WHO tools and guidelines on HCWM planning and costing playa very important role in helping participating countries for the following reasons: • A national action plan for HCWM needs to be developed based on assessment of the current situation using the rapid assessment tool recommended by WHO. Financing is a fundamental issue. Government funding for sound health care waste management is inadequate at the moment. National governments should create an effective funding mechanism and increase funding. National and local governments should allocate adequate budget funds for operation and maintenance of equipment. It is indicated that 1%-2% of the total health care budget should be allocated to
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HCWM. • The tools introduced in the workshop should be applied to develop and finalize national action plans. Other tools also need to be developed to monitor and evaluate implementation of the plans.
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Future actions An appropriate national action plan for integrated HCWM should be developed and finalized in each country. In the process of implementation of the approved national action plan, common treatment facilities for treatment and disposal of health care waste from city and rural health care facilities should be promoted. Health care waste incineration should be replaced by non-bum technologies to prevent dioxin and furan emissions. Health care facilities should investigate the potential options for recycling of non-hazardous waste. Participation of the private sector in HCWM needs to be promoted. Biomedical engineers/technicians need to be recruited for proper equipment maintenance and training of technicians/operators. As recommended at the international meeting on HCWM held in WHO Headquarters in June 2007, countries should take measures to mobilize additional resources for HCWM (refer to the conference papers).
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All countries should encourage capacity-building of health care staff. HCWM should be integrated into university and college curricula, and use made of the distance-learning certificate programmes already available. Education and networking should be encouraged. Pilot projects on sound HCWM need to be carried out. Lessons learnt from the pilot tests should be disseminated within and among countries. The use of mercury-free devices in health care facilities should be promoted. Mercury-containing waste has to be stored in a temporary safe storage area until appropriate disposal technology is available. Further support is required from WHO and other stakeholders, such as the GA VI Alliance, Health Care Without Harm, and IGNOU, among others.
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TABLE OF CONTENTS
I.
INTRODUCTION 1.1 1.2. 1.3. 1.4 1.5 1.6 Background ... ...... ............ .................................. ........................................ ........ Objectives ................................................ ...................... ..... ............................... Participants .................. ........ ............................ ................................. .......... ....... Organization ...................................................... ......................................... ....... Opening remarks ............................ ............................... .................................... Appointment of Chairperson, Vice-Chairperson and Rapporteur .................... 1 1 I 2 2 3 3
2.
PROCEEDINGS ................................... ................................................................... 2.1 2.2 2.3 2.4 2.5
Country reports .... .......... ..... .................................................................. ............. 3 Summary of presentations ..................... ..................................................... ....... 4 Field trips ....... .................................. .................................................................. 6 Summary of working group reports ................................................................... 7 Plenary discussion on national action plans .................................................... 11 ................................................................................................... 11 1I 12 12
3.
CONCLUSIONS 3.1
National policies and plans for integrated management of health care waste .......... ....... ........ ............................. .......................... .............. 3.2 WHO tools and guidelines on health care waste management planning and costing ................ ............................. ................ ............. ........ ...... 3.3 Future actions ........... ............................... ........ .................................. .............. ANNEXES: ANNEX I ANNEX 2 ANNEX 3 ANNEX 4 LIST OF PARTICIPANTS, TEMPORARY ADVISERS, OBSERVERSIREPRESENTATIVES AND SECRETARIAT WORKSHOP PROGRAMME LIST OF DOCUMENTS DISTRIBUTED SUMMARY OF COlJNTRY REPORTS
Keywords Medical waste disposal/waste managementlMongolia
I. INTRODUCTION
1.1
Background
Health care activities can generate significant amounts of infectious waste and toxic materials, such as mercury and expired phannaceuticals, as well as large amounts of general waste. If not managed safely, health care waste has the potential to cause serious hann. In many developing countries with limited resources, management of waste generated within large health care facilities and immunization programmes presents a challenge. Working in partnership, WHO and the GAVI Alliance have supported national authorities in developing national integrated health care waste management (HCWM) plans in several countries in the Western Pacific Region that are eligible for GAVI support. The holistic management of heath care waste is an essential component for the preventive health system and should include delegation of responsibilities, capacity-building, workplace health and safety, waste minimization and segregation, and adoption of safe and environmentally sustainable technologies. To improve the development and implementation of national plans for integrated health care waste management, and to stimulate and support countries' efforts towards finalizing and adopting such plans, it was proposed that a workshop on health care waste management be convened for Cambodia, the Lao People's Democratic, Mongolia and Viet Nam. 1.2. Objectives The obj ectives of the workshop were: (I) to review the progress of the participating countries towards development and implementation of national policies and plans for integrated management of health care waste; (2) to learn about WHO tools and technical guidelines on health care waste management planning and costing; and (3) to formulate country-specific national action plans for health care waste management and identify actions needed to establish or strengthen implementation of national action plans for health care waste management.
1.3.
Participants
The workshop was attended by 32 participants, including 17 country representatives from Cambodia, the Lao People's Democratic Republic, Mongolia and Viet Nam; two resource persons; six observers; and seven WHO staff members representing Headquarters, the Regional Office for the Western Pacific and various country offices. The list of participants is provided in Annex I.
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1.4
Organization
The workshop programme is provided in Annex 2, and a list of documents distributed during the workshop in Annex 3. The documents include country reports on the.~CWM situation, WHO publications and other materials on various aspects ofHCWM, InjectIon safety and mercury in health care, and capacity building and training from the WHO expert and temporary advisers. Copies of these papers can be obtained upon request from the WHO Regional Office for the Western Pacific. The proceedings comprised presentation of country reports by participants and working papers by WHO expert and staff members summarizing the situation in each country with respect to health care waste management and relevant programmes and activities undertaken. An overview of policy for mercury in health care was presented by an expert from WHO Headquarters. A presentation was made by the temporary adviser from Viet Nam on the Global Environment Facility (GEF) project related to mercury management. Two field trips were conducted to the National Centre for Communicable Diseases in Ulaanbaatar and a health care station in a rural area. Based on the discussions, participants prepared outlines of country-specific national action plans to strengthen HCWM programmes in their respective countries, as well as workshop conclusions and suggestions for future actions. 1.5 Opening remarks
On behalf of Dr Shigeru Omi, WHO Regional Director for the Western Pacific, Mr Robert Hagan, WHO Representative in Mongolia, delivered the opening speech. Mr Hagan mentioned that health care waste is a by-product of health care activities and includes sharps, such as syringes, needles and blades; non-sharps, such as swabs and bandages; blood and body parts; chemicals, such as mercury, solvents and disinfectants; pharmaceuticals; and radioactive materials. If these materials are not handled properly, they can pose risks of infection, toxic effects and injuries to health care personnel, waste handlers and the community, and may also cause damage to the environment. In addition, poor management of health care waste contributes to a significant portion of the burden of disease worldwide. Health care waste management is considered an integral part of health care, since creating harm through inadequate waste management reduces the overall benefits of health care. Policies and plans need to be developed to establish an effective system to cover the generation of waste, waste treatment and disposal, the training of all involved, increasing awareness, and the selection of safe, efficient and environmentally friendly options for the management of health care waste. In 1993, WHO started supporting a number ofHCWM activities in the Western Pacific Region, such as the development of technical guidelines and a training programme in Malaysia. This was followed, in December 1994, by the first regional workshop on clinical waste management, convened by WHO. Since then, WHO has supported the development of comprehensive national HCWM programmes in several developing countries in the Region, most notably the countries represented in the workshop (Cambodia, the Lao People's Democratic Republic, Mongolia and Viet Nam), as well as other countries of the Region (Papua New Guinea, the Philippines and many of the Pacific island countries and areas). Since 2006, WHO has cooperated with the GAVI Alliance to support the preparation of national integrated HCWM plans in countries that are eligible for GAVI support. Draft national plans have been prepared in most ofthose countries and a concerted effort is needed now to
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finalize the plans and secure their adoption by the national governments. The national plans will serve as a framework for continued support to countries by WHO and GA VI in the future. Mr Robert Hagan closed his opening speech with an expectation that, after the three-day workshop, with a good combination of presentations, group discussions and field trips to hospitals in Mongolia, all participants would corne up with valuable recommendations for national action plans for integrated HCWM in their respective countries. Ms I.Tsolmon, Vice-Minister of Health, Mongolia, welcomed the participants warmly and encouraged them to learn from each other during the workshop. She also mentioned that HCWM was an issue challenging environmental health in many developing countries, including Mongolia. It was considered a good opportunity for Mongolia to organize the workshop on HCWM, since the country has been supporting environmentally friendly HCWM that helps to protect medical personnel and the population from the risks associated with health care waste, as well as supporting global activities to decrease hazardous gas emissions and protect people from the health effects caused by global climate change. At present, Mongolia is developing its strategy and national action plan in line with global HCWM trends and recommendations from international organizations. Ms Tsolmon also emphasized that the approval of US$ 400 000 from the state budget for development of the central treatment facility in Ulaanbaatar was an important step forward. In spite of these efforts, however, more needs to be done to help improve HCWM at the provincial, district and commune levels. 1.6 Appointment of Chairperson, Vice-Chairperson and Rapporteur
Workshop officers were selected. Dr Ts. Bujin, Director for Health Policy and Planning Division, Ministry of Health, Mongolia was elected Chairperson, Professor Koum Kanal, Director for the National Maternal and Child Health Centre, Mongolia, as Vice-Chairperson, and Mr Nguyen Trong Khoa, Medical Office for the Department of Therapy, Ministry of Health, Viet Nam, as Rapporteur for the meeting. 2. PROCEEDINGS
2.1
Country reports
Participants from the four countries attending the workshop, Cambodia, the Lao People's Democratic Republic, Mongolia and Viet Nam, presented their country reports. These presentations covered problems associated with improper management of health care waste, current HCWM practices, national programmes on HCWM and constraints being faced. Some presentations also described successes and lessons learnt, as well as future plans for HCWM. The issue of replacing incineration by other alternative technologies was raised by some countries. The problems reported included insufficient segregation of waste due to the lack of a colour-coding system for health care waste collection and treatment; treatment of infectious waste by inappropriate and poorly operated and maintained incinerators, causing gas emission issues, and the disposal of the remains in open dumps; open burning and pit burying of health care waste in some countries, especially in rural areas; and reuse and overloading of sharps containers.
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National action plans for HCWM have not been developed fully in the four participating countries due to various constraints and problems, including: a lack of specific provisions for health care waste management in national policy and legislation related to public health and solid waste management; a lack of HCWM plans and programmes at all levels; the absence of HCWM monitoring and assessment systems; a lack of disposal facilities and inefficient existing facilities; health care staff and personnel who are poorly trained in the area of waste management; and a lack of human and financial resources. A summary of the country reports is provided in Annex 4. 2.2 2.2.1 Summary of presentations Rapid assessment tool
Mr Yves Chartier, Public Health Engineer for Water, Sanitation and Health, WHO Headquarters, gave a presentation on the rapid assessment tool, which was created to help provide an overall picture of the HCWM situation prevailing within a country at all levels (ministerial down to small health care facility). It enables users to assess management, training, regulatory, technical and financial issues, and its analysis should help pinpoint critical issues that need to be addressed within the framework of a national action plan. The rapid assessment tool was introduced to be used at different levels with a number of tools, mainly questionnaires, to collect data from associations, nongovernmental organizations (NGO), universities or other institutes, or from the personnel of health care facilities. 2.2.2 Guidance for development and implementation of a national action plan
Mr Chartier also introduced and explained the objectives of the guidance document that is part of the overall WHO strategy aimed at reducing the disease burden caused by poor HCWM through the promotion of best practices and the development of safety standards. This document provides guidance for assessment and analysis of the HCWM situation at the national level to facilitate drafting of a national action plan, with the aim of improving the overall HCWM system in the country. It is important to set priorities for action through a national action plan in order to tackle the most sensitive problems related to HCWM (e.g. disposal of sharps or expired drugs) and to present these actions as part of a more global framework. In addition, ways should be identified for financing ofHCWM by proposing parts of the national action plan to donor agencies. Users of the guidance document may include national policy-makers in charge of developing, implementing and evaluating HCWM plans at the national level; international organizations; institutions or donor agencies involved in the HCWM sector; municipals planners; or health care professionals. 2.2.3 WHO costing tools
Mr Chartier introduced the WHO costing tools that aim to facilitate the estimation of costs and annual budgets related HCWM. Various approaches are used, including calculations based on key indicative values, costing done at facility and national levels, and an equivalent annual-cost method. The four tools include: the Costing Assessment Tool (CAT), the Expanded Costing Assessment Tool for low-income countries (ECA T -L), the Expanded Costing Assessment Tool for Middle-income countries (ECAT-M) and the Expanded Costing Assessment Tool for high-income countries (ECAT -H). In general, the ECATs differentiate between low-, middle- and high-income countries, cover a wide size range of health care facilities and allow several treatment options. The ECATs allow for centralized and decentralized treatment, and can also compute potential revenues from the sale of sterilized plastic parts for re-melting. Some sample ECA T results were presented.
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2.2.4
Overview on mercury in health care
Mr Chartier provided an overview of mercury issues, starting with a case of mercury poisoning. Afterwards, sources of mercury were introduced, with an emphasis on mercury released from medical activities, products and instruments; waste treatment such as waste incineration, cremation, landfills; and recycling and storage. The awareness of participants on the risk of mercury exposure was raised when the fate of mercury and the symptoms and signs of mercury exposure, as well as the way people may be affected, were presented. Mr Chartier also mentioned the role of WHO in pointing out concerns about environmental health in the WHO policy with regards to mercury in health care, which is based on short-, medium- and long-term strategies.
2.2.5
Global environment facility (GEF) project
Mr Nguyen ThanhYen, Officer for Pollution Control Division of the Viet Nam Protection Agency, Ministry of Natural Resources and Environment, gave a presentation on the GEF project, with a geographical scope covering many countries, including Argentina, India, Latvia, Lebanon, the Philippines, Senegal, Tanzania and Viet Nam. This project, with a total budget of US$ 23 870892, will be implemented by the United Nations Development Programme (UNDP) over four years starting from 2008. The executing agency will be the United Nations Office of Project Services (UNOPS), and the principle cooperating agencies will be WHO and Health Care Without Harm. The Ministry of Natural Resources and Environment (Vietnam Environment Protection Agency) works as the Vietnamese executing agency, in cooperation with the Ministry of Health.
Results of a survey on mercury released from health care waste facilities were shown. An estimate of dioxin/furan release from health care waste incineration and photographs illustrating survey activities were also presented. Mr Yen concluded that health care waste incineration should be replaced by proper, non-burning technologies to prevent dioxin/furan release (particularly in Viet Nam, where incineration used to be considered the best technology for health care waste disposal). In addition, feasible good HCWM with alternative, non-mercury equipment is the best practice for preventing mercury release from the health care sector. It is expected that, once finished, the full-scale GEF project will provide a comprehensive set of replicable solutions for all countries in terms of management and technology, as well as policy and education/training, by demonstrating a series of models in a wide range of geological and cultural contexts.
2.2.6
Capacity building for health care waste management
Dr Ashok Agarwal, School of Health Sciences, Indira Gandhi National Open University (IGNOU), spoke on capacity building for health care waste management. Pressing issues related to health care waste, such as the negative impacts of health care waste on human health, and the current situation and practice of improper waste handling, treatment and disposal, were reviewed in the presentation as a firm basis for the development of the IGNOU certificate programme. IGNOU is the largest university in the world, with a presence in 35 countries and 1.5 million enrolled students. Through its system of satellite interactive learning centres, the University carries out capacity-building for distance-education institutions in Africa, the Caribbean, Central Asia, China and India, and offers 125 programmes, including distance learning on HCWM.
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The objectives of the HCWM programme in IGNOU are to sensitize learners about health care waste and its impacts on health and the environment; to acquaint learners with existing legislation, knowledge and practices regarding HCWM in the countries of the WHO South-East Asia Region; and to equip learners with the skills to manage health care waste effectively and safely. A programme package and design, as well as feedback mechanisms, were presented. The first results for 2006-2007 were mentioned, including the launch of the first course in January 2006, with a total of 3 50 students. A new batch of students started in January 2008 and functional study centres in Bangladesh, Bhutan, India, Indonesia, Maldives, Nepal and Sri Lanka are planned for 2008. More IGNOU Study Centres will be opened in India and other countries of the WHO South-East Asia Region, with 1000 students projected by mid-2008, and the scope of the course will be broadened to cover patient safety and health system development by 2009. An evaluation on the impact will be carried out by the WHO Regional Office for South-East Asia (SEARO) in early 2008. Dr Argarwal requested the GA VI Alliance and WHO to support the dissemination of this programme to other regions. 2.3 2.3.1 Field trips Field trip to a central hospital
A field trip to visit the National Centre for Communicable Diseases (NCCD) was organized, where a representative presented current NCCD waste management practices. There is a six-person Infection Control Committee, established by the General Director of NCCD. A diagram showing the HCWM system at the Centre was introduced to the participants. The Centre is running an incinerator with a capacity to incinerate 50 kilograms of health care waste at !OOO ·C within two hours. Waste generation is approximately 200 kilograms per day, or 1000 -1200 kilograms per week. Outstanding issues were mentioned, including the fact that the incinerator has not been renovated since commencement, and that the health care waste load being incinerated has increased by 3-4 times. There is an insufficient supply of safety boxes and inadequate occupational safety. Air pollution is also a problem due to poor servicing of the filter. Participants rated the enthusiasm and excellent waste management practices in the hospital very highly, especially in the context of limited funding sources. Most of the participants recommended that the old existing incinerator be upgraded. They observed that the hospital is still facing problems with incineration, emission cleaning and disposal of expired vaccines. Several participants expressed concern about operational costs and the lack of state funding for HCWM. The Vice-Director of the hospital mentioned a plan to improve HCWM; further guidance and support from WHO are needed to improve the situation. During the discussion, it was mentioned that the category of waste collection area (rural or urban) needs to be taken into account and that the hospital needs to use better and more environmentally friendly incinerators. Other participants expressed the view that syringes could be disposed of safely and properly without incineration. One of the points highlighted in the discussions was that lessons learnt from Cambodia should be disseminated because community awareness needs to be raised about the harmful effects of health care waste and there needs to be proper collection of hazardous health care waste before incineration.
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2.3.2
Field trip to a rural health care facility
A field trip to visit Erdene soum hospital of Tuv aimag was organized. Dr D. Badamkhand, Chief of Erdene Hospital, briefly introduced and provided infonnation about the hospital and its activities. The hospital was built in 1981 and serves 3600 people. The facility has 15 beds, receiving around 380 patients per year. There is a total of24 staff, including two doctors. Main activities include immunization, preventive medical check-ups and deliveries. There are different sources of waste, including that from inpatients, immunization activities and infection control. Segregation is done using colour-coded plastic bags, and there is a separate area for storage of waste. There is a pit for placentas and vaccine residues. A small incinerator is used to bum sharps, syringes and other infectious wastes. The main waste source is drinking water from the soum well, which is supplied to the hospital twice a week by water trucks. Hand-washing facilities are available, with a proper hand-washing procedure. One good sign noted by participants is that a deep burial pit is in place. Medical workers put only placentas into the pit. It is possible that this pit could be modernized by lining it with cement to prevent ground water contamination. Some participants argued that it is not necessary to line the pit in such a remote area, but most agreed that, ideally, the pit should be lined. It was pointed out that sharps management is always a big problem. After disinfection by 1% sodium hypochlorite, sharps can be placed in the pit. The ideal method is encapsulation. It was pointed out that the incinerator used in this hospital has a very simple form, using paper and plastic as fuel sources. A rudimentary incinerator can be one option for a rural area, but better fuel should be used for more efficient combustion. In any case, gas emissions should be better controlled.
The limited water supply raised concern among some participants. In certain weather conditions, the hospital has no stable water supply. Since water is key to quality medical services and safe HCWM, the health care facility needed to become independent as regards water supply by building several water wells. According to observations by the participants, the soum hospital was clean and well organized, indicating that waste management was being carried out well. Some participants considered this an important demonstration of commitment and a good baseline. However, the water supply and sanitation conditions need to be improved with some additional investment, and waste segregation at the point of generation is very important. In addition, more attention needs to be given to training of medical staff. Most participants considered their visit to the rural health care facility as useful, although the HCWM situation is not as good as it should be. A lack of guidelines on HCWM was also observed. 2.4 2.4.1 Summarv of working group reports Cambodia
The Cambodia team presented the results of their group discussion as ideas for a national action plan with a vision of reducing human health and environmental risks related to HCWM based on the following strategies: • to reduce the risk of harm to patients, staff, visitors, the general public and environment immediately, and beyond the boundaries ofthe facility;
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to improve coordination within and between ministries; to improve information, education and communication (IEC) activities for communities; and to ensure proper management of health care wastes.
A national action plan (2008-2010) was presented as follows: No. 1 2 3 4 Activity Endorsement of HCWM regulations by Ministry of Health National Consultative Workshop on HCWM Strategic Plan Strengthening of HCWM network at PHD and OD level Finalization of the strategic plan Dissemination of HCWM regulations Endorsement of infection-control guidelines Dissemination of infection-control guidelines Installation of proper incinerators at every OD (770Ds) Pilot testing ofHCWM in Phnom Penh municipality Proper implementation of the HCWM (at PHDs & ODs) I-Waste minimization 2- Risk management 3-Education and networking Monitoring and evaluation Time-frame 3rd trimester 2008 22nd May 2008 22nd May 2008 Jun 2008 4th trimester 2008 December 2008 I sf trimester 2009 2008-2010 From 2009 2008-2010
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2.4.2
Lao People's Democratic Republic
The team from the Lao People's Democratic Republic presented the results of their working group discussion on setting up a draft national action plan. The following challenges were pointed out: • Most of the funding agencies require the Government to put up matching resources for HCWM to be implemented. The financial contribution from the Government is very limited. Hospitals are not willing to pay user fees. One of the major challenges in coordinating with donors is the limitation of coordinating mechanisms between the implementing agencies and donors (each donor has a different strategy). Capacity-building in HCWM is limited (NGO-supported). There is no legislation for HCWM.
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The available technology is obsolete. There is no common treatment facility. Segregation, transportation, disinfection, colour-coding and treatment of health care waste are poor. Staff knowledge on waste management is poor.
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Expectations and suggestions: • A draft policy and strategy, and a national action plan, are expected to be developed soon. Coordination between government agencies, and multisectoral agencies and organizations should be increased. There should be advocacy for greater involvement of the Chief Executive Officers, Presidents, Human Resource Development Officers, Managers, company physicians and health care providers, and other top officials of companies to get them interested in the HCWM cause.
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Viet Nam
The Viet Nam team started its presentation on the results of their group discussion by briefly reviewing the current HCWM situation in the countrY: • •
There was a new HCWM regulation in 2007. An HCWM master plan is at the stage of review and comment collection from ministries and sectors.
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A national action plan is going to be developed by a WHO consultant and local experts. A national assessment and survey have been carried out.
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Based on the analysis of the current situation, the tentative content of a draft national action plan was presented, including: • • • • • • a legislative framework, policy; guidelines and standard operating procedures; capacity-building and awareness-raising; technological application; financial arrangements; a monitoring programme;
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a framework for development of provincial action plans; and support for provinces to develop action plans.
In tenus of legislative framework and policy, Viet Nam should improve its legal documents on HCWM, issue national standards on alternative technologies and equipment, and develop policies on HCWM investment, penalties and operational cost support. There is also a need to set up technical guidelines based on the new HCWM regulations; and to standardize practices in hospitals at all levels, as well as procedures for HCWM collection, segregation, transportation, treatment, storage and disposal. In tenus of capacity-building, the national action plan will cover training programmes for medical staff and operators, as well as raising awareness among management boards, the public and the community. The effectiveness of the existing technologies needs to be improved; appropriate new technologies should be selected to replace incineration. Pilot tests need to be conducted to provide lessons for future application, and the experience and the lessons learnt should be disseminated widely. In the national action plan, funding resources for operational and maintenance costs need to be covered. In addition, the private sector needs to playa more important role in mobilization of funding for HCWM activities. 2.4.4 Mongolia
The Mongolian team presented the results of their discussions on the development of a national action plan, in which strategy was discussed. The following was pointed out: • • • • HCWM is integrated with the broader goal of quality medical care. HCWM is linked with the infection-control system. The involvement and awareness of private hospitals should be increased. Competitive, private sector involvement in the supply of standard bags, bins, safety boxes and transportation should be encouraged. Health care waste standards need to be set up. A national plan time-frame (2008-2013) needs to be set up.
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Based on the strategy discussed, next steps to be followed include: • discussion in the professional committees under the Ministry of Health: Communicable disease committeelHygiene committee or public health committee; Public health committee;
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discussion with relevant stakeholders: Ministry of Nature and Environment; State Specialized Inspection Agency; Health centers, district and tertiary level hospitals; and
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improvement of internal quality control.
2.5
Plenary discussion on national action plans
It was emphasized during the discussion that it is important to have milestones and a timeframe for each national action plan. It is good that Mongolia has a 2008-2013 national action plan. Another issue discussed was the financial arrangements to ensure enough funding for HCWM activities. Viet Nam has had experience in this area and should share this with other countries. The point was raised that the selection of appropriate technologies should not be based on recommendations from donors or investors, but on the objectives of environmental protection and human health. Experience in comparing the advantages and disadvantages of incineration versus non-incineration could be shared among countries by Health Care Without Harm through the WHO Regional Office for the Western Pacific. One participant pointed out that all participating countries have been requested to take appropriate measures to finalize national policies and plans, but support was needed for provinces to develop and implement provincial action plans. National action plans should be based on detailed assessments and cost estimates, and legislative aspect also needs to be taken into consideration. Environmental friendly technologies should be chosen instead of donor- or producer-driven technologies. Since financing is a fundamental issue, governments need to provide funding for sound HCWM, while private sector participation in HCWM should also be promoted. 3. CONCLUSIONS
Participants agreed on the following conclusions: 3.1 National policy and plans for integrated management of health care waste (I) Legislation and policy frameworks are not in place in most countries and should be considered urgent priorities. (2) All countries are requested to take appropriate measures to finalize their national HCWM policies, strategies and plans by the end of 2008. The national plans should address short-, medium- and long-term actions, and should be based on detailed assessment and cost estimation measures.
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(3) After finalization of national action plans for HCWM, governments should support provinces in developing and implementing provincial HCWM action plans. (4) HCWM needs to be integrated within the broader context of safety, quality of medical care and infection control. Donor-driven technologies should be avoided. Selection and choice of technologies should be strongly directed towards the objective of protecting the environment and the health of medical staff and the community. (5) Health care facility practices for segregation, collection, transportation, storage, treatment and disposal of health care waste need to be standardized. All health care facilities should focus on waste minimization and risk reduction. All collection of health care wastes, from public to private hospitals, needs to be improved. 3.2 WHO tools and guidelines on health care waste management planning and costing
WHO tools and guidelines on HCWM planning and costing playa very important role in helping participating countries for the following reasons: (I) A national action plan for HCWM needs to be developed based on assessment of the
current situation using the rapid assessment tool recommended by WHO. (2) Financing is a fundamental issue. Government funding for sound health care waste management is inadequate at the moment. National governments should create an effective funding mechanism and increase funding. (3) National and local governments should allocate adequate budget funds for operation and maintenance of equipment. (4) It is indicated that 1%-2% of the total health care budget should be allocated to HCWM. (5) The tools introduced in the workshop should be applied to develop and finalize national action plans. Other tools also need to be developed to monitor and evaluate implementation of the plans. 3.3 Future actions • An appropriate national action plan for integrated HCWM should be developed and finalized in each country. In the process of implementation of the approved national action plan, common treatment facilities for treatment and disposal of health care wastes from city and rural health care facilities should be promoted. Health care waste incineration should be replaced by non-bum technologies to prevent dioxin and furan emissions. Health care facilities should investigate the potential options for recycling of nonhazardous wastes. Participation of the private sector in HCWM needs to be promoted. Bio-medical engineers/technicians need to be recruited for proper equipment maintenance and training of technicians/operators. As recommended at the international meeting on HC\VM held in WHO Headquarters in June 2007, countries should take measures to mobilize additional resources for HCWM (refer to the conference papers).
•
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•
All countries should encourage capacity-building of health care staff. HCWM should be integrated into university and college curricula, and use made of the distance-learning certificate programmes already available. Education and networking should be encouraged. Pilot projects on sound HCWM need to be carried out. Lessons learnt from the pilot tests should be disseminated within and among countries. The use of mercury-free devices in health care facilities should be promoted. Mercury-containing waste has to be stored in a temporary safe storage area until appropriate disposal technology is available. Further support is required from WHO and other stakeholders, such as the GAVI Alliance, Health Care Without Harm, and JGNOU, among others.
•
•
•
ANNEXl LIST OF PARTICIPANTS, TEMPORARY ADVISERS, OBSERVERSIREPRESENTATIVES AND SECRETARIAT CAMBODIA
Professor Koum Kanal Director National Maternal and Child Health Centre 31A, France Street Sangkat Stras Chak Khan Daun Penh Phnom Penh Tel. No.: +855 12943785 Fax No.: +855 12724257 E-mail: nmchc@online.com.kh DrSokSrun Deputy Director The Department of Hospital Services Ministry of Health 151-153 KampucheaKrom Avenue Khan 7 Makara Phnom Penh Tel. No.:+855 23 427566/12 912122 Fax No.: +855 23 426034 E-mail: sokrun@camnet.com.kh Dr Svay Sarath Deputy Manager National Immunization Programme National Maternal and Child Health Center Ministry of Health 151-153 Kampuchea Krom Avenue Khan 7 Makara Phnom Penh Tel. No.: +855 12 870992 Fax No.: +855 23 246167 E-mail: sv_sarath@yahoo.com Dr Ngy Mean Heng Head Technical Office Phnom Penh Municipal Health Department IO I Monireth Boulevard Sangkat Psa Doeurn KOT Khan Tuol Kork Phnom Penh Tel. No.: +855 11 848687 Fax No.: E-mail: ngymeanheng@hotmail.com
Annex 1
LAO PEOPLE'S DEMOCRATIC REPUBLIC
Dr Vilayvone Mangkhaseum Deputy Chief Environmental Health Division Department of Hygiene and Prevention Ministry of Health Vientiane Tel. No.: +85621214010 Fax No.: +856 21241924 E-mail: vone_1960@yahoo.com Dr Chanhsay Pathammavong Head IEC Section ofEPI Unit Maternal and Child Health Centre Nongbom Road Xaysetha District Vientiane Tel. No.: +85621312352/452519 Fax No.: +856 21312120 E-mail: chansay_epi@yahoo.com Dr Chanphet Phothilath Chief of Medical Technology Department of Curative Meillcine Ministry of Health Sisavone Village Saysettha District Vientiane Capital Tel. No.: +85621 21401 I Fax No.: +856 21 2 I 7848 E-mail: chanpheth@yahoo.com
MONGOLIA
Dr Tserensodnom Bujin Director Health Policy and Planning Division Ministry of Health Government Building - 8 Olympic Street-2 Ulaanbaatar-210648 Tel.lFax. No.: +976 51262901 E-mail: tbujin@magicnet.com
Annex I MONGOLIA (Cont.)
Dr Batmunkh Tsetsegsaikhan Officer in Charge Environmental Health Ministry of Health Government Building - 8 Olympic Street-2 Ulaanbaatar-21 0648 Tel. No.: +976 51 263925 Fax No.: +976 11 323541 E-mail: tsetsegsaikhan@yahoo.com Ms Ganjuurjav Endenebayasgalan Officer Chemical Strategy and Hazardous Waste Management Ministry of Nature and Environment Government Building 3 Baga Toiruu 44 Ulaanbaatar Tel. No.: +976 51260718 Fax No.: +976 51320287 E-mail: erdenebayasgalan@yahoo.com Ms Jambalsuren A1targana Officer Foundation of Waste Services Ulaanbaatar city Mayor's Office Bagatoiruu Chingeltei District Ulaanbaatar Tel. No.: +976 99 275492 Fax No.: +976 II 323674 E-mail: aagiij@yahoo.com Ms Dashdulam Surenkhorloo Quality Manager National Centre for Communicable Diseases Chingeltei Dictrict VIII Khoroo, Dund-tasgar 7-67 Ulaanbaatar Tel. No.: +976 451466 Fax No.: E-mail:
Annex I MONGOLIA (Cont.) Dr Ayurzana Enkhtuya State Senior Inspector Hygiene and Epidemiology State Professional Inspection Agency Regulatory Agency of the Government of Mongolia Builder's-13 Government Building 12 Ulaan baatar Tel. No.: 911 76264342 Fax No.: E-mail: enkhtuya-ssia@yahoo.com Dr Le Van Chinh Expert on Environmental Health Administration of Preventive Medicine and Environmental Health Ministry of Health 135 Nui Truc Badinh District HaNoi Tel. No.: +8447367169 Fax No.: +8447367379 E-mail: chinh.mtmoh@gmail.com Dr Nguyen Trong Khoa Medical Officer Department of Therapy Ministry of Health 138A Giang Vo Street Ba Dinh District HaNoi Tel. No.: +84 4 2732273 (ext. 1703) Fax No.: +8442732289 E-mail: nt_khoa@yahoo.com.au Dr Hoang Van Tuan EPI Offficer EPI - National Institute of Hygiene and Epidemiology 1 Yersit Street HaNoi Tel. No.: +8448213764 Fax No.: +84 48213782 E-mail: hoangvantuan@fot.vn
VIETNAM
Annex 1
VIET NAM (Cont.)
Mrs Hoang Thi Ngoc Ngan Chief Public Health Department 699 Tran Hung Dao Street District 5 HQ Chi Minh City Tel. No.: +84 8 5114001 Fax No.: +0908 100945 E-mail: khoaskmt@yahoo.com
2. TEMPORARY ADVISERS
Dr Ashok K. Agarwal
Professor School of Health Sciences Indira Gandhi National Open University (IGNOU) New Delhi 110068 India Tel. No.: +91 II 2953 3078/2602 5961 Fax No.: +91 1129534935 E-mail: akagarwal@ignou.ac.in Mr Nguyen Thanh Yen Officer Pollution Control Division Viet Nam Protection Agency Ministry of Natural Resources and Environment No 24,37116 Le Thanh Nghi Street Bach Khoa Ward, Hai Ba District HaNoi VietNam Tel. No.: +844 8695904 E-mail: ngthanhyen@gmail.com
Annex I
3. OBSERVERS/REPRESENT ATIVES
HEALTH CARE WITHOUT HARM
Ms Mercedes V. Ferrer Executive Director Health Care Without Harm Unit 330, Eagle Court Condominium 26 Matalino Street, Barangay Central, Diliman Ouezon City Philippines Tel. No.: +63 2 9287572 Fax No.: +63 2 9262649 E-mail: merci@hcwh.org Ms N. Oyunbileg Head Public Health Division Health Department of Ulaanbaatar city Erkh chuluu street-16a Chingeltei District Ulaanbaatar Mogolia Tel: +976 99156217 Tel: 976 11-325076 E-mail:
CITY HEALTH DEPARTMENT OF ULAANBAATAR
NATIONAL HEALTH SCIENCE UNIVERSITY OF MONGOLIA
Mr N. Sumberzul Dean School of Public Health National Health Science University Choidog street-3 Ulaanbaatar Mongolia Tel: +976 II 329126 Tel: + 976 99 284642 E-mail: Ms D. Boldmaa Officer National Center for Health Development Enkhtivan street- J3b Ulaanbaatar Mongolia Tel: + 976 11 7011 0893 Tel: + 976 99 870461 E-mail:dboldmaa@yahoo.com
NATIONAL CENTER FOR HEALTH DEVELOPMENT
Annex I PUBLIC HEALTH INSTITUTE
Mr J. Oyunbileg Director Public Health Institute Enkhtaivnii urgun chuluu-17 Ulaanbaatar Mongolia Tel: +976 99 762000 E-mail: jobileg@magicnet.rnn Mr N. KhureIbaatar Deputy Director Research, Training and International Relations National Center for Communicable Diseases Nam-Y an-Ju street Ulaanbaatar-210648 Mongolia Tel: +976 II 45 8475 E-mail:khurel@nccd.gov.mn
NATIONAL CENTER FOR COMMUNICABLE DISEASES
4. SECRETARIAT
WHO WESTERN PACIFIC REGIONAL OFFICE (WHOIWPRO)
Mr Terrence Thompson (Responsible Officer) Regional Adviser Environmental Health WHO/WPRO U.N. Avenue 1000 Manila Philippines Tel. No.: (632) 528 9890 Fax No.: (632) 526-0279 E-mail: thompsont@wpro.who.int Dr Yoshikuni Sato Medical Officer Expanded Programme on Immunization WHO/WPRO U.N. Avenue 1000 Manila Philippines Tel. No.: +63 2 5289742 Fax No.: +632 5260279 E-mail: satoy@wpro.who.int
Annex 1
WHO-MONGOLIA
Mr Robert Hagan WHO Representative in Mongolia Office of the WHO Representative in Mongolia Post Box - 663 Ulaanbaatar-13 Mongolia Tel. No.: +976 11 327870/322430 Fax No.: +976 11 324683 E-mail: haganr@mog.wpro.who.int
Dr Jamsran Mendsaikhan National Professional Officer Immunization and Vaccine Develpoment Office of the WHO Representative Office in Mongolia Post Box - 663 Ulaanbaatar-13 Mongolia +976 11 327870/322430 Fax No.: +976 11 324683 E-mail: jarnsranm@mog.wpro.who.int
Dr Shinee Enkhtsetseg Water Sanitation and Hygiene Programme Officer Office of the WHO Representative Office in Mongolia Post Box - 663 Ulaanbaatar-13 Mongolia Tel. No.: +976 II 327870/322430 Fax No.: +976 11 324683 E-mail: shineee@wpro.who.int WHO-VIETNAM
Mr Ton Tuan Nghia Environmental Health Officer Office of the WHO Representative in Viet Nam P.O. Box 52 HaNoi Socialist Republic of Viet Nam Tel. No.: 844 9433734 to 83858 Fax No.: 844 9433740 E-mail: tontuann@ wpro.who.int
Annex 1
WHO HEADQUARTERS
Mr Yves Chartier Public Health Engineer Water, Sanitation and Health Department for Public Health and Environment World Health Organization 20 Avenue Appia CH-1211 Geneva 27 Switzerland Tel. No.: +41 22 7911607 Fax No.: +41227914159 E-mail: chartiery@who.int
ANNEX 2 WORKSHOP PROGRAMME
Presentation/Subject/Issues
Presenter
Day 1, Tuesday, 6 May
08:30-09:00 09:00 - 10:00
Registration Opening session Welcome remarks WR, Mongolia Ministry of Health, Mongolia
Introductions Election of chair and rapporteur Adoption of Agenda Background and objectives Country reports • Mongolia
Mr Terrence Thompson
10:00 - 10:30 10:30 - 12:00
Coffee break and group photo Country reports (continued) • • • Cambodia Lao People's Democratic Republic VietNam
WHO tools and technical guidance • • • Rapid assessment tool Guidance on national planning Cost estimating tool
Mr Yves Chartier
12:00 - 13:30 13:30 -17:00
Lunch break Field visit to central hospital
Annex 2
Day 2, Wednesday, 7 May 08:30-10:00
Discussion on field visit Facilitated work groups on national health care waste management plans • • • • Mongolia Cambodia Lao People's Democratic Republic Viet Nam
10:00 - 10:30 10:30 - 12:00 12:00 - 13:30 13:30 - 17:00
Coffee break
Field visit to rural hospital Lunch break (in the field)
Field visit to rural hospital (continued)
Day 3, Thursday, 8 May 08:30 - 10:00
Discussion on field visit Facilitated work groups (continued) • Work group reports
Plenary discussion • 10:00 - 10:30 10:30 - 12:00
Formulation of recommendations
Coffee break
Special topics session • Mercury in health care o o WHOpolicy Presentation on GEF Project in VietNam Mr Yves Chartier
MrNguyen Thanh Yen
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Distance learning for health care waste management
Dr Ashok Agarwal
Workshop conclusions CLOSING
ANNEX 3 LIST OF DOCUMENTS DISTRIBUTED
I. Introduction - Rapid Assessment Tool (Yves Chartier) 2. Guidance for Development and Implementation of a National Action Plan (Yves Chartier) 3. WHO Costing Tools (Yves Chartier) 4. Mercury in Health Care (Yves Chartier) 5. Presentation on GEF project (Nguyen Thanh Yen) 6. Capacity building for health care waste management (IGNOU) (A.K. Agarwal) 7. Management of Solid Health-care Waste at Primary Health-care CentresA Decision Making Guide (WHO Geneva 2005). 8. Preparation ofNationaI Health-care Waste Management Plans in Sub-Saharan Countries - Guidance Manual (WHOIUNEP 2005 - Bale Convention)
ANNEX 4 SUMMARY OF COUNTRY REPORTS
1. Mongolia
General introduction of Mongolia and health care system was introduced. A. The current situation was briefly described, including: The national action plan on "Improvement of solid waste management" was set up in 2002. Law on "Municipal and Industrial Waste" was issued in 2004. Several regulations were developed on: }> Removal and disposal of hazardous waste - (2002) }> Improvement of Health Care Waste Management (2002) }> Chemical waste management (2003) Healthcare Sector Master Plan (HSMP) (2006-2015) was approved by the Govermnent Resolution # 72 in 2005. The HSMP Implementation Framework was endorsed in February 2007 by resolution #43 of Minister of Health. National Environmental Health Action Plan was developed and endorsed by the Govermnent in 2005 A multisectoral working group for Water and Sanitation and Healthcare Waste Management was established by Minister of Health in 2006. B. Recent activities in HCWM show that there is poor management of health care wastes produced in Ulaanbaatar, including: • Inadequate practice of collection and storage of sharps, infectious and chemical wastes • No special service for transporting medical wastes in the city • Lack of clear requirements for medical waste disposal (combustion) facilities and unsafe combustion • 11.5% of healthcare facilities had on-site small-scale, low temperature incinerators • 79.4% had contracts with above facilities to bum the medical waste, and • 9.1 % discharged (bumt or buried) the wastes at the disposal site. • Incinerators in the capital city do not meet the WHO safety requirements. C. GAVI Alliance funded activities include the development of policy and strategy on
HCWM, a questionnaire survey on healthcare waste management in 220 Saums, case studies, national assessment of health care waste management in Mongolia in 2007. Achievements: Formulation of the draft of National Plan of Action, Budget allocation on HCWM }>400000 USD allocated from the state budget for centralized facility for treatment and disposal in Ulaanbaatar city }> 100000 USD allocated from the state budget for operational expenses National assessment on HCWM
Annex 4
Challenges: Improve administrative structure for management of health care wastes and establish functional multi-sectoral coordination mechanism on HCWM Create appropriate legal environment on healthcare waste management. Create an appropriate mechanism for financing of health care waste management and increase budget for establishment and regular maintenance of HCWM system. Develop adequate infrastructure for segregation, collection, storage, transportation, disposal and treatment of HCWs at each level of health care service. Build human resource and research capacity on HCWM, improve waste management awareness among the decision makers, stakeholders and the community. Strengthen monitoring and evaluation ofHCWM system.
2. Cambodia
An overview and background of Cambodia was introduced by a presenter. A. A history on HCWM was also introduced in which: • • • • • • • • • • • • Sharp waste only (injection safety) has been taken care since 2001 Circular of MoH on waste segregation & incineration for infectious waste was issued. Construction Sicim Incinerator and training injection provider & incinerator operators were conducted. Guideline on sharp waste was developed in 2001. National survey on HCWM was conducted in 2006. Integrated National Workshop was organized in 2007. Integrated HCWM Plan was set up. Draft regulation on HCWM was prepared. National Consultative Workshop on Draft Regulation on HCWM was organized in 2007. Proposed Action Plan on HCWM Pilot HCWM Plan was implemented at National Maternal & Child Health Centre Training in Injection Safety of Health Staff supported by WHO was organized.
B. The structural organization was introduced by a diagram. • Aspects were on focus, including: }> Financial }> Regulation aspect }> Sharp waste management safety boxes The following constraints were pointed out: }> Not available space for incinerator's installation }> Not sufficient dry leave for Sicim incinerator burning }> Difficult for maintenance (no spare part ) }> No proper incinerator for other Health care waste
•
Annex 4
C. Injection safety plan of action was developed and implemented in Cambodia followed
by a National workshop on safety injection. D. Plans of Action will be developed with a main focus on: • Achieving safe injection practices especially in the therapeutic sector ;.. Revising the National Policy ~ Updating training materials for health care workers Integrating sharps waste management into health care waste management ~ Expand coverage of incinerators and safety boxes to all Health Operational Districts Reducing injection overuse ~ Promoting oral medication to providers and educating general population
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•
3. Lao People's Democratic Republic General information on the country and hospital network in the Lao People's Democratic Republic was introduced by a presenter from the Ministry of Health. A. Some strengths of health care system were pointed out as follows: • • • • Government shows highly concerns as it becomes immediate and long term issues Ministerial regulation still has to wait for the deVelopment of policy Good starting points in expanded programme on immunization (EPI) were achieved including guidelines, training, provision of safety boxes, incinerators and follow-up A strong partnership with WHO was maintained including technical assistance, piloting, assessment of health care waste
B. The current situation of HCWM was briefly described in which some common technologies of waste treatment have been applied in practice such as:
• • •
Disposed at landfill (rudimentary pits at rural health facilities) Incinerator (for provincial and central hospitals) Discharge untreated waste together with general waste
C. Healthcare waste production The mean of health care waste production per bed is 1.8 kilograms per day (minimum: 0.24 kilograms per day and maximum of 4.29 kilograms per day
D. Issues in HCWM were pointed out to be solved: • • Lack of controlling mechanism leading to unorganized of system management Harm to individuals, public and environment
Annex 4
• • • • • • •
Health care waste treatment is not met tool management Health care wastes are mixed with general waste at rural areas. Incinerators are not available. Health care waste treatment is differently managed upon fund allocation, perception of the leadership and quantity of waste. Poor knowledge on waste management among staff. Existing ministerial regulation is not largely distributed and enforced. Regulation is strictly applied and monitored by line agencies (Ministry of Transport, Water Resource and Environment Agency)
E. The Ministry of Health, Lao People's Democratic Republic, has a plan for the future as follows: • • • • • Piloting the concept in selected areas Developing integrated strategy / Policy including long term plan Endorsed the strategylPolicy by the Government of the Lao People's Democratic Republic Regulation strictly applied and monitored by line agencies (Ministry of Transport, Water Resource and Environment Agency) Formulation of a National Action Plan for HCWM
4. VietNam Dr Khoa from the Ministry of Health, Viet Nam presented an overview of Viet Nam, health care facilities and current situation and activities in health care waste generation, health care waste treatment facilities. According to Dr Khoa the Ministry of Health, Viet Nam has revised and issued a new HCWM regulation in November 2007. There was a re-structure in HCWM system in which the former Department of Therapy is in charge of HCWM. There was a new agency which was Environmental Police established in 2006, contributing to making the HCWM to be in order. At present, a master plan of HCWM is in the stage of collecting comments and recommendations from line ministries and agencies. The master plan of HCWM generally covered models of HCWM treatment, technologies applied in Viet Nam, utilizing and upgrading incinerators until 2015, application of alternative technologies such as microwave system, autoclave, etc. Dr Khoa also introduced recent activities in HCWM, including the pilot of applying WHO Guidelines on management of wastes from injection activities at district level: using needle cutters and needle pits for disposal. The Ministry of Health, Viet Nam has a plan for improving HCWM as follows: • • • • Developing a National Action Plan for HCWM Continuing scaling up of implementing injection waste management Developing and implementing a model of integrated HCWM Improving policies, standards, strategies