MEDICAL WASTE MANAGEMENTMEDICAL WASTE MANAGEMENT      

Health Facilities in BangladeshHealth Facilities in Bangladesh

At Union LevelAt Union Level-Union Sub centre (USC)--Union Sub centre (USC)-13621362-Health and Family Welfare Centre (HFWC)- 3053-Health and Family Welfare Centre (HFWC)- 3053 At Upazila LevelAt Upazila Level – – Upazila Health Complex-460Upazila Health Complex-460

At District LevelAt District Level- District Hospital-59- District Hospital-59

At National LevelAt National Level- Government Medical Colleges- 15- Government Medical Colleges- 15

- Postgraduate/specialized hospitals-7- Postgraduate/specialized hospitals-7

Beside these there are about 33 private medical and Beside these there are about 33 private medical and dental colleges and 1213 registered clinics in and dental colleges and 1213 registered clinics in and outside Dhaka. The number of diagnostic centers is outside Dhaka. The number of diagnostic centers is 1,541 of which 580 are in Dhaka city. 1,541 of which 580 are in Dhaka city. The total number of hospital beds is 51, 684 in The total number of hospital beds is 51, 684 in 2005. 2005.

““Medical Waste’ has been defined as all Medical Waste’ has been defined as all the Solid, Liquid, Gaseous, high the Solid, Liquid, Gaseous, high pressurized and scrap of Radioactive pressurized and scrap of Radioactive waste, effluent, by-product, organism or waste, effluent, by-product, organism or surplus materials which directly or by surplus materials which directly or by broken or by worn out or by contaminated broken or by worn out or by contaminated or by damaging develop adverse or or by damaging develop adverse or negative change/effect or risk to human or negative change/effect or risk to human or environment. environment.

Between 75% and 90% of the waste produced by Between 75% and 90% of the waste produced by health-care providers ishealth-care providers isnon-risk or ‘general’ health-care waste, non-risk or ‘general’ health-care waste, comparable to domestic waste. It comes mostly comparable to domestic waste. It comes mostly from the administrative and housekeeping from the administrative and housekeeping functions of health-care establishments and may functions of health-care establishments and may also include waste generated during also include waste generated during maintenance of health-care premises. maintenance of health-care premises.

The remaining 10-25% of healthcare waste is The remaining 10-25% of healthcare waste is regarded as hazardous and may create a variety regarded as hazardous and may create a variety of health risks.of health risks.

Major sources of health-care wasteMajor sources of health-care waste

HospitalsHospitals — — University hospitalUniversity hospital

— — General hospitalGeneral hospital— — District hospitalDistrict hospital

Other health-care establishmentsOther health-care establishments— — Emergency medical care servicesEmergency medical care services— — Health-care centres and dispensariesHealth-care centres and dispensaries— — Obstetric and maternity clinicsObstetric and maternity clinics— — Outpatient clinicsOutpatient clinics— — Dialysis centresDialysis centres— — First-aid posts and sick baysFirst-aid posts and sick bays— — Long-term health-care establishments and hospicesLong-term health-care establishments and hospices— — Transfusion centresTransfusion centres— — Military medical servicesMilitary medical services

Related laboratories and research centresRelated laboratories and research centres— — Medical and biomedical laboratoriesMedical and biomedical laboratories— — Biotechnology laboratories and institutionsBiotechnology laboratories and institutions— — Medical research centresMedical research centres

Mortuary and autopsy centresMortuary and autopsy centres Animal research and testingAnimal research and testing Blood banks and blood collection servicesBlood banks and blood collection services Nursing homes for the elderlyNursing homes for the elderly

Hazards of Medical WasteHazards of Medical Waste A small amount of hazardous waste may infected the large A small amount of hazardous waste may infected the large

amount of general wasteamount of general waste Organic portion ferments and attracts fly breedingOrganic portion ferments and attracts fly breeding Injuries from sharps to all categories of health care personnel Injuries from sharps to all categories of health care personnel

and waste handlersand waste handlers Increase risk of infections to medical, nursing and other Increase risk of infections to medical, nursing and other

hospital staffhospital staff Injuries from sharps to health workers and waste handlersInjuries from sharps to health workers and waste handlers Poor infection control can lead to nosocomial infections in Poor infection control can lead to nosocomial infections in

patients particularly HIV, Hepatitis B & Cpatients particularly HIV, Hepatitis B & C Increase in risk associated with hazardous chemicals and Increase in risk associated with hazardous chemicals and

drugs being handled by persons handling wastedrugs being handled by persons handling waste Poor waste management encourages unscrupulous persons to Poor waste management encourages unscrupulous persons to

recycle disposables and disposed drugs for   repacking and recycle disposables and disposed drugs for   repacking and resellingreselling

Development of resistant strains of microorganismsDevelopment of resistant strains of microorganisms

Disadvantages of Poor Health Care Waste Disadvantages of Poor Health Care Waste ManagementManagement

RISKS TO HEALTH CARE WORKERS AND WASTE HANDLERSRISKS TO HEALTH CARE WORKERS AND WASTE HANDLERS

Poor management of health-care waste can Poor management of health-care waste can cause serious disease to health-care personnel, to cause serious disease to health-care personnel, to waste workers, patients and to the general public. waste workers, patients and to the general public. The greatest risk posed by infectious waste are The greatest risk posed by infectious waste are accidental needle stick injuries, which can cause accidental needle stick injuries, which can cause hepatitis B and hepatitis C and HIV infection. There hepatitis B and hepatitis C and HIV infection. There are however numerous other diseases which could are however numerous other diseases which could be transmitted by contact with infectious health-be transmitted by contact with infectious health-care wastes. During the handling of wastes, injuries care wastes. During the handling of wastes, injuries occur when syringe-needles or other sharps have occur when syringe-needles or other sharps have not been collected in rigid puncture proof not been collected in rigid puncture proof containers. Inappropriate design and/or overflow of containers. Inappropriate design and/or overflow of existing sharps container and moreover existing sharps container and moreover unprotected pits increase risk exposure of the unprotected pits increase risk exposure of the health care workers, of waste handlers and of the health care workers, of waste handlers and of the community at large, to needle stick injuries. community at large, to needle stick injuries.

RISK TO THE GENERAL PUBLICRISK TO THE GENERAL PUBLIC The reuse of infectious syringes represents a major threat to The reuse of infectious syringes represents a major threat to

public health. WHO estimated that, in 2000, worldwide, injections public health. WHO estimated that, in 2000, worldwide, injections undertaken with contaminated syringes caused about 23 million undertaken with contaminated syringes caused about 23 million infections of Hepatitis B and Hepatitis C and HIV. Such situations infections of Hepatitis B and Hepatitis C and HIV. Such situations are very likely to happen when health-care waste is dumped on are very likely to happen when health-care waste is dumped on uncontrolled sites where it can be easily accessed by the public: uncontrolled sites where it can be easily accessed by the public: Children are particularly at risk to come in contact with infectious Children are particularly at risk to come in contact with infectious wastes. The contact with toxic chemicals, such as disinfectants wastes. The contact with toxic chemicals, such as disinfectants may cause accidents when they are accessible to the public. In may cause accidents when they are accessible to the public. In 2002, the results of a WHO assessment conducted in 22 2002, the results of a WHO assessment conducted in 22 developing countries showed that the proportion of health care developing countries showed that the proportion of health care facilities that do not use proper waste disposal methods range facilities that do not use proper waste disposal methods range from 18% to 64% .from 18% to 64% .

Persons at risk of the hazards of Persons at risk of the hazards of medical wastemedical waste

Depending on the type of procedures, the Depending on the type of procedures, the persons at risk and mode of transmission persons at risk and mode of transmission in some common medical procedures are: in some common medical procedures are: Patient Health worker, Laboratory Patient Health worker, Laboratory personnel, Supporting staff, Transport personnel, Supporting staff, Transport workerworker

Classification of Medical Waste Classification of Medical Waste in Bangladeshin Bangladesh

General WasteGeneral Waste Pieces of paperPieces of paper BoxesBoxes ContainerContainer CorkCork Food wastes; Fish, Meat, Food wastes; Fish, Meat,

Vegetables, fruit coveringsVegetables, fruit coverings Egg shell, coconut shellEgg shell, coconut shell Non-infectious dressing gauze, Non-infectious dressing gauze,

plasterplaster

Infectious WasteInfectious Waste Infected clothing, bandage, Infected clothing, bandage,

sponge/swab, plaster, syringesponge/swab, plaster, syringe Coagulated Blood/ PlasmaCoagulated Blood/ Plasma Used sanitary padUsed sanitary pad Dialysis related wasteDialysis related waste Ryles tube, Gloves, Masks, Ryles tube, Gloves, Masks,

Airway Tube, Endotracheal Tube, Airway Tube, Endotracheal Tube, Catheter, Drainage Tube/bag, Catheter, Drainage Tube/bag, Blood Transfuse tube /bag, Blood Transfuse tube /bag,

Culture Media (Autoclaved just Culture Media (Autoclaved just immidiate to use)immidiate to use)

Blood collection SyringeBlood collection Syringe Amputed parts of the body/ Amputed parts of the body/

tumour, tissues, placenta, etc.tumour, tissues, placenta, etc.

Sharp WastesSharp Wastes All types of needles; All types of needles; hypodermic needles, hypodermic needles, Infusion sets, Infusion sets, saws, saws, scalpels; scalpels; knives;knives; blades; blades; broken glass, and broken glass, and

nailsnails

Recyclable WasteRecyclable Waste Uninfected plastic Uninfected plastic

materialsmaterials PapersPapers CardboardCardboard Metallic containersMetallic containers Saline setSaline set Mineral water bottleMineral water bottle

Radioactive wasteRadioactive waste Radioactive waste Radioactive waste

includes solid, liquid, includes solid, liquid, and gaseous and gaseous materials materials contaminated with contaminated with radionuclide.radionuclide.

Unused X-Machine Unused X-Machine HeadHead

Liquid WasteLiquid Waste Used WaterUsed Water Vomit, CoughVomit, Cough Suction fluidSuction fluid Pus, Serum, Pus, Serum,

coagulated Bloodcoagulated Blood Amniotic fluidAmniotic fluid Liquid chemicalLiquid chemical Unused medicineUnused medicine Drainage pipe waste Drainage pipe waste

waterwater

Uniform Colour CodeUniform Colour Code Government initiative to standardize colour Government initiative to standardize colour

coding of hospital wastes for in-house coding of hospital wastes for in-house management. management.

Black for general wasteBlack for general waste Yellow for infectious wasteYellow for infectious waste Red for sharp wasteRed for sharp waste Green for recyclable wasteGreen for recyclable waste Silver for radioactive wasteSilver for radioactive waste Blue for liquid wasteBlue for liquid waste

Medical waste ManagementMedical waste Management Proper internal managementProper internal management Safe waste transportationSafe waste transportation Final Disposal managementFinal Disposal management

Proper internal managementProper internal management SegregationSegregation: Separating different types of waste at the point of : Separating different types of waste at the point of

generation and keeping them isolated from each other. By doing this, generation and keeping them isolated from each other. By doing this, appropriate resource recovery and recycling techniques can be applied to appropriate resource recovery and recycling techniques can be applied to each separate waste stream. The amounts of infectious waste, hazardous each separate waste stream. The amounts of infectious waste, hazardous waste and low-level radioactive waste that must be treated according to waste and low-level radioactive waste that must be treated according to special (and usually costly) requirements are minimized. If not segregated, special (and usually costly) requirements are minimized. If not segregated, all hospital waste must be treated as potentially bio-infectiousall hospital waste must be treated as potentially bio-infectious

Source ReductionSource Reduction: Minimizing or eliminating the generation of waste at : Minimizing or eliminating the generation of waste at the source itself through techniques such as product substitution, the source itself through techniques such as product substitution, technology change and good operating practices. technology change and good operating practices.

Resource Recovery and RecyclingResource Recovery and Recycling: Recovery and reuse of materials : Recovery and reuse of materials from the waste stream. The majority of waste from health care facilities is from the waste stream. The majority of waste from health care facilities is surprisingly similar to that of an office building or hotel -- paper, cardboard surprisingly similar to that of an office building or hotel -- paper, cardboard and food waste. Hospitals can implement fairly simple programs that divert and food waste. Hospitals can implement fairly simple programs that divert these materials from the solid waste stream, lowering disposal costs these materials from the solid waste stream, lowering disposal costs

Internal transportation: Internal transportation: Internal transportation: Transportation of Internal transportation: Transportation of wastes from its source of generation to central collection/storage section.wastes from its source of generation to central collection/storage section.

Central waste disposal: Central waste disposal: Methods and equipments used to dispose Methods and equipments used to dispose the waste.the waste.

Colour Code Types of Waste Characteristics of Waste Container

Black General Waste¨Non-hazardous, non-contaminated,

Non-punctured Plastic Bin

Yellow Infectious wasteAnatomical, Pathological, infectious, contaminated

Non-punctured Plastic Bin

Red Sharp WasteContaminated and non-contaminated, Infectious, non-infectious

Non-punctured Plastic Bin, Box

Blue Liquid Waste

Hazardous, Non-hazardous, Infectious, Non-infectious, Contaminated, Non-contaminated

Non-punctured Plastic Bin, Bowl

Silver Radioactive RadioactiveNon-punctured Lidded Box

Green Recyclable WasteNon-hazardous, Non-infectious, Non-contaminated

Non-punctured Plastic Bin

Final Disposal ManagementFinal Disposal Management IncinerationIncineration AutoclavingAutoclaving Deep burialDeep burial RecyclingRecycling

Wastes requiring Wastes requiring incinerationincineration

Anatomical parts and animal carcasses, Anatomical parts and animal carcasses, andand

Cytotoxic drugs (outdated), toxic Cytotoxic drugs (outdated), toxic laboratory chemicals other than mercury.laboratory chemicals other than mercury.

Patient contaminated non-plastics and Patient contaminated non-plastics and non-chlorinated plastics. non-chlorinated plastics.

Waste that cannot be incineratedWaste that cannot be incinerated Chlorinated plastics, volatile toxic wastes Chlorinated plastics, volatile toxic wastes

such as mercury.such as mercury.

Shredding machineShredding machine

Hospital Waste GenerationHospital Waste Generation Generation of hospital waste in Bangladesh is Generation of hospital waste in Bangladesh is

0.78 kg/bed/day. 0.78 kg/bed/day. Non-hazardous waste is 0.64 kg/bed/day Non-hazardous waste is 0.64 kg/bed/day

(82.05%)(82.05%) Infectious waste is 0.11 kg/bed/day (14.10%) Infectious waste is 0.11 kg/bed/day (14.10%) Sharp waste is 0.03kg/bed/day (3.85%) Sharp waste is 0.03kg/bed/day (3.85%) World Bank estimates, 36,000 tons of healthcare World Bank estimates, 36,000 tons of healthcare

waste is generated every year in Bangladesh. waste is generated every year in Bangladesh. Out of this amount approximately 7,200 tons may Out of this amount approximately 7,200 tons may be considered hazardous.be considered hazardous.

Evidently, Generation of hazardous waste in Evidently, Generation of hazardous waste in Specialized Hospitals is more than secondary Specialized Hospitals is more than secondary and tertiary level hospitals and tertiary level hospitals

Legal provisionsLegal provisions The Ministry of Health and Family Welfare of Bangladesh The Ministry of Health and Family Welfare of Bangladesh

formulated the Medical Waste Management Regulations, formulated the Medical Waste Management Regulations, which is now in the final stage, under The Bangladesh which is now in the final stage, under The Bangladesh Environment Conservation Act, 1995.Environment Conservation Act, 1995.

In this proposed rule, the responsibilities of medical waste In this proposed rule, the responsibilities of medical waste generator has been documented with direction of Internal generator has been documented with direction of Internal management (segregation, color coding, packaging, management (segregation, color coding, packaging, transportation and storage), External transportation, and transportation and storage), External transportation, and category wised treatment and disposal methods. category wised treatment and disposal methods.

In the proposed rule there is also provision of penalty for In the proposed rule there is also provision of penalty for contravention of rules such as unsafe practices, such as contravention of rules such as unsafe practices, such as disposing of hazardous health-care waste in municipal areasdisposing of hazardous health-care waste in municipal areas

Important schedules as enclosed with the proposed Important schedules as enclosed with the proposed rule are as follows;rule are as follows;

Schedule-1.A:Schedule-1.A: Category wise properties of Category wise properties of medical waste (category, type, examples, and medical waste (category, type, examples, and treatment and disposal methods).treatment and disposal methods).

Schedule-1.BSchedule-1.B: List of health care waste : List of health care waste generator (Large and small producers of health-generator (Large and small producers of health-care waste)care waste)

Schedule-2Schedule-2: Specification of container and color : Specification of container and color code for storage and transportation of individual code for storage and transportation of individual types of medical waste types of medical waste

Schedule-5Schedule-5 : Standard of treatment and disposal : Standard of treatment and disposal of medical waste of medical waste

RECENT TRENDS and CURRENT CONDITIONSRECENT TRENDS and CURRENT CONDITIONS Hospital waste management in Bangladesh is still not Hospital waste management in Bangladesh is still not

satisfactory. satisfactory. Earlier no provision of proper segregation and collection Earlier no provision of proper segregation and collection

system in the health care facilities. system in the health care facilities. The waste generated inside the hospitals were collected by The waste generated inside the hospitals were collected by

untrained, unprotected and unaware cleaners without untrained, unprotected and unaware cleaners without necessary protective equipment. necessary protective equipment.

The wastes were dumped either into the dustbin or in outside The wastes were dumped either into the dustbin or in outside hospital premises or dumped on the ground within the hospital premises or dumped on the ground within the hospital premises. hospital premises.

Only few facilities have incinerator, but not properly working Only few facilities have incinerator, but not properly working or used.or used.

Lack of awareness. Lack of awareness. Absence of training facilities for the concerned staff. Absence of training facilities for the concerned staff. Shortage of supply of equipment and materials required for Shortage of supply of equipment and materials required for

the disposal of hospital wastes.the disposal of hospital wastes. Hospital waste recycling trade is very small and in a very Hospital waste recycling trade is very small and in a very

confidential way mainly from primary collection site. confidential way mainly from primary collection site.

RECENT TRENDS and CURRENT RECENT TRENDS and CURRENT CONDITIONSCONDITIONS

In 2003, under HNSPS, DGHS started to In 2003, under HNSPS, DGHS started to implement one Operational Plan (OP) for implement one Operational Plan (OP) for hospital waste management in 20 upazilas hospital waste management in 20 upazilas and now extended to 133.and now extended to 133.

A financially viable program for elimination A financially viable program for elimination of environmental and health hazards of environmental and health hazards

Component of the programComponent of the program

TrainingTraining Waste SegregationWaste Segregation at source in colour bin at source in colour bin Waste CollectionWaste Collection by trolley, provision of Personal Protective by trolley, provision of Personal Protective

Devices for handlers. Devices for handlers. Waste Storage Waste Storage in a separate room out side of hospital in a separate room out side of hospital

buildingbuilding DisposalDisposal General wastes over to the municipal waste collectors or General wastes over to the municipal waste collectors or

bins. bins. The infectious and sharp materials are to be kept in double The infectious and sharp materials are to be kept in double

chambered concrete pit constructed in the hospital premises chambered concrete pit constructed in the hospital premises for dumping . for dumping .

Medical Waste Management for Medical Waste Management for Private and NGO FacilitiesPrivate and NGO Facilities

Recently some organizations are operating Recently some organizations are operating hospital waste management pilot projects hospital waste management pilot projects under under public-private partnership arrangementpublic-private partnership arrangement

Dhaka, Khulna, Rajshahi City Corporations, Dhaka, Khulna, Rajshahi City Corporations, Bogra and Gazipur PourashavaBogra and Gazipur Pourashava

Only the private and NGO health Care Facilities Only the private and NGO health Care Facilities are participating with support of Local are participating with support of Local Government InstituteGovernment Institute

Case Study- KhulnaCase Study- Khulna Khulna city, however, is now an exception. It remains the only city in the Khulna city, however, is now an exception. It remains the only city in the

country with a hospital waste management program (HWMP) running country with a hospital waste management program (HWMP) running since 2000 under a public-private partnership arrangement. since 2000 under a public-private partnership arrangement.

At present the number of participating facilities under this project is 42 At present the number of participating facilities under this project is 42 including the Khulna Sadar Hospitalincluding the Khulna Sadar Hospital

A number of dialogues, workshops, seminars and roundtable A number of dialogues, workshops, seminars and roundtable discussions with the Bangladesh Medical Association (BMA), the clinic discussions with the Bangladesh Medical Association (BMA), the clinic owners’ association and some progressive doctors of Khulna were held owners’ association and some progressive doctors of Khulna were held to build consensus. to build consensus.

Finally all concerned parties agreed to participate in the program. The Finally all concerned parties agreed to participate in the program. The participating hospitals and clinics agreed to pay a service charge participating hospitals and clinics agreed to pay a service charge between Tk. 100 and Tk. 600 (US$ 1.5 to 9) depending on the volume between Tk. 100 and Tk. 600 (US$ 1.5 to 9) depending on the volume of waste generatedof waste generated

Three PillarsThree Pillars The Program has been delivering quality service.The Program has been delivering quality service. Awareness among healthcare institutions has been Awareness among healthcare institutions has been

raised through meetings and dialogues. There have raised through meetings and dialogues. There have also been public awareness campaigns, which in turns also been public awareness campaigns, which in turns put pressure on the healthcare institutions to put pressure on the healthcare institutions to demonstrate their social responsibility in managing demonstrate their social responsibility in managing their waste properly. their waste properly.

The Khulna City Corporation has issued letters to the The Khulna City Corporation has issued letters to the city’s healthcare facilities to encourage them to join city’s healthcare facilities to encourage them to join this program and reduce public health hazards. KCC this program and reduce public health hazards. KCC has also leased a piece of land measuring about 2,000 has also leased a piece of land measuring about 2,000 sq ft (185 sq. m) in the city’s dumpsite area for the sq ft (185 sq. m) in the city’s dumpsite area for the final disposal of hospital waste.final disposal of hospital waste.

ComponentComponent

TrainingTrainingThe first step was to train doctors, nurses, ayas (female aides) and cleaners about segregating and safely The first step was to train doctors, nurses, ayas (female aides) and cleaners about segregating and safely storing various kinds of waste i.storing various kinds of waste i.

Segregation and storageSegregation and storage The producers categorize the wastes by sorting and keep them in to color coded plastic bags or The producers categorize the wastes by sorting and keep them in to color coded plastic bags or

containers. containers. Needles and sharps: A fresh plastic bottle is used for storage .Needles and sharps: A fresh plastic bottle is used for storage . Syringe, saline bag and other plastics: In a covered plastic bin. Syringe, saline bag and other plastics: In a covered plastic bin. Gauze, bandages, human organs, paper materials and others: In separate covered plastic bin.Gauze, bandages, human organs, paper materials and others: In separate covered plastic bin. Kitchen waste: Kept outside in a plastic covered bin. Kitchen waste: Kept outside in a plastic covered bin.

Collection and transportationCollection and transportation Collection staff collects the waste everyday from each participating clinic, load it into a specially designed Collection staff collects the waste everyday from each participating clinic, load it into a specially designed

1.5 ton capacity truck . 1.5 ton capacity truck . waste collectors wear protective clothing including face masks, aprons, boot and globes through out the waste collectors wear protective clothing including face masks, aprons, boot and globes through out the

time of handling waste. time of handling waste.

Final DisposalFinal Disposal All sharps (e.g. needles, blades) and plastics are placed in a All sharps (e.g. needles, blades) and plastics are placed in a container dipped in the disinfectant solution container dipped in the disinfectant solution

and then kept in a and then kept in a concrete pit with a lockable lid. concrete pit with a lockable lid. All bandages, gauze, cotton, body parts, and paper are burned in locally-made/ imported incinerator All bandages, gauze, cotton, body parts, and paper are burned in locally-made/ imported incinerator and and

incinerated right on the day.incinerated right on the day. Non-hazardous kitchen waste is disposed of in the municipal dumpsite.Non-hazardous kitchen waste is disposed of in the municipal dumpsite.

Recent developments in waste handling Recent developments in waste handling equipmentsequipments

CompactorsCompactors Shredding machineShredding machine: : waste is crushed by rotating anvils, waste is crushed by rotating anvils,

and then forced through perforations of about and then forced through perforations of about ½½΄΄ diameter in a ΄΄ diameter in a stationery platestationery plate

Slurry waste systemSlurry waste system: : slurry or pulping system reduce the slurry or pulping system reduce the volume of wastevolume of waste

Pneumatic systemPneumatic system: : used for transporting soiled linensused for transporting soiled linens

Hammermill SystemHammermill System: : reduce the waste to a solid brickreduce the waste to a solid brick

CompactorsCompactors

ReducerReducer

KEY ISSUES FOR CONSIDERATIONKEY ISSUES FOR CONSIDERATION

Development of public-private partnership Development of public-private partnership in managing the hospital wastesin managing the hospital wastes

Financing systemFinancing system Proposed regulationProposed regulation Best Management Practices (including Best Management Practices (including

technology selection).technology selection). Institutional structure and capacity building.Institutional structure and capacity building.