Waste Management 27 (2007) 626638

www.elsevier.com/locate/wasman

Developing a master plan for hospital solid waste management:

A case study
Mohammad Karamouz a, Banafsheh Zahraie a, Reza Kerachian a,*
,
Nemat Jaafarzadeh b, Najmeh Mahjouri c
a
School of Civil Engineering, University of Tehran, Tehran, Iran
b
Faculty of Health Science, University of Ahvaz, Ahvaz, Iran
c
School of Environmental Engineering, University of Tehran, Tehran, Iran

Accepted 13 March 2006

Available online 27 June 2006

Abstract

Disposal of about 1750 tons of solid wastes per day is the result of a rapid population growth in the province of Khuzestan in the
south west of Iran. Most of these wastes, especially hospital solid wastes which have contributed to the pollution of the environment
in the study area, are not properly managed considering environmental standards and regulations. In this paper, the framework of a
master plan for managing hospital solid wastes is proposed considering dierent criteria which are usually used for evaluating the pol-
lution of hospital solid waste loads. The eectiveness of the management schemes is also evaluated. In order to rank the hospitals and
determine the share of each hospital in the total hospital solid waste pollution load, a multiple criteria decision making technique, namely
analytical hierarchy process (AHP), is used. A set of projects are proposed for solid waste pollution control and reduction in the pro-
posed framework. It is partially applied for hospital solid waste management in the province of Khuzestan, Iran. The results have shown
that the hospitals located near the capital city of the province, Ahvaz, produce more than 43% of the total hospital solid waste pollution
load of the province. The results have also shown the importance of improving management techniques rather than building new facil-
ities. The proposed methodology is used to formulate a master plan for hospital solid waste management.
 2006 Elsevier Ltd. All rights reserved.

1. Introduction transportation), and incineration of hospital wastes pro-

With rapid population growth and industrialization, dis-
posal of hospital solid wastes, which include a wide range
of infectious hazardous wastes pollutants, has become
one of the main environmental issues. A limited number
of studies related to the hospital solid waste management
have been made, especially for the development of manage-
ment schemes for hospital wastes.
Liberti et al. (1996) proposed a model to provide an
optimal solution to the overall waste management system
involving characterization, handling (collection, storage,
*
Corresponding author. Tel.: +98 21 61112176; fax: +98 21 66403808.
E-mail addresses: karamouz@ut.ac.ir (M. Karamouz), bzahraie@ut.
ac.ir (B. Zahraie), kerachian@ut.ac.ir (R. Kerachian), n_jaafarzadeh@
yahoo.com (N. Jaafarzaheh), mahjouri@ut.ac.ir (N. Mahjouri).
duced by a large sanitary district.
Awad et al. (2004) carried out statistical analyses to
develop models for predicting the quantity of waste gener-
ated at two public and private hospitals in Jordan. In their
models, number of patients, beds, and hospitals were iden-
tied as signicant factors on quantity of waste generated.
Multiple regression was also used to estimate the quantities
of wastes generated.
Morrissey and Browne (2004) reviewed dierent types of
models that are currently being used in the area of munici-
pal, hospital, and industrial waste management and high-
lighted some major shortcomings of these models. Based
on their work, most of the models identied in the litera-
ture are decision support models that are divided into three
categories based on: costbenet analysis, life cycle assess-
ment, and multi-criteria decision making. They showed

0956-053X/$ - see front matter  2006 Elsevier Ltd. All rights reserved.
doi:10.1016/j.wasman.2006.03.018
 M. Karamouz et al. / Waste Management 27 (2007) 626638
Nomenclature
k Eigen value of pair-wise comparison matrix
kmax dominant eigenvalue
A pair-wise comparison matrix
aij elements of pair-wise comparison matrix
cij value of criterion i for alternative j
CRIn inconsistency index for randomly lled matrixes
with dimension n
II inconsistency index
IIh inconsistency index for basic criteria
IR inconsistency ratio
that the shortcomings of the current waste management
models include concerns regarding the renements of the
evaluation steps rather than addressing the decision mak-
ing process.
Karamouz et al. (2003) proposed a framework for devel-
oping a master plan for water resources pollution control
using Multiple Criteria Decision Making (MCDM) tech-
niques. They proposed an integrated set of direct, indirect
and supporting water pollution control projects. Source
reduction, demand management, capacity expansion,
human resources development, development of monitoring
and sampling network, research and technology transfer,
institutional changes, and improvement of legal framework
have been the major initiatives recommended in the master
plan.
A new framework to develop a master plan for hospital
solid waste management is introduced in this paper. Dier-
ent criteria can be used for evaluating the pollution of exist-
ing hospital solid waste loads and the eectiveness of the
management schemes. In order to rank the hospitals and
determine the share of each hospital in the total hospital
solid waste pollution load, a multiple criteria decision mak-
ing technique, namely analytical hierarchy process (AHP), is
used. In this framework a comprehensive set of direct, indi-
rect, and supporting projects are proposed for hospital solid
waste pollution control. The proposed methodology is eval-
uated using data from 40 hospitals in the province of Khuze-
stan. In this province, most of the hospital solid wastes are
stored, disposed or burnt in open spaces. In some cases,
these solid wastes (including infectious wastes) are disposed
in landlls used for the disposal of domestic wastes, which
can cause considerable environmental and health problems.
The proposed framework includes the following steps:
 Data gathering.
 Identication of system components and the interac-
tions among them.
 Analysis of economic and social consequences of the
hospital solid waste pollution.
 Selection of a comprehensive set of indicators, which
shows dierent aspects of the hospital solid waste pollu-
tion load and management.
627
m1, . . . , mn index of sub-criteria
N number of decision-makers
rij elements of row iand column j in the dimension-
less decision matrix
w Eigen vector of pair-wise comparison matrix
wai weight of alternative i
Wi weight of alternative i
wai relative weight of alternative i
wI MAX the maximum weight of the intervals related to
the corresponding criterion
 Determination of the spatial and temporal variations of
the hospital solid waste pollution loads (pollution load
zoning).
 Ranking of the pollution sources and determining the
share of each hospital in the environmental pollution
through solid waste disposal.
 Development of a GIS-based data bank and a Manage-
ment Information System (MIS).
 Proposing a set of direct, indirect, and supporting pro-
jects considering the relative share of hospitals.
 Evaluation of the proposed projects in pollution control
in the study area.
 Development of a timetable for project implementation.
 Determination of the needed budget on an annual basis.
The owchart of the activities required for developing a
hospital solid waste pollution control master plan is pre-
sented in Fig. 1.
2. Analytical hierarchy process (AHP)
The AHP method was rst developed by Saaty (1980
and 1994) and has been widely used in both elds of theory
and practice. This method is based on the pair-wise com-
parison of the importance of dierent criteria and sub-cri-
teria. The consistency of comparisons should also be
veried. The dierence between the dominant eigenvalue
of the pair-wise comparison matrix, kmax, and the matrix
dimension, k, is used by Saaty (1980 and 1994) in dening
the inconsistency Index, II:
kmax  k
II : 1
k1
The inconsistency ratio, IR, is then dened as:
IR II=CRI; 2
where, CRI is the Inconsistency Index of the random matrix
obtained by calculating II for randomly lled matrix. If
IR < 10%, then the consistency criterion is satised; other-
wise the decision maker should be asked to revisit the
pair-wise comparisons. This procedure continues until all
pair-wise comparisons satisfy the consistency criterion.
628 M. Karamouz et al. / Waste Management 27 (2007) 626638

Major Steps

Data gathering using questionnaires or by reviewing reports

First Phase: Problem Identification

Identification of systems components and interactions among them

Development of a GIS-based data bank and a MIS

Analysis of economic, social, and political consequences of the solid waste pollution

Selection of a comprehensive set of indicators, which show different aspects of hospital

solid waste pollution load and solid waste management.

Determination of the spatial and temporal variations of the solid waste pollution loads

Ranking the pollution sources and determining the share of each medical unit in
environmental pollution through solid waste disposal

Flexible Planning Approaches

Proposing a set of direct and supporting projects
considering the relative share of hospitals in

Second Phase: Master Plan Development

environmental pollution through solid waste disposal

Environmental impacts of current Evaluation of the effectiveness of the proposed

and Action Items

and ongoing projects projects in pollution control in the study area

Budget associated with each proposed project

Socio-economic impacts of the
proposed projects

Priority of implementation of the projects

Time table for budget spending

Framework of cooperation among

sectors and public Time table of action items

Development of monitoring and

Monitoring and

Monitoring and Evaluation

Third Phase:

evaluation system
Evaluation

Adjustments considering
changing needs

Fig. 1. Major phases for development of a master plan for hospital solid waste pollution control.

The eigenvector of pair-wise comparison matrix is used vector for pair-wise comparison matrix of basic criteria; ci,k
for estimating the relative weight (importance or priority) the value of sub-criterion k for alternative i divided by the
of dierent alternatives. For this purpose, the following maximum value of that sub-criterion for all alternatives;
relation is used: wj,k the relative weight of sub-criterion k of basic criterion
! j; W ai the relative weight of alternative i; m/n the total num-
Xn Xmi
a
wi wj  ci;k  wj;k  3 ber of alternatives/basic criteria and mi is the number of sub-
j1
k1 criteria dened for basic criteria i. The selected criteria and
wai sub-criteria for this study are shown in Fig. 2. Dierent hos-
a
W Pm
i a
; 4 pitals are considered as alternatives. The relative weight of
j1 wj
alternative i, W ai , which is calculated based on the pro-
where, wai is the weight of alternative (sector) i; wj the relative posed method, can show the share of the hospital i in con-
weight of basic criterion j which is the jth element of eigen- taminating the environment through solid waste disposal.
 M. Karamouz et al. / Waste Management 27 (2007) 626638 629

Level 1 Level 2 Level 3 Level 4

Separation (0.25)

Storage (0.15)

Hazardous Transportation (0.15)

Solid
Wastes Disposal (0.45)
(0.65)
Solid waste
management Separation (0.3)
(0.35)
Storage (0.15)
Objective: Non-
Determination of the hazardous Transportation (0.15)
share of each hospital Solid
in total hospital solid Wastes Disposal (0.4)
waste pollution (0.35) Pharmaceutical
Wastes (0.25)
Hazardous
Sharps (0.3)
Solid
Wastes
Human tissues (0.45)
Solid waste (0.75)
generation
(0.65) Semi-domestic (0.2)

Paper (0.1)
Non-
hazardous Food wastes (03)
Solid
Wastes Miscellaneous (0.4)
(0.25)

Fig. 2. Proposed hierarchy structure of indicators and their relative weights (numbers in the parentheses) for ranking of hospitals based on their solid
waste generation and management.

3. Case study ods of treatment or disposal were also gathered. This

The proposed methodology is applied for classication
and ranking of the hospitals located in the Khuzestan prov-
ince of Iran. About 40 hospitals are considered in the
study. The total hospital solid waste generated in the study
area is about 13 tons per day, of which about 27% is haz-
ardous wastes (Karamouz, 2003).
In this study, by revising an existing questionnaire pro-
vided by the Department of Environment (DOE) in Iran,
a more comprehensive questionnaire was designed for
gathering the basic data related to the main characteristics
of hospital solid wastes and their disposal in the study
area. The main criteria proposed for the hospital solid
waste classication, as stated in the American Resource
Conservation Recovery Act (RCRA) and Australian
guidelines for waste management in the health industry
(NHMRC, 1999) are considered in developing the new
questionnaire. The questionnaires were completed by eval-
uating the qualitative and quantitative characteristics of
the solid wastes, as well as the processes utilized for sepa-
ration, packing, transportation, incineration, and disposal
of the hazardous and non-hazardous wastes in each hospi-
tal. Some additional data such as the number of beds, the
amount of disposed waste and wastewater, and the meth-
information includes the composition of the hospital solid
wastes such as the relative weights of the semi-domestic,
non-hazardous, infectious, paper, food, and other types
of solid waste materials in each hospital, as well as in
the province.
Dierent steps in developing the master plan for hospital
solid waste management were listed in the previous section.
Some of the main steps are explained as follows:
 Data gathering: Detailed data and information which
are required for evaluating each hospital should be gath-
ered by visiting the medical unit, sending questionnaires
and reviewing related reports. Data deciencies may be
tackled via engineering judgment and using experts
opinion.
 Identication of the pollution sources: Identication of
the biomedical pollution sources is the rst step in devel-
oping of a master plan. Dierent criteria such as hospi-
tal solid waste quantity and quality can be used for
classication of these pollution sources.
 Determination of the evaluation criteria: A comprehen-
sive set of indicators should be selected for evaluating
the pollution load, environmental impacts, and solid
waste management in each hospital. Indicators can be
630 M. Karamouz et al. / Waste Management 27 (2007) 626638
classied to two main criteria, namely solid waste gener-
ation and management. For these criteria, some sub-cri-
teria related to the separation, storage, packing, transfer
and disposal of the dierent types of hospital wastes can
be dened.
 Determination of the share of each hospital in environ-
mental pollution through solid waste disposal: Ranking
of hospitals based on a hierarchy structure of indicators
is important for identifying the main pollution sources.
The proposed hierarchy structure of indicators pre-
sented in Fig. 2 can be used for this purpose.
The related weight of the criteria and sub-criteria in each
level should be determined using a pair-wise comparison.
As stated by Pomerol and Barba-Romero (2000), the idea
of introducing pair-wise comparisons between dierent cri-
teria is to make pair-wise comparisons at a time rather than
assigning weights to the whole set of criteria. In order to
incorporate engineering judgment, a group decision-mak-
ing method developed by Aczel and Saaty (1983) has been
used. In this method, each element in group pair-wise com-
parison matrix is assumed to be equal to the geometric
mean of corresponding elements in dierent pair-wise com-
parison matrixes of decision makers.
The analytical hierarchy process (AHP), which is
described in the following section, can be used for ranking
the hospitals, as well as determining their relative share of
solid waste pollution.
 Development of a GIS-based data bank and MIS: The
collected data is stored in a bank with statistical anal-
ysis and report generation capabilities. The GIS-based
maps of the study area are for evaluating the spatial
and temporal variations of the solid waste pollution
loads. They include pollution loads and solid waste
characteristics.
 Proposing solid waste pollution control projects: The
major projects of the master plan are selected and
ranked based on how eective they are in reducing the
environmental pollution through hospital solid waste
disposal. The projects are usually proposed by managers
and experts of dierent hospitals located in the study
area, and then they are prioritized considering their
impacts on the overall master plan. Finally, the most
eective projects are selected in three classes namely
the direct projects, the indirect projects, and the sup-
porting projects. The direct projects, which can directly
reduce the solid waste disposal pollution load, can be
categorized in the following categories:
Source reduction.
Solid waste recycling and reuse.
Solid waste treatment.
Solid waste incineration and disposal considering
environmental issues.
Other projects that have an indirect impact on solid
waste pollution control, as well as the projects aimed to
improve the eectiveness of the direct projects, are usually
proposed as the indirect and support projects, respectively.
The supporting projects are proposed considering the fol-
lowing general themes:
 Integrated sampling and monitoring network.
 Research and technology transfer.
 Human resources capacity building and improvement of
legal framework.
 Monitoring and evaluation.
4. Results of applying the AHP method for ranking of
hospitals
A hierarchy structure of indicators is proposed (Fig. 2)
for ranking the hospitals based on their solid waste genera-
tion and the management techniques. As shown in Fig. 2,
there are two main criteria for evaluating the solid waste
generation and management in the second level of the struc-
ture, which are evaluated based on the characteristics of the
hazardous and non-hazardous hospital solid wastes. In this
structure, some sub-criteria such as separation, storage,
transportation and disposal of dierent types of hospital
solid wastes are used, which are related to the solid waste
management criterion in level 2 in the hierarchy structure
of the criteria. Solid waste generation is qualied by evalu-
ating the amount of hazardous and non-hazardous hospital
wastes. Hazardous hospital wastes include pharmaceutical
wastes, sharps, and human and animal tissues. The relative
weights of the criteria are calculated based on pair-wise
comparisons set by the decision-makers and experts familiar
with the system. These comparisons are usually presented in
the form of pair-wise comparison matrices. Decision-mak-
ers can assign a consistent weight when only two criteria
are involved; however when there are several criteria, the
weighting and judgments about their importance in envi-
ronmental polluting through solid waste disposal are rather
dicult and could result in inconsistent assessments. In this
study, a group of decision makers and experts, including six
environmental and system engineers who were experts in
hospital waste management and analytical hierarchy pro-
cess, set the pair wise comparison matrices. The geometric
mean method (Saaty, 1994) is used to nd the group judg-
ment about the relative importance of sub-indicators, which
resulted in the weights shown in Fig. 2.
The following matrix shows the group judgments for the
sub-criteria of the non-hazardous solid wastes as an exam-
ple:
 M. Karamouz et al. / Waste Management 27 (2007) 626638 631

Table 1
Classication of the daily weight of disposed hospital solid wastes in the province of Khuzestan, Iran (tons/year)
Class number Type of hospital solid waste
Semi-domestic Paper Food wastes Miscellaneous Infectious Pharmaceutical wastes
Human tissues Sharps
1 0.120 0.11 0.19 0.14.5 0.13.5 0.11.1 0.13.9
2 2044 14 919 4.58.5 3.59 1.13.1 3.99.5
3 4460 46 1934 8.511 920 3.15.6 9.514.5
4 6072 68 3459 1113.5 2029 5.67.1 14.520
5 7290 810 5979 13.515.5 2936 7.19.5 2029
6 90140 1014 79114 15.519 3649 9.514.5 2943
7 140210 1418 114200 1929 4986 14.518.5 4345
8 210365 1827 200319 2950 86147 18.527 4575
9 365751 2753 319453 5056 147160 2733 75102

As it can be seen in this matrix, the group judgments are grade (PG) related to each criterion located in the last level
inconsistent. For example, the relative importance of of hierarchy structure. PG is calculated as follows:
separation compared with storage is equal to two and the wInd  wI
relative importance of storage compared with transporta- PG ; 5
wI MAX
tion is equal to one. If the decision-maker comparisons
were consistent, the relative importance of separation where wI is the weight of the interval I that the evaluator
compared with transportation would be 2 1 = 2 but the score falls into; wInd the weight of the indicator in the last le-
decision maker indicated 1.5. In this study, the inconsis- vel (Fig. 2), which is the relative importance of the indicator
tency of pair-wise comparison matrices are quantied using compared to the others and wI MAX is the maximum weight of
the inconsistency index (IIb), which is equal to 0.01 for the the intervals related to the corresponding criterion.
above matrix. It is less than 0.1, so it is considered The relative weight of each hospital (its share in environ-
consistent. mental pollution through solid waste disposal) is calculated
As the number of alternatives (hospitals) is more than 9, for each alternative (hospital) by the summation of partial
application of ordinary AHP method will be limited as sug- grades of the indicators located in the last level and the
gested by Saaty (1990). Therefore, the value of the indica- nal ranking is obtained.
tors located in the third level of the hierarchy structure is The overall inconsistency index II is estimated by com-
clustered into nine classes considering their range of varia- bining the inconsistency index of basic criteria and the
tions. Table 1 presents the characteristics of the selected eects of sub-criteria as follows:
classes for ranking the hospitals located in the Province    
of Khuzestan. For dierent types of hospital wastes, the IIb IIe
II IIa 0:35 0:65   0:65 0:35 
range of weight of solid wastes that are annually generated IIc IIf
 
in dierent hospitals is divided into nine classes so that the IIg
numbers of hospitals located within dierent classes are 0:75 0:25  ; 6
IIh
almost the same. For each class, an indicator value is
selected, which is the average weight of solid wastes of hos- where, IIa is the inconsistency index of the pair-wise
pitals located in the class (Table 2). The total score (grade) comparison matrix of the basic criteria located in level
of each hospital is calculated by summation of a partial 1; IIb, IIc are the inconsistency indices of the pair-wise

Table 2
Selected indicator values for each class of the annual weight of disposed hospital solid wastes in the province of Khuzestan, Iran (tons/year)
Class number Type of hospital solid waste
Semi-domestic Paper Food wastes Miscellaneous Infectious Pharmaceutical wastes
Human tissues Sharps
1 9.17 2.33 3.5 1.67 1.5 0.75 0.92
2 33.5 5.2 12.4 5.25 5.4 2.4 5.2
3 52.4 7.5 22.5 9.75 15.5 4.82 11.91
4 68.14 9.75 42.8 12.2 24.5 6.5 15.88
5 81.5 12 63.33 14.82 31.25 7.9 23.5
6 133.3 16.2 90.9 16.75 39.8 11.1 32.9
7 166.58 20.14 131.83 21.71 53.4 16 44
8 303.5 21 224.75 34 92.08 20.3 55.4
9 572 46.5 386 53.78 149 29.2 100
632 M. Karamouz et al. / Waste Management 27 (2007) 626638

comparison matrices of the indicators located in level 2, The overall Inconsistency Ratio is then estimated using Eq.
which are related to the Solid Waste Generation and (2) as 0.04, which is less than 10%. Therefore, the group
Solid Waste Management criterion, respectively; and judgments in matrices are used for estimating the share
IIe, IIf, IIg, IIh are the inconsistency indices of the of dierent hospitals in pollution of the system due to waste
pair-wise comparison matrices of the indicators located disposal.
in level 3. Tables 3 and 4 present the shares of contamination for
The overall random inconsistency index of the hierarchy dierent zones as well as the top 10 most polluting hospi-
structure CRI is then estimated similar to II, but in Eq. (6), tals, which are estimated using Eqs. (3) and (4). As shown
IIi, which is the inconsistency index of matrix i, is replaced in Table 3, Ahvaz region produces the highest load of hos-
with CRIn. CRIn is the inconsistency index of a n n ran- pital solid waste disposal. The share of this region in pollut-
dom matrix and n is the dimension of the pair wise compar- ing the environment is more than 50%. Table 5 presents the
ison matrix (Saaty, 1990). Therefore, CRI can be calculated share of all investigated hospitals considering dierent rel-
as: ative weights for solid waste generation and management.
    As presented in this table, the share of each hospital in pol-
CRI2 CRI4 luting the environment is not considerably dependent on
CRI CRI2 0:35 0:65  0:65 0:35 
CRI2 CRI4 the relative weights of the criteria. Therefore, the calculated
    values can be properly used in developing the master plan.
CRI3 0
0:75 0:25  0 0:35 0:65  Ranking of hospitals may depend on the selected set of cri-
CRI4 0
    teria. For example, Table 6 presents shares of the 10 most
0:9 0:58
0:65 0:35  0:75 0:25  1:56 polluting hospitals in generating infectious wastes, which
0:9 0:9 are partially dierent with the 10 most polluting hospitals
7 based on hierarchy structure of criteria presented in Fig. 2.

Table 3
Share of hospitals located in dierent regions in the province of Khuzestan (Iran) in polluting the environment through solid waste disposal (%)
Rank Region (city) Hospital Beds Inpatient and out-patient dischargesa Share (%)
1 Ahvaz 3151 42,74,535 53.8
2 Behbahan 208 N/A 6.7
3 Abadan 424 49,216 5.4
4 Dezful 542 N/A 4.1
5 Masjedsoleiman N/A N/A 3.8
6 Khorramshahr 224 N/A 3.4
7 Ramhormoz 174 270,000 3.2
8 Shoosh 157 5502 2.9
9 Eazeh 150 N/A 2.5
10 Mahshahr 270 N/A 2.4
11 Shooshtar 134 10,311 2.3
12 Sousangerd 126 N/A 2.2
13 Andimeshk 100 72,000 2.2
14 Omidieh N/A 988,420 2
15 Shadgan N/A 44,200 1.6
16 Aghajaary 50 33,725 1.5
a
Aproximate numbers.

Table 4
Share of 10 most polluting hospitals in the province of Khuzestan (Iran) in polluting the environment through solid waste disposal (%)
Rank Hospital code Hospital beds Inpatient and out-patient discharges Region (city) Share (%)
1 H1 500 N/A Ahvaz 6
2 H2 350 14,354 Ahvaz 4.6
3 H3 401 166,216 Ahvaz 4
4 H4 225 83,493 Ahvaz 3.8
5 H5 224 N/A Khoramshahr 3.4
6 H6 50 N/A Behbahan 3.3
7 H7 164 288,740 Ahvaz 3.2
8 H8 174 270,000 Ramhormoz 3.2
9 H9 182 13,518 Abadan 2.9
10 H10 130 6000 Ahvaz 2.8
 M. Karamouz et al. / Waste Management 27 (2007) 626638 633

Table 5 jects of the master plan are selected and ranked based on
Share of hospitals in polluting the environment considering dierent weights for
main criteria of solid waste generation and management
how eective they are in reducing the environmental
impacts through solid waste disposal in the study area.
Hospital WSM: 0.2, WSM: 0.28, WSM: 0.35, WSM: 0.43, WSM 0.5,
code WSP: 0.8 WSP: 0.72 WSP: 0.65 WSP: 0.64 WSP: 0.5 The projects are initially proposed by the managers and
H1 7.3 6.6 6 5.4 5 experts of dierent hospitals; then they are prioritized con-
H2 5.6 5 4.6 4.2 3.9 sidering their impacts toward the objective of this study.
H3 4.6 4.3 4 3.8 3.6 Finally, the most eective projects are selected as follows:
H4 4.4 4.1 3.8 3.6 3.4
H5 3.6 3.5 3.4 3.4 3.3
H6 3.8 3.5 3.3 3 2.8  Equipping all hospitals in the study area with solid
H7 3.5 3.3 3.2 3 2.9
H8 3.3 3.2 3.2 3.1 3.1
waste collection, separation, and packing systems based
H9 2.7 2.8 2.9 3 3.1 on the DOE standards and the guidelines proposed in
H10 2.9 2.8 2.8 2.8 2.6 this master plan.
H11 2.7 2.7 2.8 2.8 2.8
H12 2.8 2.7 2.7 2.6 2.6
 Providing hospitals with transportation of the hospital
H13 2.4 2.6 2.7 2.8 2.8 solid wastes.
H14 2.8 2.8 2.7 2.7 2.7  Disposing the domestic and semi-domestic solid wastes
H15 2.3 2.4 2.6 2.7 2.8
H16 2.6 2.6 2.6 2.6 2.7 generated in the hospitals in municipal landlls.
H17 2.8 2.7 2.6 2.4 2.4  Expanding the existing hospital waste management
H18 2.1 2.3 2.5 2.7 2.8 capacities.
H19 2.5 2.5 2.5 2.4 2.4
H20 2.3 2.4 2.4 2.5 2.5  Developing guidelines for solid waste management in
H21 1.8 2.1 2.3 2.5 2.7 emergency conditions.
H22 2.2 2.3 2.3 2.3 2.4
H23 2.3 2.3 2.3 2.4 2.4
 Developing comprehensive MIS for hospital solid waste
H24 2.1 2.1 2.2 2.2 2.2 generation and management in the study area.
H25 2.2 2.2 2.2 2.3 2.3  Proposing and implementing the research projects
H26 2.1 2.2 2.2 2.3 2.3
H27 2.5 2.3 2.2 2.1 2
related to the hospital solid waste recycling.
H28 1.9 2 2.1 2.2 2.3  Developing local regulations and guidelines for hospital
H29 2 2.1 2.1 2.1 2.1 solid waste collection, separation, storage, transporta-
H30 1.5 1.7 2 2.2 2.4
H31 1.7 1.7 1.8 1.8 1.9 tion, and disposal considering the existing national
H32 1.7 1.7 1.7 1.7 1.7 regulations.
H33 1.4 1.6 1.7 1.9 2  Optimally locating incinerators and hospital waste treat-
H34 1.1 1.4 1.6 1.8 2
H35 1 1.3 1.5 1.7 1.8 ment facilities.
H36 1.2 1.4 1.5 1.6 1.8  Capacity building and human resources for solid waste
H37 1.3 1.4 1.4 1.5 1.6
H38 1.2 1.2 1.2 1.3 1.3
recycling in hospitals.
H39 1.1 1.2 1.2 1.3 1.3  Training the sta for solid waste management systems in
H40 1 1.1 1.2 1.3 1.3 dierent hospitals.
WSM: weight of solid waste management.
WSP: weight of solid waste production. Table 7
Comparing the generated hospital wastes and the capacity of incinerators
in the Khuzestan province, Iran
Table 6 City Generated Special wastes Capacity of Capacity of
Share of 10 most polluting hospitals in the province of Khuzestan (Iran) in waste(kg/h) which should the needed the existing
generating infectious wastes (%) be incinerated incinerators incinerators
(kg/h) (kg/h)a (kg/h)
Rank 1 2 3 4 5 6 7 8 9 10
Abadan 39.71 9.37 49 350
Hospital H6 H5 H8 H31 H17 H27 H9 H10 H19 H31
Aghajary 0.54 0.08 0 150
code
Omidieh 8.79 5.42 28
Share in 5.86 2.49 2.13 2.02 1.85 1.74 1.6 1.6 1.24 1.17
Andimeshk 0.00 0 0 150
total
Ahvaz 168.71 105.42 713 1900
infectious
Eizeh 21.13 6.25 65 150
waste
Behbahan 17.00 10.12 53 600
generation
Khoramshahr 20.83 6.25 33 300
Dezful 43.75 2.3 12 400
Ramhormoz 10.42 4.17 22 250
5. Outline of the master plan for hospital solid waste Sousangerd 13.71 2.08 22 150
Shadgan 0.75 0.08 0 200
management in the Khuzestan province
Shoosh 12.50 4.17 22 150
Shooshtar 4.50 2.21 13 250
The main objective of this plan is to comply with the Mahshahr 9.75 0.8 5 350
regulations developed by the DOE during a 2-year time Masjedsoleiman 14.88 4.46 23 50
horizon in processes such as hospital solid waste separa- Sum 386.97 163.2 1060 5400
a
tion, storage, transportation, and disposal. The major pro- The on-line time for each incinerator should be less than 5 h/day.
 634
Table 8
Proposed methods and their priorities for storage, transportation, treatment and disposal of hospital solid waste in the province of Khuzestan, Iran
Type of Waste management processes
wastes
Storage Transportation Waste volume reduction Waste disinfection techniques Waste disposal
Indoor Outdoor Indoor Outdoor Interior Exterior
Packs and Special Cans Open Comp- Hand Hydraulic Pneumatic Shouting Waste Incinera- Comp- Paper Waste Steriliza- Incine- Radia- Chemical Incinera- Steriliza- Land Incinera- Recycling
cans for packs for cans ressing lorries machines instruments system carrying tion ression recycling grinding tion ration tion disinfec- tion tion lling tion and
infectious sharp machines trucks tion ash
wastes objects disposal
Semi-domestic 1 2 1 2 1 4 3 1 3 1 2 3 2 3 1
Paper 1 2 1 2 1 1 3 1 2 4 3 2 1
Food wastes 1 1 2 2 2 3 1 2 1 1 2
Infectious 1 1 2 1 1 1 2 3 2 1 3 4 1 2 2 1

M. Karamouz et al. / Waste Management 27 (2007) 626638

wastes
Pharmaceutical 1 1 1 2 1 2 1 1 4 2 3 2 1 2 2
wastes
Sharps 1 1 2 1 1 2 1 1 4 2 3 2 1 2 3 1
Toxic and 1 1 2 1 1 1 2 3 1 1
carcinogenic
wastes
1. First priority; 2. Second priority; 3. Third priority.

Table 9
Proposed methods for disinfecting and disposing hospital solid waste in the study area
Hospital type Disinfection and volume reduction methods Disposal methods
First priority Second priority Third priority In emergency conditions First priority Second priority Third priority
Clinics Disinfection Transferring to the Disinfection Grinding and Landlling
incinerators landlling without grinding
Medical laboratories Disinfection Transferring to the Disinfection by autoclave Grinding and Landlling
incinerators landlling without grinding
Small clinics Disinfection by Transferring to the Disinfection by autoclave Grinding and Landlling
autoclave incinerators landlling without grinding
Hospitals with less Incinerator Disinfection and Transferring to Disinfecting by autoclave Landlling of ash Grinding and Landlling of
than 50 beds (in all grinding incinerators or transporting to the landlling disinfected waste
cities except Ahvaz) other hospitals (without grinding)
Hospitals with less than Incinerator Transferring to Disinfection and Disinfecting by autoclave Landlling of ash Grinding and Landlling of
50 beds (in Ahvaz) incinerators grinding or transporting to the landlling disinfected waste
other hospitals (without grinding)
Hospitals with less Incinerator Disinfection and Disinfecting by autoclave Landlling of ash Grinding and Landlling of
than 200 beds grinding or transporting to the landlling disinfected waste
other hospitals (without grinding)
 M. Karamouz et al. / Waste Management 27 (2007) 626638 635

Fig. 3. The main menu of Khuzestan hospital solid waste Management Information System.

Fig. 4. The main data retrieval menu in Farsi for each hospital and the English translation.
636 M. Karamouz et al. / Waste Management 27 (2007) 626638

Fig. 5. The main menu of data and information report generation.

Fig. 6. The menu of data and information report generation based on the location of the hospitals.
 M. Karamouz et al. / Waste Management 27 (2007) 626638
 Monitoring and evaluation of the solid waste manage-
ment systems in the hospitals.
The proposed AHP-based model is also used for
assessing the eectiveness of the above projects. The eec-
tiveness of the proposed projects is evaluated using the
hierarchical structure of the criteria and their relative
weights, as calculated in this study (Fig. 2). In proposing
the pollution control projects, the existing capacities
should be considered. As an example, Table 7 provides
a comparison between the generated hospital wastes
and the capacity of incinerators in the Khuzestan prov-
ince. As can be seen in this table, in most of the cities,
the total existing capacity of the incinerators is usually
much more than required capacity. It should also be
noted that the existing incinerators are in suitable condi-
tion. Therefore, the main problem of hospital solid waste
management in the study area is due to improper solid
waste storage, packing and transportation rather than
lack of facilities. Tables 8 and 9 present the proposed
methods for storage, transportation, treatment, and dis-
posal of the hospital solid wastes in the study area.
The capital budget needed for improving the environ-
mental problems of hospital solid wastes by implementing
direct/indirect and supporting projects are estimated as 340
million Iranian Rials (42,000 US Dollars) and 490 million
Iranian Rials (61,000 US Dollars), respectively. The
monthly operating cost for direct/indirect and supporting
projects are 417 million Iranian Rials (51,000 US Dollars)
and 437 million Iranian Rials (53,000 US Dollars), respec-
tively. Most of the required capital budget should be
expended during the rst year after implementing the mas-
ter plan.
As mentioned before, the collected data should be
stored in a data bank with the capabilities of statistical
analysis and generating management reports. In this
study, a data bank and GIS-based maps of the study area
have been developed. The main menu of this system is
shown in Fig. 3. The main cities are shown in the right
hand side of the map. By selecting each city, the main
related hospitals are shown in the province map. By click-
ing on each hospital, some information related to the
selected hospital such as solid waste quantity and quality,
solid waste separation, storage, transportation, and dis-
posal are presented (Fig. 4). In order to generate reports,
a menu has been developed (Fig. 5). In this menu, gener-
ating reports can be based on dierent characteristics of
the hospitals. For example, Fig. 6 shows the menu of
generating reports based on the location of the hospital.
The reports include all data that has been stored in the
data bank.
6. Summary and conclusion
Dierent aspects of developing a master plan for hospi-
tal solid waste pollution reduction are discussed in this
paper. Denition of objectives, identication of system
637
components and action items, and identication of a set
of proposed waste reduction projects are considered and
described in the context of a case study for Khuzestan
Province in Iran.
In order to estimate the eects of dierent hospitals on
the environmental pollution in the study area, a multi-cri-
teria decision making (MCDM) technique, namely the
AHP method, is used. Subjective information about rela-
tive importance of dierent criteria is also incorporated
in this analysis. The consistency in engineering judgments
were also assessed and considered in nding the relative
importance of dierent waste indicators by utilizing the
AHP method.
Besides the proposed AHP based method, an economic
analysis is also introduced in order to consider the cost
associated with the environmental impacts of the pollution
load of dierent hospitals. It also shows how cost eective
the waste pollution control projects are. Since the eco-
nomic-based methods, especially in the developing coun-
tries, suer from data deciencies and uncertainties
associated with ination and high interest rates, the pro-
posed MCDM method can be helpful because it is not
too data intensive and can combine the limited data,
experts opinions, and engineering judgments in dening
the criteria and their relative weights.
In this paper, the main objective of developing a master
plan framework has been to comply with the existing reg-
ulations and standards in a 2-year time horizon. The major
projects proposed in the master plan are pollution load
reduction, development of hospital solid waste separation,
storage, transportation and disposal systems, human
resources development, development of monitoring, treat-
ment and sampling networks, research and technology
transfer, institutional changes and improvement of the
legal framework.
The breakdown of the total percentage of waste pollu-
tion generated through the activities of dierent hospitals,
the cost associated with dierent projects, and the esti-
mated rate of pollution reduction by dierent projects have
also been determined.
The results show that the main problem of hospital solid
waste management in the province of Khuzestan is due to
improper solid waste storage, packing and transportation
rather than absence of facilities. The results of application
of the proposed framework in the province of Khuzestan
show that this methodology can be eectively used for
development of a master plan for hospital solid waste pol-
lution control.
Acknowledgements
This study was partially supported by the Khuzestan
Department of Environment. Contributions of managers
and engineers of this department, especially Mr. Sepehrfar,
Mr. Lahijanzadeh, and Ms. Kaabi, as well as the contribu-
tion of research sta: Ashra, Saba, Karimi, Zolfaghar-
pour, Saberi, and Ghobadi are hereby acknowledged.
638 M. Karamouz et al. / Waste Management 27 (2007) 626638
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