Introduction

Globally, medical waste management has attracted more public concern in the last decade [1]. In particular, studies have shown that these wastes are among the most problematic types for municipal solid waste management authorities in developing countries [2]. Although medical wastes represent a relatively small portion of the total waste generated at a regional level, effective and efficient management of such wastes receives increased attention worldwide due to their potential environmental hazards and public health risks [3]. With rapid economic development and continuing population growth, China, the largest developing country with an average of 8 % GDP increase per year, is also facing such a challenge with respect to managing these medical wastes. Many relevant studies in developed or developing countries have been undertaken at the country level, such as in China [4], Thailand [5], Brazil [6], Nigeria [7], Korea [8], the UK [9] and the USA [10]. With regard to China, several studies have been undertaken, especially after the outbreak of severe acute respiratory syndrome (SARS) in 2003. For instance, Duan and his colleagues reviewed the general hazardous waste management in China [11], in which general management perspectives on medical wastes were reviewed, including the total amount, components, treatment methods and final disposal, as well as relevant regulation and enforcement. Chen and his colleagues also introduced management perspectives on healthcare wastes in China [12], summarizing the main advantages and shortcoming of different technologies for dealing with healthcare wastes and the related management measures by adopting a life-cycle analysis approach. At the provincial level, Gai et al. [13] assessed the current situation of medical waste management in Shandong province and identified the key factors that can improve effective medical waste management through statistical analysis. At the city level, Zhang and his colleagues also conducted a questionnaire-based survey in Nanjing to collect information on different medical waste management aspects, including medical waste generation, segregation and collection, storage, training and education, transportation and disposal [14], but they failed to further analyze the main barriers from management perspectives, thus, providing the whole picture, but not the essence. Generally, the Chinese studies on medical waste management are still in the early stage, few have paid enough attention on regional (such as city-scale level) medical waste management except one study for Nanjing [14]. Since the regional government is the main body for enforcing relevant regulations and monitoring the collection, treatment and final disposal of such wastes, it is crucial to have more regional studies so that the real barriers can be recognized and the appropriate recommendations can be raised by considering the local realities.

This paper aims to fill such a gap by employing a case study approach. We first introduce our methodology and present the general information on medical waste management in China. We then provide a detailed description on how the medical wastes are managed in Shenyang. Our main focus is to identify the key problems on medical waste management in Shenyang and then raise appropriate recommendations. Finally, we draw our conclusions.

Methodology

This study has a qualitative, rather than quantitative, nature. The data and information used to create this paper were derived from unpublished municipal government reports and published papers, as well as semi-structured interviews with key informants in the city. Before the interviews, a brief session and several formal workshops were hosted by the authors so that the interviews could probe respondents for greater clarity in answers and consistency in relation to the objectives of the questions. The whole investigation process was administered with the endorsement and support of the Shenyang Environmental Protection Bureau (Shenyang EPB), which assigned a specific department (solid waste management department) to be in charge of this project. Responses were obtained from 28 officials and hospital managers out of 34 investigated, providing an overall response rate of 82.4 %. To appreciate the value of our investigation, one needs to understand the general difficulties of interviewing government officials and hospital managers in China, given the regime’s apprehension that interview results may be used as a basis for criticizing the Chinese government. Also, it is impossible to conduct these interviews without the endorsement, support, and collaboration of the government units concerned. Consequently, such interviews represent a rare opportunity for examining the attitudes and enforcement styles of medical management related officials in China, as well as identifying the key barriers for the implementation of medical waste regulations. In addition, interviewees were promised anonymity, and thus interviewee responses have been pooled and in some cases slightly reworded to obscure interviewee identities. We observed no evidence that the leadership in the investigated units made any effort to affect the outcomes of the interviews, and we explained clearly both in our briefing that all data were collected solely for academic purposes and would remain strictly confidential. Thus we can reasonably believe that the responses represent the true opinions of the respondents.

In addition, in order to better identify the key problems on medical solid waste management in Shenyang, we employ a GIS tool to position all the medical waste generators. With the strong support of Shenyang EPB, as well as our site visits in many remote areas within the Shenyang region, we establish a spatial database for our analysis. Such a database can facilitate us to better understand the medical waste flow information, including their generation sites, intensity, final destinations and potential impact areas.

An overview on medical waste management in China

Generation, treatment, disposal and components of medical wastes

Since a higher proportion of medical wastes are mixed with other municipal solid wastes for landfill, detailed statistical data for medical waste management in China is currently still lacking [15]. However, with the rapid development, the total amount of medical wastes in China has also increased rapidly over the past decade. The bulletin of the first national census of pollution sources, conducted by Ministry of Environmental Protection (MEP), Ministry of Agriculture (MOA) and National Bureau of Statistics (NBS) based on the year of 2007, showed that the generation of medical wastes was 0.45 million tons, of which 0.39 million tons were safely disposed of. Currently, there are 184 medical waste treatment plants across the whole country, of which eighteen are located in Guangdong Province, fourteen are located in Shandong Province, and twelve in Sichuan Province, respectively (Fig. 1).

Fig. 1
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The distribution of disposal facilities in China

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The main components of medical wastes in China are presented in Fig. 2 [16], where we can see that in China organic matter constitutes a high proportion of medical wastes, of which 22.08 % is paper, 17.91 % is plastics, 11.53 % is fabrics, 9.36 % is tampon and viscera is 0.05 %, respectively. For inorganic matters, glasses have the highest portion with a percentage of 26.67 %.

Fig. 2
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The main components of medical wastes in China

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Regulations and standards

Medical wastes have severely dangerous impacts on the natural environment due to their infectious and hazardous nature [17]; hence, they receive more consideration both by the governmental agencies and the public. The effective and efficient management of such wastes mainly relies on the appropriate regulations and enforcement of such regulations so as to avoid or at least alleviate the related health risks and damage to the local environment. Specific regulations and standards for medical waste management systems have been effectively implemented in many developed countries, but not in developing countries. Historically, little attention had been paid to the treatment and final disposal of medical wastes in China before the outbreak of SARS in 2003 [18]. Experiencing the dire calamity of SARS, China has enacted several regulations and standard for management of medical wastes, which are listed in Tables 1 and 2. Table 3 lists the national classifications of medical wastes in China, jointly prepared by the former State Environmental Protection Administration (SEPA, Association changed to MEP in March 2008) and Ministry of Health (MOH). Among them, the most important one is the national medical waste management order (Order No. 380 of China State Council, 2003), approved and effective from June 16, 2003. This regulation classified medical wastes into five groups (e.g., infectious waste, pathological waste, sharps, pharmaceutical waste and chemical waste), clarifying the responsibilities of hospitals and other medical waste generators on collecting, delivering and treating such wastes, as well as the responsibilities of local governmental agencies on monitoring, treating and disposing of such wastes. Legal responsibilities regarding medical waste management are also presented, including the roles of different governmental agencies and medical waste generators and deliverers and the punishments for violations (such as the amount of compensation to affected groups, remediation for the damage, and the withdrawal of licenses). Other regulations and standards, enacted by different ministries (such as MEP and MOH) and provincial governments (such as Liaoning, Jiangsu and Sichuan), provided more detailed stipulations on addressing the definitions, collection, delivery, treatment and final disposal of medical wastes by considering their own administrative functions and regional realities [19].

Table 1 Recent regulation with respect to management of medical wastes in China
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Table 2 Recent standards about medical waste management
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Table 3 Classification of medical wastes (MOH and SEPA, 2003)
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Generally, from the whole country point of view, a holistic regulation framework on medical waste management has been established. However, effective enforcement on such regulations is still in its early stage [19–22]. There is a great demand on improving the enforcement effectiveness and efficiency at the local level.

Medical waste management in Shenyang

Spatial, social and political context

The political and administrative systems in China are highly centralized, but also have significant decentralization features. Understanding these features is necessary for exploration of possible initiatives to coordinate and enhance medical waste management. The national or central government is the highest level of government and has ultimate authority. At the next level, China is divided into 23 provinces, 5 autonomous regions and 4 municipalities (Beijing, Tianjin, Shanghai, and Chongqing) which are directly accountable to the central government. With the exception of the four municipalities identified above, and the 15 subprovincial municipalities noted below, the provincial governments oversee cities, counties, towns and townships. At a lower level than the municipalities directly responsible to the central government is the next type of municipality, which is categorized as having a ‘sub-provincial rank’. These are relatively large cities (a total of 15, one being Shenyang in the Liaoning province), enjoying considerable independence relative to the provincial level of government. The next level of municipal government is the ‘prefectural’ category, which includes urban areas with medium to large populations (at least 200,000) and which report to provincial governments.

Shenyang, the largest and central city in Northeast China, is the economical, cultural, and commercial hub of the Northeastern region of China. Shenyang is the capital of Liaoning province, one of the largest heavy industrial provinces in China. According to the latest Shenyang Statistical Yearbook of 2012, the city is administratively divided into 9 districts and 4 counties, with a total area of 12, 980 km2, and a total population of 8.1 million. Figure 3 shows its geographical position in China.

Fig. 3
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The geographical position of Shenyang in China

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Medical waste generation and distribution

In Shenyang medical wastes include those wastes coming from health-care-related facilities (e.g., medical schools, hospitals and clinics, and pharmaceutical firms), waste of animals intentionally exposed to pathogen, bulk human blood and blood products, pathological waste, microbiological waste and medical sharps (Shenyang EPB, 2009). The total amount of medical institutions in Shenyang over the last decade has dramatically increased, from 739 in 1998 to 1771 in 2012, with an average annual rate of 7 %. With the rapid population growth and healthcare technology improvement, the amount of medical wastes being generated is also increasing. Consequently, the question of how to manage the increasing amounts of medical wastes and how to improve the management level have become crucial in Shenyang. In order to better reflect the locations of those facilities that generate medical wastes, we employed a GIS system to position these sites. Such an application can build up a spacial database on regional medical waste management and identify the current distribution of medical waste producers, as well as their sizes, scales, densities, waste flow directions, and historical changes. It can assist the decision-makers to better manage such wastes. Figure 4 shows all the sites of such facilities, where we can see that most medical institutions in Shenyang are located in the five urban districts (Heping, Shenhe, Tiexi, Dadong, and Huanggu), accounting for about 53 % of the total. Due to the fact that many well-known hospitals are located in Heping district, this district is the most important urban district for medical waste management. Although many scattered medical sites locate in the rural area, the total amount of their medical wastes is still very low due to their small sizes, which means that the prioritized management area should be the urban Shenyang.

Fig. 4
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The distribution of medical institutions and medical waste generation in Shenyang

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Historical evolution of medical waste management system in Shenyang

Due to the polluting and infectious nature of medical waste, the Shenyang government has given a lot of attention to medical waste management. The municipal environmental protection bureau (EPB) and its subordinate environmental protection offices (EPOs) at the district level are responsible for enforcing a wide array of medical waste management regulations. With its supervision, the Eastern Comprehensive Disposal Company of Solid Waste (ECDCSW, a city government-owned public company), was established in early 1993 and is responsible for the collection, transportation and final disposal of medical wastes. Before that, medical wastes had been simply mixed with other municipal wastes and dumped to the local landfills, with a few exceptions of burning those pathological wastes.

The medical waste incineration plant was originally established by the city government in early 1980s, but with its low technology and backward equipment, this plant could not meet with the increasing demand, as well as meet with the national standard on PCDD/PCDFs (polychlorinated dibenzo-p-dioxins and polychlorinated dibenzofurans) releases. Thanks to the SARS outbreak in 2003, the city government decided to upgrade this plant by providing more investment. Since then, a new incineration facility has been set up and operated with a daily treatment capacity of 40 tons. With a total investment of 34.85 million RMB (1USD = 6.32 RMB), this facility is equipped with advanced Japanese technologies. The main feature of this facility is that it applied fixed-bed, pyrolysis and gasification technologies. The final ash is delivered to the local landfill site. In terms of operating such a facility, Hanyang environmental company was franchised to manage the whole facility under the scrutiny of Shenyang EPB. Their revenue includes the treatment fee charged from all the medical waste producers (currently 1 RMB for one kilogram of medical waste) and a special medical subsidy provided by the city government (currently with a fixed figure of 3.6 million RMB per year).

The main management measures on medical wastes

In order to improve the management level of hazardous wastes, the city government issued a special regulation on “the prevention and control of environmental pollution from hazardous wastes” on 1 Jan 2009. This regulation has special items on managing medical wastes which take into accoutn the local situations. For instance, the illegal dumping of medical wastes should be fined up to 100,000 RMB per case. As such, only franchised companies can collect, deliver and treat such wastes with the city EPB’s supervision. The baseline of this regulation is that all the medical waste management activities should comply with the national regulations and standards.

In order to gain strong allies for managing medical wastes, the city EPB actively works with other related agencies, especially the city health bureau in charge of managing all the medical institutions. A roundtable was established so that all the stakeholders can express their concerns and share the views. Members of such a roundtable include city EPB, health bureau, pricing bureau, infrastructure bureau, Hanyang Company, and ECDCWW. The key mission of this roundtable is to discuss all related issues, such as how to decide the collection fee and treatment fee, how to coordinate conflicts among different stakeholders, how to better enforce both national and local regulations on medical waste management, how to design and develop new medical waste treatment and disposal facilities, as well as how to better disseminate the advanced medical waste management practices to the public.

With their joint efforts, the city has now built up a solid foundation for medical waste management. In particular, since there are numerous small clinics located in both urban and rural areas, and most of them do not have focused awareness, the roundtable initiated a pilot project for managing medical wastes from all small clinics in 2007. This project divided each administrative district into twelve small grid areas. All large hospitals within each grid were required to provide their daily report on medical waste generation to the city EPB. All the small clinics within each grid were required to deliver all of their medical wastes to one appointed big hospital locating in the same grid. Then this appointed hospital set up a medical waste collection site in their designated area and received all the wastes from the same grid. Finally, those wastes were delivered by the franchised firm. Each small clinic was allocated with a code and had to report its daily waste generation to this hospital. If anyone fails to report its delivery, this hospital would directly report to the local EPB so that the EPB can take necessary actions. Such hospitals also need to periodically provide training programs to those small clinics so that the best practices and related regulations can be quickly delivered to the small clinics. Such a system can guarantee that all the medical wastes from small clinics be collected and delivered through a legal channel. To date, according to the city EPB’s officials in charge of solid waste management, 100 % of medical wastes have been effectively collected, delivered, treated and disposed of in Shenyang urban areas.

Challenges of medical waste management in Shenyang

Although some achievements have been gained in Shenyang, there are still several challenges that impede sustainable medical waste management. In this section we will detail these challenges.

First of all, effective and efficient enforcement of relevant medical waste management regulations is still an unmet goal. It is known that the effectiveness of government institutions in implementing regulations varies greatly across China [23]. Such heterogeneity also extends to environmental conditions. This situation influences institutional forces and shapes managerial attitudes about the responsibility of various groups for pollution problems. Although the central government sets the overall policy direction, the policies are both fleshed out and enforced at the local level and with local funding [24]. Even though a full set of regulations on medical waste management has been established in Shenyang, a culture of corruption in some locations creates opportunities for powerful polluters effectively to violate regulations, and the fragmented bureaucratic administration creates overlapping jurisdictions and insufficient coordination. Also, enforcement officials on medical waste management often lack adequate support from outside constituencies to do their jobs effectively. This lack of support takes a serious toll on their commitment to their agency that further erodes their effectiveness. In addition, the key to success in medical waste management depends on how field regulators approach polluting problems, and hence how they condition the decision situations. Medical waste management involves a substantial degree of discretion at the field level among field regulators who are physically dispersed and isolated for most of the day while tending a complex and unpredictable environment. Working in the absence of direct and visual superiors with substantial discretion, the field regulators are working in a discretion-prone situation. The role and performance of regulators in pollution control is decisive. If field regulators are not environmentally sympathetic and not given sufficient institutional supports, the effectiveness of medical waste management will be compromised and its importance diminished. Now the reality is that the lack of technical support and training seriously reduces field regulators’ ability to enforce medical waste regulations. The problem is compounded by the factors of a lack of rule, legal support, and funding, and heavy workload. In enforcing those medical waste management regulations, those field regulators have to develop measures that combine laws and techniques in order to monitor the effectiveness of relevant regulations. They have to specify, for example, sterilization standards, collection standards, incineration standards, and final disposal methods (Shenyang EPB, 2009). If they were to develop these measures, their training, their belief paradigm, the perception of their role and policy legitimacy, and their technical know-how would be the main determinants of success. Also, the Shenyang EPB’s capacity has been constrained by its limited budget and personnel (only 2 million RMB for annual enforcement budget and 42 field officials for hazardous waste management across the whole region). They often found themselves faced with a lack of support in setting standards and pressing for more aggressive medical waste management policies (Shenyang EPB, 2009). In addition, medical waste management is still a new concept in China; specific implementation procedures are yet to be worked out and the content, procedures, and methods of audit remain to be improved.

Second, a strong alliance on medical waste management is still yet to be set up. Although the roundtable is a unique method to improve the collaboration among different stakeholders, a lack of leadership has already impeded its further function. This type of inter-departmental cooperation is not the norm, and therefore regular meetings for the various groups have not been planned, except for the pilot project mentioned earlier, which was actually initiated by the vice mayor. Generally speaking, none of these agencies are subordinate to one another, nor can any of them play a leading role on medical waste management. Due to its relatively lower position in the municipal government, EPB always finds it difficult to acquire the necessary organizational capacity to conduct effective regulatory control as other agencies always support the pro-development policies set up by the municipal government. A lack of public participation is another concern, as there is no presence of public groups and small hospitals and clinics in the roundtable. While guidelines and principles regarding public participation are included in the legal framework, the procedures and regulations do not back these up. Major medical waste management policies are formulated and decided upon by nonelected bureau officials without any public consultation. In the absence of public participation, accountability in the medical waste regulatory process is almost nonexistent. In such a situation it is difficult for the roundtable to gain any powerful extra-bureaucratic allies to counter strong bureaucratic resistance to medical waste management. With the reality that most small hospitals and clinics are currently confronted with difficulties such as obsolete medical equipment and technology, untrained and inexperienced laborers, and insufficient financial resources, their management on medical wastes may cause significant negative environmental impacts.

Third, public awareness of medical waste management is still very low, especially in the rural areas. While a strong medical waste management platform in urban areas has been established, the broad rural areas deserve more consideration. Although the total amount of medical wastes in rural areas is relatively small, the negative impacts on the surrounding environment are not really small. For instance, from our site survey in some rural sites we found that some small rural clinics directly dumped such medical wastes to the local agricultural fields, some of them are even close to the local rivers, posing both environmental and health risks on the local communities. However, both clinic staff members and local citizens do not recognize such risks and regard such a practice as a normal one. Most of them do not know the potential impact of such wastes on the local soil and water quality and even accept the views that the local ecosystem can finally absorb such impacts through natural processes. We also found that some private firms even collect such medical wastes for further processing in some rural areas. A typical example is that one firm collects used medical gloves and condoms for plastics recycling without an effective sterilization process. With a simple cleaning process, such an operation may bring serious health risk to their staff and final consumers. However, our interview on these workers shows that most of them do not recognize that they are in danger and may be infected, as well as the cleaning water may pollute local water bodies (both surface water and groundwater). The urban situation is also not very optimistic. With relatively normative operation of urban hospitals and clinics, the general citizens do not recognize the importance of separating medical waste from normal garbage. Many households mix their home medical wastes with other wastes together, resulting in potential risks to both scavengers and landfills. Consequently, to disseminate such knowledge to general public and rural clinics is a crucial mission. An effective capacity building program should be initiated and implemented.

Finally, lack of financial resource is one key barrier that impedes sustainable medical waste management. Just as in many developing countries' experience, medical waste management in Shenyang is not the local government’s priority, therefore receiving less financial resource from public budget. The main budget for medical waste management is from collection fee and disposal fee, as well as regular enforcement fee allocated to EPB. Most of them are used to cover the basic expenditures, including staff’s salary and welfare packages, operation costs for medical waste collection, delivery and treatment. However, with the fact that many hospitals and clinics often delay to defray their collection and treatment fees, the ECDCSW often feels it difficult to maintain their normal operation, thus, reducing their efficiency and effectiveness. The enforcement fee for local EPB is also limited, only enough for enforcement officials’ salaries and occasional site checking. The total amount of such officials is far away from the real requirement. To increase more enforcement officials and more frequent site checks, especially in rural areas, as well as upgrading their equipment for site checks, need significant investment.

Recommendations for further improvement

From the above analysis, we can see that the city of Shenyang needs to adopt an integrated medical waste management framework so that the overall eco-efficiency on such an issue can be improved. We propose such a framework as Fig. 5, where four characteristics of best practices are presented. In the following discussion, we consider what initiatives might be taken with reference to the four characteristics of best practice associated with integrated medical waste management.

Fig. 5
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Integrated medical waste management (MWM) framework

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First of all, from institutional point of view, it is necessary to establish a specific department on managing medical wastes within the city EPB. Such a department can exercise a relatively large degree of flexibility to adopt and enforce its own policies, so that more specific regulations can be established by considering the local realities. For instance, regulations on solving the illegal dumping of medical wastes in rural areas need to be set up. Such an effort can secure cooperation from other stakeholders and also alleviate the problem that EPB lacks support in setting standards and pressing for more aggressive policies on medical waste management. While the current practice is that EPB works together with other related governmental agencies for discussing various matters, the proposed new department within EPB can integrate all the functions and authorities from those different agencies and make smart decisions by addressing all the concerns, avoiding inefficient discussions among different stakeholders and any inappropriate and ineffective actions initiated by any single agency. Also, in order to encourage local citizens to voice their grievances about medical waste management, a number of institutional channels should be established by this new department, including direct communication to the responsible senior officials, a dedicated telephone line and a petition unit set up by the city EPB and its local agencies at the district or county levels, as well as communication through the delegates to the municipal people’s congress and the members of the municipal people’s political consultative conference. These people are formally empowered to raise the relevant questions and demand greater government involvement. In addition, this new department should take a leading role on facilitating local non-governmental organizations (NGOs) to further improve medical waste management through transferring advanced technologies, conducting research, facilitating foreign assistance, mobilizing popular support, and socializing green values.

Second, a city-scaled capacity building program should be developed in order to improve the public awareness on medical waste management. Such a program should encourage activities such as TV promotions, newsletters and regional symposia and workshops. These awareness-raising activities can help build understanding, since such initiatives provide forums at which experiences from different parts of the world and from different institutions could be objectively reviewed and lessons drawn. These activities can also create opportunities for stakeholders to strengthen their mutual understandings, trust and respect, which will become a solid foundation for further collaboration in the field of medical waste management. Unlike other capacity building programs, the focus of such a program should move from the urban areas to the remote rural areas as many medical units are still employing obsolete equipment and technologies on managing medical wastes and feel reluctant to make changes for their daily operation of medical wastes, and most rural citizens do not have appropriate knowledge on properly dealing with such wastes. From the whole region point of view, the final objective is to set up a municipal publicity network on improving medical waste management. Stakeholders, including all the medical units, EPB, health bureau, NGOs, community groups, local pharmaceutical firms, and local media, should join this network and discuss how to better disseminate the related knowledge to the general public. Local television channels should be increasingly used to bring the message of smart medical waste management into local citizens’ homes. In addition, international collaboration efforts should be encouraged so that the city can receive both financial and technological supports from various international agencies. Such supports play a catalytic role to encourage both the local governmental agencies and medical units to further improve their medical waste management and can facilitate the transfer of the state-of-the-art technologies and information from developed countries to Shenyang.

Third, it is necessary for the proposed new department of EPB to build up an information platform on medical waste management. Such platform refers broadly to a computer-based system that provides decision makers with the tools needed to monitor, evaluate, treat and dispose of medical wastes. In order to provide past, present, and predictive information on medical waste management, this information system should include software that helps decision making, data resources such as databases, the hardware resources of a system, human resource management on medical waste management (such as enforcement area of each enforcement official), and computerized processes that enable enforcement officials to predict the potential impacts of illegal dumping and discharge. Such a platform can provide accurate and timely information to decision makers for their strategic planning of medical waste management, and then facilitate the effective implementation of medical waste management. It will be appropriate to also develop a public website so that the related information on medical waste management can be publicized. The GIS-based spacial database developed for this study could serve as the starting point for developing such a platform, although more efforts need to be integrated through collaborating with the local research organizations so that more functions can be added. In addition, it is expected that this platform can link with the city’s emergency response system, currently operated by the city police bureau, as the severe accidents raised by medical wastes may become a public security issue (such as SARS outbreak).

Fourth, more funds should be provided to the newly established department within EPB so that they can employ more staff members and conduct more frequent on-site inspections to ensure that the pollution problems raised by medical waste dumping will be resolved to their satisfaction. Such an investment can come from EPB’s regular emission fee as the main function of such an emission fee is used for improving the overall efficiency on various environmental management matters. Another approach is to increase the current medical waste collection, delivery, and treatment fee, due to the fact that the current rate cannot meet with the increasing demands. Moreover, other governmental agencies should involve in it. For instance, the city science and technology bureau, in charge of allocating research funds in Shenyang, should support innovative research efforts in the field of medical waste management so that more research funds can be allocated to the appropriate research organizations for solving more specific technology issues related to medical waste management, such as how to clean the polluted soil and water bodies and how to increase the efficiency of incinerators. Finally, we propose an environmental compensation system so that money for recovering polluted ecosystem can be collected. Both soil and water are common property sources. Equity requires that the influenced citizens should be compensated for their polluted soil and water, resulted from illegal dumping of medical wastes. This requires clear ownership of resources (land, water, vegetation) and scientific evidence to determine the amount of compensation. Thus, the key questions that remain to be addressed are how much the water or soil is worth, as well as other ecosystem services, who should pay for it and how. This will require a further study on the real value of different resources, the real value of local ecosystem services, and the long-term impact on local ecosystems.

Conclusions

Medical waste management is of great importance due to its potential environmental hazards and public health risks, especially in developing countries where both financial and technological resources on medical waste management are still lacking. The case of Shenyang indicates that although significant progresses on medical waste management at the city level have been gained, several challenges still exist, including ineffective and inefficient enforcement on related regulations, fragmented institutional efforts, and lack of awareness, transparent information and financial resources. For better managing medical wastes, an integrated medical waste management framework should be developed and implemented. Necessary initiatives include the establishment of a specific medical waste management authority, a city scaled capacity building program on improving the general public’s awareness, an information platform, application of state-of-the-art technologies, as well as creation of an effective financial system. With such a combination of various initiatives, we believe that the overall efficiency of medical waste management at the regional level can be improved, and regional sustainable development can become a reality. Particularly, due to the representative nature of Shenyang’s medical waste management, the proposed recommendations can also be shared by other Chinese cities or cities in other developing countries that face the same challenges.