TERMS OF REFENCE

FEASIBILITY STUDY FOR HOSPITAL WASTE MANAGEMENT

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STUDY AREA
A feasibility study is planned for the study area of [], []. The study area is located [], covers an area of []
square kilometers and a population of [] inhabitants. The income level of the study area, expressed as
Gross Domestic Product per capita per year, is [].
INTRODUCTION
Most wastes generated by hospitals and medical clinics are non-hazardous general wastes from hospital
organization activities (i.e., including kitchen wastes, office materials, workshop residuals) and patient
processing activities in wards which are not handling infectious diseases (i.e., first aid packaging, used
but emptied disposable bed liners and diapers, disposable masks, pharmaceutical packaging, etc.). After
source segregation of recyclables, disposal is typically by sanitary landfill.
Potentially hazardous wastes from hospitals and clinics which have a pathogenic, chemical, explosive, or
radioactive nature are called medical wastes. Medical wastes include the following:

pathological wastes (i.e., body parts, aborted fetus, tissue and body fluids from surgery; and
dead infected laboratory animals);
infectious waste (i.e., surgical dressings and bandages, infected laboratory beddings,
infectious cultures and stocks from laboratories, and all waste from patients in isolation
wards handling infectious diseases);
sharps (i.e., needles, syringes, used instruments, broken glass);
pharmaceutical wastes (i.e., soiled or out-of-date pharmaceutical products);
chemical wastes (i.e., spent solvents, disinfectants, pesticides and diagnostic chemicals);
aerosols (i.e., aerosol containers or gas canisters which may explode if incinerated or
punctured);
radioactive wastes (i.e., sealed sources in instruments, and open sources used in vitro
diagnosis or nuclear medical therapy); and
sludges from any on-site wastewater treatment facilities may be potentially hazardous.

Pathological wastes should be destroyed by incineration under high heat (i.e., over 900o C with an
afterburner temperature at over 800o C), although some countries require burial of human pathological
wastes at official cemeteries for religious reasons. To reach these temperatures and have adequate
afterburning and pollution control typically requires development of a regional medical waste facility.
Smaller individual hospital or clinic incinerators may not be able to reach these temperatures and
afterburning retention periods. Volatilized metals (such as arsenic, mercury, lead) and dioxins and furans
could result from inadequate burning temperatures and retention periods.
Other procedures to consider may include chemical disinfection or sterilization (i.e., irradiation,
microwave, autoclave, or hydroclave) followed by secure landfill disposal of residuals. In some cases,
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following complete disinfection, some wastes may be recycled. For example, recycling by specialized
contractors is sometimes arranged after disinfection of thick plastics, such as intravenous bags and tubs,
and syringes.
Pharmaceutical wastes require destruction, secure land disposal or return to the manufacturer for
destruction through chemical or incineration methods.
Chemical wastes need to be source segregated according to their recycling potential and compatibility;
and those which are non-recyclable may require stabilization, neutralization, encapsulation, or
incineration.
Hospital wastewater treatment sludges require treatment (i.e., anaerobic digestion, composting,
incineration, etc.) which raises temperatures to levels that destroy pathogenic microorganisms.
Radioactive medical therapy and diagnosis in high-income countries are divided into two categories:
open sources which derive from direct use of the radiochemical substance, and sealed sources which
involve indirect use of the substance within a sealed apparatus or equipment unit. Only open sources
tend to result in radioactive wastes, as sealed sources are returned to the manufacture for recycling when
exhausted or no longer required. Radioactive wastes typically include isotopes such as technetium 99,
gallium 67, iodine 125, iodine 131, cesium 137, iridium 192, thallium 201, and thallium 204. These
wastes are seldom present in low-income and middle-income developing countries, because the hospitals
do not have the equipment and technology to generate these wastes. If generated, these wastes should be
stored safely until the radioactivity has declined to acceptable levels and then disposed with general
refuse to sanitary landfill. The half-lives of commonly used medical radionuclides for therapy, diagnosis,
or imaging range from 6 hours to several days. Storage on-site in a secured chamber is typically
recommended for a period of 10 half-lives, or for one to two months.
The overall quantity of wastes generated in hospitals varies according to the income level of the country.
For developing countries, the data base is limited, but it appears that the following range of quantities is
likely:
general waste which is not contaminated, and can be handled with general municipal refuse:
1.0 to 2.0 kg/bed/day; and
contaminated medical waste which needs special management, and is considered potentially
hazardous: 0.2 to 0.8 kg/bed/day.
Low-income countries would tend to generate medical wastes on the low end of this range, while middleincome countries would tend to generate medical wastes on the upper end of this range. The study area
is within a [] income country, based on ranking criteria established by the World Bank and published in
its annual development report.
Medical wastes, if not properly managed, pose a risk to the personnel who are handling these wastes,
including custodial personnel and waste collectors, as well as to those providing disposal or picking
through the wastes for recyclables. There is the danger that syringes will be recovered from transfer
depots and disposal sites by waste pickers for recycling (i.e., by drug users). Contaminated containers
for collection of medical wastes are not usually dedicated to only one site, but are circulated throughout

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cities as each skip truck brings an empty container to the hospital or clinic and removes the full one while
it covers its daily collection route for general refuse.
Incineration is generally considered the preferred technology for some, if not all, medical wastes. At a
minimum, infected tissue, body parts, and laboratory animal carcasses are generally recommended to be
incinerated. On-site incinerators operating on a batch basis or regional incinerators operating on a
continuous basis are considered appropriate technology. Because of the cost of meeting stringent air
pollution control emission standards, many high-income countries are taking steps to steam sterilize,
irradiate, chemically disinfect, or gas/vapor sterilize some of the medical wastes.
One hospital incinerator with a capacity of 0.75 tonne/hour, operating on a continuous feed, could cost
from $US 0.5 to 1.0 million to implement. Air pollution control systems, if they are added to meet 1995
USA standards, could cost another $ 0.5 to 1.0 million to implement. Incinerators which operate on a
batch basis are typically dedicated to one hospital, as their capacity is limited to less than 1 tonne/day.
Regional incinerators would typically be designed to operate on a continuous feed basis.
These equipment costs do not include transportation, customs, and setup costs within the study area.
Transportation and setup may add about 10% to these costs. If government imports the equipment,
especially as it is for waste management purposes, customs may not need to be paid. However, if the
private sector is building the facility and needs to import the equipment, customs could add about to
these costs. Civil works and land costs which are local costs may add about 30% to these costs.
While the costs/tonne of treatment/destruction are likely to be high (about $100 to $300/tonne depending
on the level of pollution control required), the low quantities of medical wastes in developing countries
would result in a costs which generally would be less than 1% of the most hospital's operating budget,
exclusive of salaries. Therefore, the proper treatment/destruction facilities are likely to be affordable.
Hospitals interviewed in various developing countries have indicated a willingness to pay to cover these
costs.
Hospital waste treatment/destruction facilities could be implemented through one or more Design, Build,
Own, and Operate (DBOO) or Design, Build, Operate and Transfer (DBOT) concession agreements of 10
to 15 years duration. Or the government could implement the facilities and arrange for service contracts
of 2 to 5 years for operation and maintenance. Each hospital would be required to pay tipping fees which
fully cover the costs of investment, debt service and operation. As part of the privatization agreement,
the company providing the treatment/destruction services could also be awarded the task of also
providing collection of the wastes from each hospital and maintaining a manifest system to track the
waste from source to ultimate disposal.
Secured sanitary landfill is generally considered the preferred technology for medical wastes which do
not require incineration or disinfection, such as packaging materials and general kitchen wastes.
Nevertheless, special measures to fence and control access to the area of landfilling for medical wastes
are essential. No waste picking should be allowed in the secured area. Also, the machinery for
compacting refuse should not come in direct contact with the waste. Instead, the waste should be
dumped into a trench and a adequate layer of soil dumped over the waste. Only thereafter is it
recommendable that the machinery work over the soil covered waste to compact it and grade the surface
so that infiltration of rainwater is minimized.

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STUDY OBJECTIVES
The feasibility study will assess the technology options for medical waste treatment/destruction. The
study will result in recommendations which outline proposed numbers, sizes, and types of medical waste
treatment/destruction facilities. Technologies to be considered include incineration, irradiation, chemical
disinfection and sterilization.
For purposes of the proposed study on hospital waste management, the following objectives are to be
addressed:

determine the quantity and character of hazardous medical wastes generated by hospitals and
clinics in the study area;
evaluate the progress being made in source segregation and develop recommendations for
improving the source segregation systems of hospitals and clinics in the study area;
estimate the capacity requirements for existing hospital treatment/destruction facilities for
the study area;
determine the optimum technology for cost-effective and environmentally safe
treatment/destruction of medical wastes in the study area;
based on transport distances and economies of scale, as well as available sites for
implementation, determine the number and size of hospital waste treatment/destruction
facilities needed;
provide a preliminary design, including a typical site layout, and estimate land, capital,
operating, and staffing requirements for each of the hospital waste treatment/destruction
facilities recommended; and
assess the environmental impact issues of implementing each the hospital waste facilities
recommended and recommend appropriate mitigative measures to enable the facilities to
meet [] environmental requirements.

SCOPE OF WORK
Task 1: Waste Quantity and Character.
Determine the quantity and character of medical wastes generated in the study area, including
pathological, infectious, sharps, pharmaceutical, chemical, aerosol, and radioactive wastes. As part of
the effort to make this determination, accomplish the following activities.
Based on the records kept by the solid waste authorities within the study area and the hospitals,
determine the volume and weight of medical wastes being collected. If data does not exist, weigh
hospital waste loads for a period of at least 4 days.
Visually describe the composition (on a percent wet weight basis) of medical wastes to be managed by
treatment/-destruction facilities, such as the contaminated paper products, plastics, fabrics, wood, rubber,
cloth, pharmaceutical, tissue, body and bedding materials.
Estimate the calorific heating value of combined mix of medical wastes, on both a dry and wet weight
basis, based on the apparent contents of the waste, from the above visual observations. This will involve

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examining wastes at least [] large hospitals and examining medical wastes being discharged at disposal
sites.
Sample, on an accepted random sampling basis, at least 4 loads of medical waste arriving at disposal
sites. Conduct laboratory analyses of the calorific values and moisture contents of the samples. Report
results in terms of wet as received lower heating value (in kcal/kg and BTU/pound), dry higher heating
value (in kcal/kg and BTU/pound), and moisture content (percent on a wet weight basis).
Assess whether there are liquid wastes from the hospitals which could be burned in conjunction with the
solid medical wastes and might add to the heat value of the overall waste mixture, such as alcohol,
coolants, oils, solvents, strippers, thinners, phenols, resins, and emulsions. Assess whether the addition
of these liquid wastes would compromise the air emissions from the proposed treatment/destruction
facility. Estimate the quantities of the liquid wastes which could be burned with the solid medical
wastes.
Task 2: Source Segregation Systems.
Visit at least [] hospitals to review their systems of medical waste segregation, storage, and disposal.
Estimate the percentage of wastes which are being segregated, out of the total being generated. Inspect
the storage facilities and estimate the pre-collection volume of medical waste being generated and
segregated.
For each of the hospitals visited, estimate the volume/bed/day of refuse. If there are wide variations
among the hospitals visited, determine whether the variance is related to compliance with the source
segregation system. Estimate the total quantity of medical waste which would be generated in the study
area if all hospitals were fully implementing adequate source segregation. Provide an estimated
breakdown in terms of the quantity of medical waste requiring: (i) special storage for radiation decay, (ii)
treatment/destruction in a medical waste facility, and (iii) amenable to recovery and recycling.
Task 3: Project Waste Quantities and Characteristics.
Based on the economic level of the study area, economic growth projections, population growth
projections, trends in hospital waste generation and source segregation, project the quantity and
characteristics of medical wastes which are expected to be generated over the next 20 years.
Task 4: Regulatory Requirements.
Determine all pollution control standards to be met by a medical waste treatment/destruction facility in
[]. Particularly determine the air emission standards which are currently required by [] law and which
would be likely to be required in the next 10 years. Assess the corresponding air pollution control
requirements for particulates removal, flue gas scrubbing, and dioxin removal. Assess the costs versus
the pollution control differences between dry versus wet scrubbing systems.
Outline the environmental permitting, building permitting, and other permitting requirements and
procedures which treatment/destruction facilities for medical wastes would need to address. Also outline
any public participation or public hearing requirements and procedures. For each requirement, list the
lead agency to be contacted. Assess the typical time demands for proposed facilities to obtain permits
and address environmental impact assessment and public participation requirements.
Task 5: Treatment/Destruction Options.
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For the types, quantities and sizes of materials included in the study areas medical wastes, assess
alternative technologies and facility sizes for treatment and destruction. The assessment shall compare
the alternatives on the basis of capital cost, operating cost, ease of operation, local availability of spare
parts, local availability of operational skills, demonstrated reliability, durability, and environmental
impacts. The technologies to be considered include: incineration, irradiation, sterilization, and chemical
disinfection, and secured landfill. On the basis of this assessment, recommend a process flow for
economic and environmentally sound management of medical wastes in the study area.
Task 6: Residuals.
For the recommended process flow which would provide treatment/destruction of study areas medical
wastes, assess the quantity and characteristics of residuals. Include assessment of process residuals (such
as incinerator ash), as well as pollution control residuals (such as flue gas cleaning sludge, particulates,
spent filters, and spent activated carbon).
Task 7: Strategic Location and Sizing.
For the recommended treatment/destruction system, assess whether there are significant economies-ofscale to be considered. Also, examine the travel times and distances to drive in the study area from the
various centers of medical waste generation to potential locations for treatment/destruction facilities.
Also, examine the travel times and distances to drive from the facilities to the location for residuals
disposal. Economically analyze whether the study area would be best served by one or more than one
treatment/destruction facility. Determine the optimum number and location(s) of facilities.
Task 8: Preliminary Design.
Develop a model process flow diagram and site layout for the recommended treatment/destruction
facilities. Include treatment processes for wastewater, cooling water, drainage, odor pollution, and air
pollution in the model process flow diagram. Include facilities for parking, gate control, weighing loads,
administration, worker sanitation and washing/changing, worker cafeteria and training, and truck
washing/disinfection in the model site layout. Provide a conceptual floor layout for each of the buildings
recommended with the site layout. Assess spatial requirements for the facilities, as a function of their
recommended medical waste handling capacities.
Determine the electrical power supply available and the type of fuel (i.e., oil, natural gas) available for
operating the facility. Assess the potential for waste-to-energy conversion and which type of energy
recovery would be preferred, such as steam, hot water, hot air, thermal liquid, electricity. Outline user
requirements, such as steam pressure requirements or hot water requirements.
Task 9: Land and Investment Requirements.
Based on the spatial requirements estimated above, determine how much land is required for each of the
recommended facilities. Outline the land acquisition issues and constraints which might exist in the
study area, including human resettlement issues and constraints. Based on local land values and
resettlement costs, estimate the costs of land acquisition.
Assess building requirements, including foundation requirements for the study area. For the model
facility designs developed above, and in keeping with local building requirements, develop budgetary
estimates for implementation. Include investment costs for site preparation, construction of civil works,
stationary equipment, and mobile equipment.

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Task 10: Operating Requirements.

Determine the cost of consumable supplies and utilities associated with operating the proposed
treatment/destruction facilities. For any potential materials recycling and/or energy recovery, estimate
the revenue potential based on current market prices.
List the manpower requirements for the proposed treatment/destruction facilities, including managers,
planners, administrators, supervisors, operators, guards, and attendants. Estimate the cost of salaries
required to operate the facilities.
Based on the cost of consumables, salaries, insurances, registrations, investment depreciation, and debt
service, estimate the total annual cost to own, operate and maintain the proposed facilities. Estimate the
cost/tonne of waste processed if operating at 70% capacity initially and 90% capacity within 10 years.
Task 11: Environmental Study and Mitigation.
Prepare an environmental report which reviews the environmental issues related to the proposed
treatment/destruction facilities. These reviews are to be conducted in accordance with local
environmental impact assessment guidance, as well as the Worlds Operational Directive 4.01,
Environmental Assessment. For adverse impacts identified within the reviews, outline mitigative
measures which need to be included within the proposed design (including mitigative by wastewater
treatment, air pollution control, odor control, etc., processes). Further outline mitigative measures which
should be included within the operational procedures. In addition, provide a monitoring program for
monitoring throughout implementation and operation activities. If any of the proposed sites for the
facilities have inhabitants or tribal nomadic dwellers, address the World Banks requirements under
Operational Directive 4.30, Involuntary Resettlement or any other relevant guidance provided by the
agencies participating in this project.
Task 12: Implementation Schedule.
Develop an anticipated schedule for securing all required permits, including environmental permits, for
implementation of the proposed facilities. Include time for public participation, as appropriate.
Develop an implementation schedule for siting, land acquisition, human resettlement, land preparation,
construction, training, demonstration, and start-up of the proposed facilities. Include scheduled steps to
advertise tenders, evaluate bids, and negotiate contracts.
Task 13: Implementation Strategy.
Assess the alternative ways in which the proposed facilities could be implemented and provide adequate
discussion of the pros and cons of each alternative to enable decision-making. Include consideration of
the following: (a) the local or central government designs, builds, owns and operates the facilities; (b) the
local or central government designs, builds and owns the facilities and contracts for operation by
government; (c) the local or central government designs, builds and owns the facilities and leases them to
the private sector for their operation; (d) the local or central government develops design performance
requirements and gives a concession to the private sector to design, build, own, and operate facilities; (e)
the local or central government licenses private firms to compete with each other to design, build, own,
and operate facilities; or (f) hospitals collectively organize a semi-private enterprise to design, build,
own, and operate facilities.
Task 14: Financial Package.
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Recommend financing arrangements for project implementation. Based on whether the money for
implementation is to be borrowed by the hospitals, the government, or invested by the private sector,
provide a financial package which would enable final design and procurement activities to begin
immediately at the conclusion of the study.
Task 15: Regulatory Framework.
Review the existing regulations, strategies, policies, and enforcement practices at the local and central
government level concerning the management of medical wastes, and the more general topic of
hazardous wastes. Identify limitations and deficiencies in the regulatory framework. Develop specific
recommendations on areas which need to be improved within the regulatory framework, so that hospitals,
communities, and waste haulers have the appropriate incentives and disincentives to provide proper
waste management.
Task 16: Technical Seminar.
Provide a seminar to government officials and hospital administrators on the findings of this feasibility
study, upon completion of the draft final report. Obtain their review comments during the seminar and
address their comments in finalization of the report.
STUDY TEAM
The team to conduct the feasibility study will need to have extensive experience in hospital waste
management and design of treatment/destruction facilities. The team will need to have practical
knowledge of the pros and cons of various hospital waste treatment/destruction options. The team will
also need to be familiar with the assessment of technology options under the range of unique skill,
management and financial conditions which exist in developing countries. The team will need to be
qualified to put together a financial proposal for implementation of the study recommendations.
Resumes of the qualifications and experience of the key members of the team will be the key criteria
used to evaluate proposals.
REPORTS
Provide a diagnostic report after completion of Tasks 1 to 4, within 2 months of the commencement date of
the contract. Provide an interim report after completion of Tasks 5 to 10, within 4 months of the
commencement date of the contract. Provide a final draft report after completion of Tasks 11 to 15, within
6 months of the commencement date of the contract. Conduct the technical seminar required under Task 16,
and then issue the final report within 8 months of the commencement date of the contract. Ten copies of
each report are to be provided.

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