Health and safety perspective on medical waste management in a developing country: A case study of Dhaka city

Health and safety perspective on medical waste management in a

developing country: A case study of Dhaka city
M. A. Patwary a*, W. T. O’Hare a, G. Street a, K. M. Elahi b, S. S. Hossainc, M. H. Sarker a

a b c
School of Science and Environmental Science, Institute of Statistical Research
Technology, University of Stamford University and Training (ISRT),
Teesside, Middlesbrough, Bangladesh, University of Dhaka,
TS1 3BA, UK Dhaka 1209, Bangladesh Dhaka 1000, Bangladesh

ABSTRACT

Mismanagement of medical waste may present an environmental health hazard. Causes of mismanagement
include a lack of appropriate legislation, effective control, financial constraints and lack of education, training
and awareness. This is specially a concern in developing countries like Bangladesh where a large number of
people are involved in the formal and informal process of medical waste management. In this paper the
management of the medical waste in Dhaka, the capital city of Bangladesh, was analyzed with an aim to propose
an integrated medical waste management system in the city. Data was collected from Healthcare Establishments
(HCEs) such as hospitals, clinics and diagnostic centers, waste disposal operatives, official and unofficial
recycling operations and scavengers. Both quantitative and qualitative data gathering techniques were used,
including observation and formal structured interview through questionnaire survey and informal dialogue.

The study focused on the character of HCE, its in-house and municipal management (collection, temporary
storage, transportation, treatment and final disposal options of medical waste) practice in the study area. The
results indicated that the management of medical waste had not been conducted properly. Deficiencies,
inconsistencies and improper processes were revealed. Malpractice was observed, among individuals involved in
handling medical waste, in mid-level management, and also in the senior management level. The study revealed
the need for training, capacity building programs of all employees involved in medical waste management, to
promote awareness and focus on environmental and health risks of medical waste. The results obtained may be
generalised to most economically developing countries where there are similar environmental problems and
strict budgets.

1. INTRODUCTION
The management of medical waste is an emerging worldwide concern. In the last few decades there has been a
rapid growth of medical and patient related services around the world [1]. These have increased not only use of
chemicals and drugs, but also increase in the use of disposable items [2] and consequently, large amounts of medical
waste are being generated on a daily basis. As medical waste contains highly toxic chemicals and pathogens [3, 4, 5,
1, 6], it is generally considered a threat to environmental health and safety. It produces unpleasant smells and
infestations. Infestations may in turn contribute to the transmission of diseases [8, 1, 9]. In most developing
countries there is a growing concern that the enormous amount of hazardous medical waste generated, not only
results in a huge disposal costs, but also creates the potential for the spread of diseases [7], Causes of medical waste
mismanagement in developing countries include a lack of appropriate legislation, effective control, financial
constrains, lack of education, training and awareness; and other related social problems [8, 9, 10].
In Bangladesh, like in many other developing countries, there is little emphasis on the proper management of
medical waste [11]. Most of the advanced and comprehensive medical care and treatment services are available in
Bangladesh. A number of reports have indicated that medical waste in Bangladesh has suffered from
mismanagement practices that deviate substantially from the standard acceptable practices suggested by World
Health Organization (WHO) [11, 13, 14, 15]. Such practices may create potential public health and safety risks,
particularly to the individuals who are involved in waste related livelihood, but also to the general population.

* Correspondence: Tel.: +44- 1642-738121, Fax: +44-(0)1642-342401; E-mailM.patwary@tees.ac.uk

 Flexible Automation and Intelligent Manufacturing, FAIM2009,Teesside, UK

The objective of this study was to investigate the contribution of mismanagement of medical waste to
environment and health risk in Dhaka city. It was intended to gather information that would contribute to the
development of medical waste management plans for developing countries, which could be adapted according to
circumstances and which could be harmonised with the European Union Health-care Waste Management
Regulations/Directives. It is likely that this would be helpful to minimize the risks of health and safety.

2. METHODOLOGY
2.1. SAMPLING AND DATA COLLECTION

Sampling: In this study the representative sample of HCEs was selected. Both purposive and authoritative
sampling system were used to select individual respondents such as scavengers, waste collectors employed by
Dhaka City Corporation (DCC), waste treatment facility employees, recycling operators and their employers, and
related government and Non-Governmental Organization (NGO) officials and academics. Sampling methodology
and sample size determination technique has previously been described [11, 12].

Qualitative Data: Qualitative data were obtained through observation, formal structured interview and informal
interview as described below;
 Physical observation
o HCEs (hospitals, clinics and pathology centers)
o Medical waste treatment facility,
o Medical waste recycling operations,
o Government departments and NGOs related with medical waste activity
 Formal Structured Interview
o Management authority of HCEs, waste treatment facility
 Informal interview
o Relevant government, NGO and academic personnel,
o Recycling operations’ employers.

Quantitative Data: Quantitative data was gathered through questionnaire survey among the individuals
described below;
 Administration of questionnaire on
o Employees of the various departments in the Health Care Establishments who are
 Working directly with the patient care
 Transferring waste from inside bins to road site bins
 Working for mortuary departments.
o DCC waste collectors, employed by DCC to collect waste from road side bins and to transport it to
designated dumping places
o Operators working at official medical waste treatment centers.
o Scavengers involved in unofficial scavenging and resale of medical waste.
o Individuals involved in informal recycling and repacking of medical waste.

2.2. DATA COLLECTION

The research methods (including the quantitative questionnaire and the structure of the formal interview) were
approved by the Ethics Committee at Teesside University.
Initially, data was collected using an observational ethnographic approach [11, 12]. In the survey phase,
administration of questionnaires was carried out between December 2005 and June 2006. Selected participants were
briefed about the study, confidentiality was assured and written consent obtained. The questionnaire was pretested
with a sub-sample of each group of selected participants.
 Health and safety perspective on medical waste management in a developing country: A case study of Dhaka city

Table 1 Methodological Approaches Adopted

Category of information

DCC waste employees

Recycling operators n

Recycling employer n
Academic personnel

Senior management
Employees of HCEs

of the HCEs n = 30

Waste treatment
NGOs personnel

employees n = 8
personnel n = 5
Governmental

Scavengers
n = 125

n = 12

n = 25
n=3

n=5

= 15

=5
Demographic II II II FSI FSI FSI FSI FSI FSI FSI
Location, structure & type of II II II FSI FSI FSI FSI FSI FSI
establishments
Internal waste management II II FSI FSI FSI FSI II
Waste transportation II II FSI FSI FSI FSI FSI FSI
Recycling activity II II FSI FSI FSI FSI FSI FSI FSI
Hygiene, Health and safety II II II FSI FSI FSI FSI FSI FSI FSI
Training II II II FSI FSI FSI FSI FSI FSI II
Legislation II II II FSI FSI FSI FSI FSI FSI FSI
Academic module II II II II FSI
FSI: Formal Structured Interview; II: Informal Interview

Table 1 shows how different methodological approaches (formal structured and informal interview) were used
with each group to gather data under the various headings considered appropriate for that group. Responses were
obtained from a total of 233 participants. The data were recorded and analyzed by descriptive statistical method
using MINITAB (version 15).

3. RESULTS AND DISCUSSION

3.1. TYPE AND LOCATION OF THE HCES

All of the clinics and pathology centers surveyed were private, while 50% of the hospitals were public and 50%
private. The only medical waste treatment centre identified in the study was found to have been jointly established
by an NGO, DCC and international donor agencies. It was operated by NGO and located on the outskirts of Dhaka
city.
Table 2 shows that most of the HCEs, 41 (59.42%) were located at the main residential area, while 2 (2.89%)
were located in industrial areas, 13 (18.84%) were located in commercial areas and 13 (18.84%) were located in
mixed use areas (residential coexisting with government and private sector commercial activities). A few of the
pathology centers (4%) were located at the industrial area. This pattern of location may present significant dangers
in the context of urban population health and safety.

Table 2 Type and Location of Surveyed HCEs

Type of location Healthcare Establishments
Hospitals (%) Clinics (%) Pathology/diagnostics (%)
Residential 2 (50%) 14 (67%) 25 (57%)
Industrial 0 0 2 (4%)
 Flexible Automation and Intelligent Manufacturing, FAIM2009,Teesside, UK

Commercial 1 (25%) 5 (24%) 7 (16%)

Mixed area 1 (25%) 2 (9%) 10 (23%)

Dhaka is a fast growing city, ranked 11th in the world by population (12.4 million) [19]. Expansion of the city is
limited due to physical constraints. Commercial buildings are predominantly built and managed by the private
sector, and mixed use developments, such as shopping malls and residential complexes, are popular. Most of the
private HCEs are established in residential areas, or within shopping malls. Senior management and owners of the
HCEs indicated, through informal interviews, that they have established their activities in residential areas to
maximize convenience for their patients; as most people have no private transport, and there is no free ambulance
service. HCEs, established in residential areas allow easy and timely access in an emergency. As there is a lack of
legislation by the city authority, HCEs are allowed to dispose of their hazardous medical waste into general DCC
waste containers intended for domestic waste. This leads to mixing of medical waste and domestic waste, resulting
in all waste becoming hazardous. However, it was identified during the interview that management did not consider
the health and safety issues for the residents of the risks of medical waste and some of them were not interested in
discussing this issue.

3.2. TYPE OF ESTABLISHMENTS STRUCTURE

Of the surveyed HCEs, only 11 (15.94%) (including all 4 hospitals) were located in an enclosed site with more
than one building while 35 (50.72) were housed in a single dedicated building, and 23 (33.33%) were located in a
shared building (Table 3). All of the HCEs located in a single building or a shared in a building were privately
owned. In some of those facilities examined, the space required for even basic provision for proper waste
segregation, storage and disposal would significantly reduce the number of beds or tests that the facility could
support and so reduce profitability. It was observed that none of the HCEs have an Effluent Treatment Plant (ETP)
suitable for highly contaminated liquid waste. HCEs located in a single building discharged liquid waste directly to
the municipal general sewerage system, and HCEs located on shared floors in a building discharged liquid waste
into the building general sewerage. It was also found that some HCEs discharged liquid waste into adjacent lakes
and rivers that were also used by local residents for washing and household purposes, as well as for agriculture. In
43 (62.31%) of HCEs liquid waste was discharged into a domestic septic tank system, and from there into the
general sewerage system. The remaining 26 (37.68%) of HCEs were connected directly to the public sewage
network. Wastewater was not being treated appropriately, the discharge may lead to potential contamination of
drinking water supplies and/or environmental degradation.
During formal and informal interviews, respondents from management of these HCEs indicated that this too was
due to lack of space, but also most of them did not have a positive attitude towards establishments of ETP. None of
the HCE owners or managers was found to have considered waste management when establishing their business.
Interviews with academics indicated that this was not due to the unwillingness of the architect or engineer, but due
to the unwillingness of the HCE owner.

Table 3: Type of the establishment structure of the conducted HCEs

Establishments Healthcare Establishments

Structure Hospitals (%) Clinics (%) Pathology/diagnostics (%)
Single building 0 11 (52%) 24 (54%)
Floor shared in a 0 5 (24%) 18 (41%)
building
Enclosed site with 4 5 (24%) 2 (5%)
More than one
building
Total 4 21 44

3.3. IN-HOUSE WASTE MANAGEMENT

In general, from top to bottom management a lack of knowledge about the magnitude of the problem was found
during interviews, and in most of the HCEs, there was no particular section or person assigned responsibility for the
in-house management of medical wastes. Even where an individual was found to have been assigned responsibility
for monitoring and managing waste, they were invariably assigned additional responsibilities and they considered
waste management to be a minor aspect of their duties.
 Health and safety perspective on medical waste management in a developing country: A case study of Dhaka city

Hazardous medical wastes, should be collected, stored and transported separately in a designed bags or
containers which are resistant to puncture. [8,17, 18]. The different colored bags having different types of wastes
can be stored in the same compartment or in the same room. Most of the HCEs did not use designated bags or
containers for the segregation and separate storage of medical waste. It was observed that most of the HCEs were
using normal bags and containers which were not sufficiently robust. Once punctured, these allow hazardous waste
to spread to the environment. On the other hand, in some instances, bags or containers designated with hazard signs
and colored for hazardous waste were used for domestic waste as well. Sometimes waste bags and containers were
placed around the HCEs reception area, emergency area, operation theatre, research laboratory or blood bank
department.
Sharps waste should be crushed before placing them in a specially designated metal box [20]. However, in
Dhaka sharps were not collected as required which may lead to injuries during the collection and transportation. In
India, 85% of sharp injuries are caused between usage and disposal [8]. No respondents indicated that their HCE
recorded any needle stick injuries, so data were not available. However, most of the waste workers (94%) had
experienced accidental injury mostly from used needles and other sharps [12]. Of these, 28% were considered
serious. This is much higher than the rates observed in other countries. In Japan 67.3% of HCE staff reported
accidental injuries, compared with 50% in Peru and 18% in USA [14].
Collection and transportation in the surveyed HCEs was carried out primarily by HCE recruited waste collectors
with little or no training. It was observed that sometimes they used patient trolleys to carry waste. Typically, the
HCE workers did not wear sufficient protective equipment during waste handling activities, increasing the potential
risk of accidents and personal injury.

3.4. EXISTING WASTE STORAGE

Most of the surveyed HCEs did not have designated temporary storage facilities, again due to lack of space. Of
the conducted HCEs 17 (24.63%) were operating internal temporary storage while 9 (13.04%) HCEs were operating
external storage. It was observed that neither internal nor external temporary storage facilities were designated and
designed for medical waste with adequate area and quality standards. None of the HCEs had refrigeration to store
infectious pathological waste, as previously recommended [2, 18.] Only 5 (7.24%) HCEs were using large
containers to store the bags of infectious waste. Usually, these containers were placed by the road outside the
establishments where there was heavy pedestrian and car traffic. It was observed that the lids of the containers were
mostly left open, so pedestrians also dumped all kinds of waste into the open containers. External storage, found in
the surveyed HCEs, was not properly designed or identified. Sometimes open space within the HCE premises were
used as an external storage. Crude storage leading to access to hazardous medical waste by birds, animals, flies and
rodents may spread germs from contaminated waste to the surrounding community and environment. When internal
spaces were used for storage, it was often observed that medical waste was placed in a room along with office
stationery or medical supplies.
Data in Table 4 shows that 7 (10.14%) of HCEs were disinfecting storage facilities. Most of the HCEs were not
using disinfectant for decontamination and were not installing appropriate equipment for final disposal of hazardous
waste. Radioactive waste were not stored for a long enough period to decay and safely managed.

Table 4: Internal and external storage structure of the conducted HCEs

Storage Structure Healthcare Establishments

Hospitals Clinics Pathology/ Total (%)
diagnostics
Temporary storage 4 6 7 24.63%
Central or external storage 2 5 2 13.04%
Designated area for 2 5 2 13.04%
hazardous waste
Disinfection for storage 2 3 2 10.14%
facility
Adequate area and quality 0 0 0 0%
of the storage facility

3.5. INTERNAL AND EXTERNAL TRANSPORTATION

 Flexible Automation and Intelligent Manufacturing, FAIM2009,Teesside, UK

Table 5 shows internal and external transport facilities used to carry medical waste within the HCEs and to waste
dumping zone. None of the HCEs was found to be equipped with transport designated for disposal of medical waste
within the premises. Therefore, waste workers transported medical waste by hand. Of the surveyed HCEs 5(7.24%)
were found to be transporting medical waste from temporary storage to central or external storage area by using a
hand held trolley with wheels which did not meet the regulatory requirements for safety (Table 5). Some of the
trolleys had a closeable lid and some of them were without. The data obtained from the surveyed HCEs indicated
that the time period for temporary storage was not followed strictly. Sometimes medical waste was stored for more
than one day while the central storage period was in excess of two days.

Table 5: Internal and external transport facility of the conducted HCEs

Transportation Structure Healthcare Establishments

Hospitals Clinics Pathology/diagnostics Total (%)
Transport waste within the HCE by 0 0 0 0
cart
Transport from internal storage to 2* 3* 0 7.24%
external storage by hand held trolley
Transport facility to dumpsite by 2 9 13 34.78%
designated vehicle
Transport non-hazardous and 2 9 13 34.78%
hazardous waste separately
HCE owned designated vehicle 0 0 0 0
*Locally made trolley operated manually

One NGO has established some medical waste management activity in Dhaka, primarily in the Dhanmondi area.
Thus, in this area some HCEs (71%) were found to transport medical waste from the premises to the dumpsite
separately and segregated as non-hazardous and hazardous through the operations of this NGO. In other areas the
percentage of HCEs following these practices was much lower (10%) None of the HCEs was found to own a
designated waste transportation vehicle. Consequently, the HCEs which were working with the NGO for medical
waste management activity were fully dependent on the NGO transportation. While awaiting collection by NGO
vehicle, the hazardous waste was stored insecurely, and sometimes for a long time, within the HCE premises. Thus
scavengers were able to obtain access to the waste.
Waste from the remaining HCEs was transported by DCC waste crew to the general waste disposal site mixed
with non-hazardous.
3.6 WASTE DISPOSAL AND RECYCLING
The survey results indicated that none of the HCEs were incinerating their infectious, pathological and sharps
waste. Interviews with senior management and city officials suggest that this was due to a lack of incinerator and
lack of interest by the city authority. An NGO had established a medical waste treatment and dumping facility. It
was located close to houses and in a low lying area, connected with water bodies which may easily be contaminated
by run-off and leachate containing pathogenic microbes. As previously mentioned, almost all HCEs discharged
mixed domestic and medical liquid waste into sewer networks or into septic tanks.
None of the surveyed HCEs were currently operating any program to recycle general waste; such as office paper,
cardboard, plastics, metal cans and selected glass. Most of the recyclable medical waste (RMW) was collected
together with the general waste and disposed of into DCC bin or dumpsite along with other waste. Most of the HCE
authorities were not aware about the RMW. Therefore, those RMW were sold mainly by the low class employee.
Those employees have no idea about the risk to sold contaminated waste which may lead to significant threat more
widely. It was observed and also found form the interview that the individuals who were involved with selling are
more interested on income and easy access to get together in a large volume. Before selling the RMW they did not
take any precaution measure if the waste was contaminated. It was found from the interview that waste was also sold
by waste scavenger to recycle operator. None of the scavenger had any knowledge of risks from medical waste
exposure. All of the recycle operators were found without any knowledge of risk from medical waste. Re-cycle
operators were found to be involved with recycle activity without any training. It was observed and also found from
the survey that re-cycle employers did not consider occupational health and safety for the employee.

4. TRAINING AND AWARENESS

 Health and safety perspective on medical waste management in a developing country: A case study of Dhaka city

The responsible personnel were not given adequate training, which leads to inappropriate management and
insufficient implementation of the management system. Neither the HCEs nor the employees of the DCC in charge
of collecting medical waste were trained. They were not aware of the importance of the appropriate handling and
management of the medical waste, and consequently there were inappropriate activities observed during the
collection and segregation of the waste generated from the HCEs.
Training programs on medical waste management for the medical staff (doctors, nurses and technicians) were
limited. None of the HCEs offered any in-house training program. While some provided limited training for support
staff through an NGO, this was the same program for all staff (senior management staff, administrative
management, medical staff, waste worker, treatment facility staff). This supports the previous study of Ahmed et.al,
(2006) who found that 70% of HCEs did not offer any training, whereas Askarian et.al. (2004) stated that training
program and educational classes are instituted repeatedly for all personnel according to their job and the content of
program is specifically designed in developed countries.
All of the waste workers indicated that orientation programs for new employees about medical waste
management was not provided. Only 4 (5.79%) of surveyed HCEs displayed posters and some leaflets on hazards of
medical waste to warn local residents of hazards, supplied by an NGO.
All of the HCEs and respondents (100%) indicated their needs and willingness to participate specialised training
programs on medical waste management in future. Most of the HCEs 50 (72.46%) would prefer regular training,
either quarterly or half yearly. All of the interviewed respondents (n=30) mentioned, training for senior management
and authority was highly required while training programs for medical staff, waste handlers, and maintenance staffs
were requested by more than 90% of the surveyed HCEs.

5. LEGISLATION

It was observed that none of the respondents were aware of legislative requirements about medical waste
management. This was mostly because of the inefficient control and enforcement of the responsible authority. It was
found from the survey that there was no legislation on medical waste management in Bangladesh. A set of
regulations is being prepared by the Ministry of Environment and Forest, Government of Bangladesh which is still
in the draft stage. However, authority could till apply to enforce for medical waste management in compliance with
the Environmental ACT 1995 and Environmental Rules and Regulations 1997 of Bangladesh. It was found that the
management of the medical waste in Bangladesh was supposed to be conducted according to the Environmental
Rules and Regulations 1997. However, the Regulations were not applied by any of the surveyed HCEs.
6. RECOMMENDATION
The proposed efficient Medical Waste Management are given below:
 The waste should be categorised according to the WHO Directives and the European Waste Catalogue for
the clear definition of hazardous medical waste and of its various categories in the Regulation.
 Location and structure of the HCE should be considered as a significant factor.
 Strict legislation of the medical waste creator regarding safe handling and disposal should be confirmed.
 Every stage of management should be documented.
 Autoclaving, sterilization, incineration must be considered before final disposal.
 If permit land filling should be considered as the final disposal methods. However, land filling would
difficult in Bangladesh since it is a densely populated small country where it will be difficult to find
appropriate land to fill. Therefore, waste generation reduction at source should be considered. Proper
treatment and recline may minimize this problem.
 There should be provision in the legislation for the designation of courts responsible for handling any
disputes may arise from the enforcement or of non-compliance with the law.
 A regular inspection system should be introduced to ensure that the enforcement of the legislation by a
third party, penalties to be imposed for contravention and the inspection procedures should be clarified.

7. CONCLUSION
In this study, current medical waste management practices were investigated and evaluated in detail in Dhaka
City, chosen as an example of the type of modern megacity found in developing countries. The findings suggest that
there are serious problems in the safe handling and transportation of medical waste, probably arising from
administrative and financial problems within HCEs, as well as the lack of awareness of the significance and the
threats of the medical waste. These issues result in mixing of medical and non-hazardous waste, greatly increasing
the total amount of hazardous waste. This could be addressed by promoting proper segregation through training,
 Flexible Automation and Intelligent Manufacturing, FAIM2009,Teesside, UK

clear standards and strict enforcement. These steps would also minimize the risk to those involved in handling
waste, both within and outside the HCEs.

ACKNOWLEDGEMENTS

Authors acknowledge financial support from Charles Wallace Trust UK, Mountbatten Memorial Grants UK and The
Hammond Trust, British Council for this research.

REFERENCES

[1] Askarian M., Vakili M., Kabir G., 2004. Result of a hospital waste survey in private hospitals in Fars province, Iran.
Waste Management, Vol.24, No. 4, pp. 347-352.
[2] Y. Jang, C. Lee, O. Yoon, H Kim: “Medical waste management in Korea”, Waste Management, Vol. 80, No. 2, pp. 107-
115, 2006.
[3] Ray M. R., Roychoudhury S., Mukherjee G., Roy S., Lahiri T., “Respiratory and general health impairments of workers
employed in a municipal solid waste disposal at an open landfill site in Delhi”, International Journal of Hygiene and
Environmental Health, Vol.208, pp.255-262, 2000.
[4] Muhlich M., Scherrer M., Daschner F. D., 2003. Comparison of infectious waste management in European hospitals.
Journal of Hospital Infection, Vol.55, pp.260-268.
[5] Chintis V., Chintis S., Vaidya K., Ravikant S., Patil S., Chintis D. S., 2004. Bacterial population changes in hospital
effluent treatment plant in central India. Water Research, Vol. 38, pp.441-447.
[6] Runner C. J., 2007. Bacterial and viral contamination of reusable sharps containers in a community hospital setting.
Am J Infect Control, 35 (8), pp. 527-530.
[7] Chen H., Su H., Guo Y., Liao P., Hung C. and Lee C., 2006. Biochemistry examinations and health disorder evaluation
of Taiwanese living near incinerators and with low serum PCDD/Fs levels. Science of the Total Environment, Vol. 366,
pp. 538-548.
[8] M.Yadav: “Hospital waste – A Major problem”, JK Practitioner, Vol.8, No. 4, pp. 276 – 282, 2001.
[9] F. Abdullah, H. A. Qdais, A. Rabi: “Site investigation on medical waste management practices in northern Jordan”,
Waste Management, Vol. 28, No. 2, pp. 450-458, 2008.
[10] B. Mbongwe, B. T. Mmereki, A. Magashula: “Healthcare waste management: Current practices in selected healthcare
facilities, Botswana” Waste Management, Vol. 28, No. 1, pp. 226-233, 2008.
[11] M. A. Patwary., W.T.O’Hare, G. Street, K.M. Elahi, S.S.Hossain, M.H. Sarker: “Quantitative assessment of medical
waste generation in the capital city of Bangladesh”, Waste Management, In Press, 2009.
[12] M. A. Patwary., W.T.O’Hare, G. Street, K.M. Elahi, S.S.Hossain, M.H. Sarker: “Qualitative assessment of current
medical waste management practice in Dhaka, Bangladesh”, 2009, (Unpublished).
[13] Rahman M. H., Ahmed S. N., Ullah M. S., 1999. A study on hospital waste management in Dhaka City. Integrated
Development for Water Supply and Sanitation, 25th WEDC Conference. Addis Ababa, Ethiopia.
[14] Rahman H. and Ali M., 2000. Healthcare waste management in developing countries, 26 th WEDC Conference. Dhaka,
Bangladesh.
[15] Rahman A, Patwary M.A. and Rahman H., 2007. Study on health care waste management practice in Dhaka
City. Building Tools and capacity for Suatainable Production, First Environmental Conference on Environmental
Research, Technology and Policy. Edited by Dr EK.Yanful Africa.
[16] Akter N. and Trankler J: “An analysis of possible scenarios of medical waste management in Bangladesh, Management
of Environmental Quality”, An International Journal, 14 (2), pp.242 – 255, 2003.
[17] R. Oweis, M. Al-Widyan, O Al-Limoon: “Medical waste management in Jordan: A study at the King Hussein Medical
Center”, Waste Management, Vol. 25, No. 6, pp. 622-625, 2005.
[18] A.Z. Alagoz and G.Kocasoy: “Determination of the best appropriate management methods for the health-care wastes
in Istanbul”, Waste Management, Vol. 28, No. 7, pp. 1227-1235, 2008.
[19] UN (United Nations): “World urbanization prospects: The 2005 revision”, New York: United Nations. 2006. Available
from: http://www.un.org/esa/population/ publications/WUP2005/2005WUPHighlights_Final_Report.pdf. Accessed
30.11.08.
[20] World Health Organization: “Safe Healthcare Waste Management, Policy Paper, Department of
Protection of the Human Environment Water, Sanitation and Health”, 20 Avenue Appia, CH-1211 Geneva
27, Switzerland. 2004.
 Health and safety perspective on medical waste management in a developing country: A case study of Dhaka city

[21] S. A. Ahmed, M. Hassan, M. A. Chowdhury: “Public service through private business: the experience of
healthcare waste management in Bangladesh”, CWG- WASH Workshop, 1 – 5 February, Kolkata, India,
2006.