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International experience in managing health - care waste


   1. Introduction:

   Health-care waste management (HCWM) has been the focus of public attention and concerns of policy makers in many countries. In Vietnam, the government, Ministry of Health, and Ministry of Natural Resource and Environment have been making efforts to improve the policy framework, including decrees, circulars and technical guidelines on HCWM. There is a Strategy and National Plan for health-care waste treatment and a commitment to intensive investment. This article introduces HCWM experiences in both developed and developing countries, focusing on the development of national policy frameworks and the implementation of international conventions relating to HCWM.

   2. Experience from developed countries 

     2.1 Development of national policy framework on HCWM

   The hazardous waste management market in a developed country is established and operated by two key players: waste generators and waste management service providers. Under a contract between two parties, the waste generator pays for waste services according to the “polluter pays” principle. The government develops and regulates this market through its policy tools and monitoring and enforcement system (see Figure 1).

Figure 1: Policy framework on HCWM


   Policy frameworks on hazardous waste management in developed countries have the following critical elements: obligations and responsibilities of waste generators and of waste management service providers; authority and responsibilities of government agencies and coordination mechanisms; systems of registration, licensing, inspection and enforcement; standards/requirements of operating procedures, record keeping, training and human resource management, facilities and equipment, and monitoring and reporting; financial mechanisms, including service fees, resource mobilization  and public private partnership in waste management.

   In the United States, Congress enacted the Medical Waste Tracking Act of 1988 that required the Environmental Protection Agency (EPA) to implement a two-year tracking program. Progressively, other federal agencies and state governments took over the role of medical waste regulation. Nearly all 50 states have enacted medical waste regulations to some extent. Multiple federal agencies are responsible for developing technical guidelines. For example, the Labor Occupational Safety and Health Administration issued the blood borne pathogens standard, while the Centers for Disease Control issued guidelines on infection control in health facilities and the EPA issued environmental best practices for health-care facilities.

   High-income countries in Europe and Asia manage health-care waste in an integrated manner. In England, policy framework includes the Environmental Protection Act of 1990 and hazardous waste regulations in 2005. HCWM in Germany involves numerous laws and regulations, with the principle law being the “Closed Substance Cycle Waste Management Act.” Transport of hazardous waste has to adhere to the Dangerous Goods Regulation, and incineration of waste must comply with the Federal Control of Pollution Act. Quality management of health facilities incorporates health-care waste segregation and disposal.1 Although the European Union (EU) has no stand-alone legislative document on HCWM, several directives and decisions regulate procedures and equipment for various types of hazardous waste. In Japan, the first rules on infectious waste management were issued in 1992, supplementing waste disposal laws of 1970. In Korea, the National Assembly modified the Waste Management Act in 1999 to better manage health-care waste from generation to final disposal.2

   In addition, developed countries issued technical guidelines to provide better information to stakeholders, such as guidelines for safe management of health-care waste (England), regulations on infection control and occupational safety (Germany), guidelines for infectious waste management (Japan),  and guidelines for HCWM (Korea).

     2.2 Implementation of international conventions relating to HCWM

   The United States, EU countries, Japan and Korea are signatories of the Basel Convention on hazardous waste, the Stockholm Convention on persistent organic pollutants (POPs), and the Minamata Convention on mercury. The Stockholm and Minamata conventions have achieved remarkable results in reducing the release of POPs and mercury.

   Incineration used to be the most common method for health-care waste treatment in the world. Germany had more than 550 health-care waste incinerators in 1984. In 1988, the EPA estimated that about 80 percent of hospital waste was incinerated in the U.S. In order to reduce release of POPs such as dioxin and furans, developed countries have used stringent emission standards to control incinerators and phased out small-scale incinerators in health facilities. In the United States, the number of health-care waste incinerators was reduced from 2,373in 1995 to 54 in 2010 and then 33 in 2013.3 In 2002, Germany shut down all small-scale incinerators in hospitals, even though several large-scale incinerators remain in operation. Ireland and Portugal have phased out all health-care waste incinerators.

   While restricting incineration, developed countries also have applied non-burn technologies including steam disinfection (autoclaves), microwave disinfection, chemical disinfection, melting or plasma technology, and others.  Many hospitals have used autoclaves to disinfect microbiological culture materials or preliminarily treat highly infectious waste since the 1970s. In 1997, a survey by a U.S. environmental industry association found that more than 1,500 non-burn technologies were installed for health-care waste treatment in the United States. Steam disinfection combined with shredding comprised 46.4 percent of health-care waste treatment methods 2002.2 In Japan, as of 2006, six percent of health-care waste treatment companies apply melting technology.4

   Developed countries have been moving away from on-site treatment to a centralized treatment model. In Japan and Korea, most health-care waste is treated by centralized treatment facilities that are situated outside of hospitals. By 2006, Japan had 296 infectious waste treatment companies providing services to 98 percent of hospitals, while less than 0.8 percent of hospitals still treated their own infectious waste.4 In Korea, centralized treatment facilities treat 90 percent of health-care waste.2

   In 2000, Japan enacted the Green Procurement Law, which restricts purchasing health-care products containing mercury. Nowadays, electronic thermometers and sphygmomanometers have generally replaced devices containing mercury, and production of devices containing mercury has sharply decreased. Demand of mercury for dental amalgam was 5,200 kilograms in 1970, but declined to 700 kilograms in 1999, 100 in 2006 and about 20 in 2010.5 U.S. regulations to control mercury release include EPA guidelines issued in 2002 for eliminating mercury in hospitals. The U.S. health sector has basically phased out medical devices containing mercury, and today it is nearly impossible to buy a mercury thermometer in the United States. The EU issued its strategy on mercury in 2005 and has banned the use of health-care measurement devices containing mercury since 2014. Korea’s Ministry of Environment issued plans and countermeasures for mercury management in 2006.

   3. Experience from developing countries in Asia

     3.1. Development of policy frameworks on HCWM

   Many developing countries strengthened their policy framework on HCWM to address environmental pollution and emerging communicable diseases. India issued its regulations on bio-medical waste management in 1998 and revised them in 2000, 2003 and 2016. The Central Pollution Control Board (CPCB) developed a series of guidelines for managing waste generated from immunization, mercury, auto-disable syringes, health-care waste incinerators, and other sources. 1,5 At the same time, India’s Ministry of Health and state governments issued guidelines on HCWM. To encourage centralization and privatization of bio-medical waste services, CPCB issued guidelines for common bio-medical waste treatment facilities and the Ministry of Environment provides 25 percent of the total project cost for establishing a common bio-medical waste treatment facility on a public-private partnership basis.6

   China issued regulations on the Control of Medical waste in 2003 after the SARS outbreak. In 2004, China approved a National Plan for building centralized treatment facilities for hazardous waste and health-care waste. Legal documents on HCWM included: measures for manifest management on transfer of hazardous waste; a catalogue of classified medical waste; measures for managing medical waste of medical and health-care institutions, and measures for administrative penalties on medical waste management. In addition, China established technical standards for medical waste incinerators, and medical waste transport vehicles. Furthermore, it developed trial technical specifications for centralized disposal of medical waste.7

   In the Association of Southeast Asian Nations (ASEAN) region, most countries have regulations, plans and guidelines on HCWM but at different levels of rigor (see Table 1). Malaysia and the Philippines have strong policy frameworks on HCWM. In the 1990s, Malaysia initiated a national strategy for centralization and privatization of health-care waste treatment services. The Philippines prohibited incineration of health-care waste in July 2003 and has a plan for gradually phasing out mercury in health facilities. Laos and Cambodia also have specific regulations and policies for HCWM.4,8 In contrast, Indonesia and Myanmar have not improved their legal framework for HCWM.9

   Vietnam has a relatively strong policy framework on HCWM, including the Environmental Protection Laws of 2014, Decree No. 38/20015/NĐ-CP on waste management, circular 36/2015/TT-BTNMT on hazardous waste and joint circular 58/2015/TTLT-BYT-BTNMT on HCWM. The government approved a national master plan for hazardous health-care waste treatment systems that requires cities and provinces to follow the centralized treatment model. To facilitate implementation, relevant government ministries issued technical regulations on health-care waste incinerators, guidelines for applying non-burn technologies, and a hospital waste management manual. While HCWM within health facilities has improved significantly, the centralized treatment model exists only in several major cities. In comparison to developing countries such as India, China, Malaysia and the Philippines that have having strong policy frameworks, Vietnam’s policy framework does not yet have technical guidelines, an action plan and public-private partnerships for centralization of health-care waste treatment and disposal.    

Table 1: Policy framework on HCWM in ASEAN countries


Law and regulation

Strategy, National Plan

Standards, technical guidelines


  • Declaration on HCWM
  • Strategic plan for infection control in health facilities 2011-2015
  • National action plan on dioxin
  • Draft national plan on HCWM
  • Technical guidelines on HCWM (2011)
  • Infection prevention and control guidelines for health-care facilities


  • Solid waste management Law No 18/2008, which has a clause on HCWM15


  • Environmental health standards for hospitals, which include HCWM15.


  • Regulation on waste management in health facilities (2004)
  • National policies on HCWM (2010)
  • Draft action plan on HCWM in the period of 2011-2015
  • Regulation on infection control (draft)


  • Environmental Quality Act (1984) and environmental quality (scheduled waste) regulations (2005), which include HCWM
  • Environmental quality (clean air) regulations (1978) and environmental quality (dioxin and furan) regulations (2004), which set limits on emissions from incinerators
  • Private Healthcare Facilities and Services Act (1998)
  • Occupational Safety and Health Act (1994)
  • Action plan for waste management in hospitals and health-care establishments (1993)
  • Privatization strategy, which calls for privatizing hospital support services including clinical waste management services
  • Management guidelines of clinical and related waste in hospitals and health-care establishments (1993)
  • Guidelines on the handling and management of clinical waste (2009)
  • Guidelines on chemical management in health facilities
  • Policies and procedures on infection control (2009)


  • Private health laws (2007), which requires private hospitals and clinics to have systematic waste disposal


  • Hospital management manual, which includes a chapter on HCWM


  • Clean Air Act (1999), which prohibits health-care waste incineration from July 2003
  • Ecological Solid Waste Management Act
  • Toxic Substances and Hazardous and Nuclear Waste Control Act
  • Policies and guidelines on effective and proper handling, collection, transportation, storage and disposal of HCW
  • Order No.2008-0021 on gradual phase-out of mercury in all Philippine health-care facilities and establishments
  • HCWM manual (1997, 2004, 2011)
  • Guidelines on the issuance of certificates of product registration for equipment or devices used for treating sharps, as well as pathological and infectious waste


   3.2 Implementation of international conventions relating to HCWM

   Many developing countries in the world are phasing out small scale health-care waste incinerators in hospitals, moving toward the centralized treatment model and applying more non-burn technologies to reduce the release of dioxin and furans into the air environment (under the Stockholm Convention). In India, incinerators are allowed to operate in common bio-medical waste treatment facilities only, while installation of incinerators in health facilities is not encouraged. India introduced non-burn technologies in its laws and regulations starting in 1996. By 2012, non-burn technologies had been applied widely with 2710 autoclaves, 179 microwaves and 4,250 shredders. Also 205 common bio-medical waste treatment facilities provided treatment services to 70 percent of health facilities nationwide.6

On-site treatment of health-care waste by autoclave and shredder in India     

Source: Lê Minh Sang/The World Bank

   China approved and implemented its national plan for building hazardous waste and health-care waste centralized disposal facilities, which included 331 such facilities. By the end of 2012, China built 272 health-care waste centralized disposal facilities in provinces and cities: 137 incinerators and 135 using non-burn technologies. The percentage of health-care waste disposal facilities applying non-burn technologies in China now exceeds 50 percent, showing that non-burn technologies have become the country’s major option.7

   In the ASEAN region, the Philippines is the first and the only country prohibiting incineration of health-care waste under the Clean Air Act of 1999, with the ban effective since 2003. Malaysia moved toward the centralized treatment model after the government assigned three private consortium to collect, transport, treat and dispose of health-care waste. However, incineration is still the main method for health-care waste treatment in Malaysia. Health-care facilities in other countries such as Cambodia, Laos, Myanmar and Indonesia are mostly using on-site incinerators.4,8,9

   Vietnam has been a signatory of the Stockholm Convention since 2001. The current policy framework includes more stringent standards on health-care waste incinerators (QCVN 02:2012/BTNMT); shutting down sub-standard incinerators (circular 36/2015/TT-BTNMT); encouraging non-burn technologies (decree No 38/20015/NĐ-CP and joined circular 58/2015/TTLT-BYT-BTNMT), and moving toward centralized treatment systems (decision 170/QD-TTg). While the regulations and strategy are sufficient, Vietnam’s monitoring and enforcement remains weak. In particular, Vietnam does not restrict new investment in on-site health-care waste incinerators, as is the case with India and Philippines.

   India, China and most ASEAN countries except Laos and Myanmar are signatories of the Minamata Convention on mercury. However, implementation of this convention is still in the starting phase. In 2008, the Philippines Department of Health issued an order on the gradual phase-out of mercury in all health-care facilities and institutions. More than 50 hospitals in the Philippines are moving toward mercury free health care, and several hospitals in India and China initiated the phase-out of medical devices containing mercury.10

   Vietnam joined the Minamata Convention starting in 2013. The Ministry of Health is initiating mercury management with surveys on the release of mercury by industries and health-care. Vietnam has not yet developed an action plan and technical guidelines for the gradual phase-out of mercury in health facilities, benchmarked against developed countries and the Philippines.

   4. Conclusions

   Countries have been strengthening their national policy framework with specific rules on HCWM, which can be stand-alone legal documents or integrated into existing waste management laws/regulations. In addition, various technical guidelines on HCWM and standards on equipment and facilities have been developed. Many countries are phasing out small-scale health-care waste incinerators in health facilities and moving toward the centralized treatment model. They also are applying non-burn technologies to reduce the release of dioxin, furans and toxic chemicals into the air environment. While developed countries has made good progress in reducing mercury in the health sector, developing countries are still in the starting phase.

   In comparison to other countries, Vietnam can improve the national policy framework and boost implementation of international conventions. Vietnam should (i) restrict new investment in on-site health-care waste incinerators and rigorously enforce shutting down sub-standard incinerators; (ii) develop technical guidelines, a realistic action plan and public-private partnerships for the development of health-care waste centralized treatment facilities; and (iii) develop action plans and technical guidelines for the gradual phase-out of mercury in health facilities.

Disclaimer: The findings, interpretations and conclusions expressed herein are those of the author(s) and do not necessarily reflect the view of the World Bank Group, its Board of Directors or the governments they represent.


  1. Dorothea Hansen, Ulrich Mikloweit, Birgit Ross, Walter Popp (2014). Healthcare waste management in Germany. Int J Infect Control 2014, v10:i1
  2. Yong-Chul Jang, Cargro Lee, Oh-Sub Yoon, Hwidong Kim (2006). Medical waste management in Korea. Journal of Environmental Management 80 (2006) 107–115
  3. US Environmental Protection Agency. Hospital/Medical/Infectious Waste Incinerators
  4. World Health Organization (2015). Status of healthcare waste management in selected countries of the Western Pacific Region (
  5. Japan Ministry of Environment (2013). Lessons from Minamata Disease and mercury management in Japan (
  6. India Central Pollution Control Board.
  7. Chen Y et al (2013). Application countermeasures of non-incineration technologies for medical waste treatment in China. Waste Manag Res.2013 Dec;31(12):1237-44
  8. Asian Institute of Technology (2008). Healthcare Waste in Asia: Intuitions & Insights.
  9. Sri Irianti (2013). Current status and future challenges of healthcare waste management in Indonesia. Media Litbangkes Vol. 23 No. 2, June 2013: 73-81
  10. Healthcare without harm. Mercury phase-out

Lê Minh Sang

Health specialist, The World Bank


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