Sewage treatment for hospitals plays a crucial role in enhancing public well-being and advancing medical science by utilizing various chemicals for precise diagnoses, effective therapies, and thorough sanitation (Mike and Rai, 2018). However, the resulting wastewater from these institutions often contains emerging contaminants like pharmaceutically active compounds (PhACs), antibiotic-resistant bacteria (ARB), antibiotic-resistant genes (ARGs), and persistent viruses (Kwak et al., 2015; Nielsen et al., 2013; Lien et al., 2016; Dires et al., 2018).

1. The Vital Role of Sewage Treatment in Hospital Waste

If left untreated, this effluent can contaminate water sources, posing serious risks to public health and contributing to environmental degradation. Therefore, efficient wastewater treatment in medical facilities is essential for mitigating these dangers and preserving both human health and ecological balance. Proper wastewater management involves the collection, filtration, and responsible disposal of contaminants to safeguard both individuals and natural ecosystems (Ibiam and Igewnyi, 2012). Investing in advanced treatment systems is critical to protecting communities and promoting a cleaner, more sustainable future.

1.1. Protecting Health and Environment with Hospital Sewage

India’s healthcare sector generates around 3 million tons of medical waste annually, rising by 8% each year (Mohankumar and Kottaiveeran, 2010). Improper management of this waste affects both public health and the environment. Studies show that many hospitals discharge untreated pharmaceuticals, including antibiotics and resistant genes, into water systems (Celic, Preeti, Astha, 2019, 2009, 2020). These contaminants in surface water, soil, and sediments threaten human health and environmental stability (Macarena, Emmanuel, 2014, 2004). Effective wastewater treatment is crucial to mitigate these risks and protect both the environment and public well-being.

Table 1: The average pollutant concentration in the influent, effluent and removal rate % of the sewage of two hospitals in Basrah province (Samar and Wisam., 2021).

Implementing effective wastewater solutions in healthcare facilities is crucial for protecting both the environment and public health. Proper management of untreated hospital effluents reduces contamination risks, safeguarding communities. Effective waste management is critical for disease prevention, as it eliminates pathogens, reducing the threat of waterborne illnesses.

In healthcare settings, the focus is on reducing the presence of chemicals and pharmaceuticals in wastewater, preventing their release into natural water bodies. This helps protect aquatic ecosystems, support environmental conservation, and maintain biodiversity. Ensuring our waste management systems are efficient and reliable is vital for promoting a clean and sustainable future, particularly through effective sewage treatment for hospitals.

1.2. Compliance and Sustainability in Hospitals

Healthcare facilities adhering to strict wastewater management protocols demonstrate not only compliance with regulations but also a strong dedication to responsible waste disposal. Following guidelines from environmental and health authorities ensures that their waste management processes meet required standards. The World Health Organization (WHO) prohibits the discharge of hazardous substances, such as photo-chemicals, aldehydes, and pharmaceuticals, into sewer systems (Astha et al., 2020).

Globally, the WHO’s “Safe Management of Wastes from Health-Care Activities,” issued in 1999 and updated in 2013, remains a key framework for managing hospital wastewater (Zotesso et al., 2017; WHO, 2013). Healthcare facilities are increasingly focusing on sustainability, aiming to minimize environmental impact and promote resource efficiency. By recovering water and energy, adopting eco-friendly technologies, and adhering to rigorous environmental standards, these institutions contribute to a circular economy and reduce their carbon footprint. Sustainable strategies, such as waste reduction, green infrastructure, and community involvement, reflect a facility’s broader commitment to environmental responsibility and community health, particularly through effective sewage treatment for hospitals.

Fig 1: Structure of pollutant reduction after treatment in WWTP( Ćetkovic et al., 2022).

2. Key Characteristics of Hospital Wastewater and Its Impact

Hospital wastewater (HWW) presents a more significant environmental risk compared to urban effluent due to its content of pathogens, pharmaceuticals, and chemicals (Sanaa and colleagues, 2019). Specialized methods for wastewater management are critical to eliminate these contaminants and meet environmental regulations.

HWW contains hazardous pollutants such as pharmaceutical residues, radioisotopes, and microbial pathogens (Bouzid and team, 2021; Achak and co-authors, 2021). A detailed examination of its microbiological, physico-chemical, and eco-toxicological characteristics is essential for pollution control and selecting the appropriate treatment technologies (Achak and co-authors, 2021).

2.1. Hospital Wastewater Sources and Composition

The complex composition of hospital wastewater (HWW) requires specialized sewage treatment for hospitals to manage its diverse contaminants, ensuring environmental protection and public health safety. Hospital wastewater is categorized into blackwater, greywater, stormwater, and specific discharges (Majumder and colleagues, 2021).

Blackwater consists of fecal matter and urine, contributing to high Biochemical Oxygen Demand (BOD) and containing pathogens and antibiotic-resistant microorganisms (Sunta and team, 2019). It also includes unmetabolized pharmaceutically active compounds (PhACs) (Verlicchi and co-authors, 2010).

Greywater comes from washing, bathing, and medical processes, containing surfactants, detergents, and toxic agents like radioactive elements (Kumari and colleagues, 2020). Stormwater is reused for flushing or irrigation, while specific discharges from labs include toxic chemicals such as pharmaceutical residues, solvents, and heavy metals like cadmium, mercury, and copper (Kumari and team, 2020; Verlicchi and co-authors, 2010).

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Fig 2: Comparison of average range of parameters of HWWs and MWWs (Astha et al., 2020).

2.2. Impact of Hospital Wastewater on Treatment Systems

Hospital wastewater (HWW) contains hazardous pollutants such as pharmaceutically active compounds (PhACs), endocrine disruptors, heavy metals, and disinfectants (Muhammad et al., 2021). It has high levels of BOD, COD, TDS, TSS, TOC, TN, and nitrates, along with infectious microbes and multi-drug-resistant bacteria (Parida et al., 2021).

Effective treatment of hospital wastewater is crucial due to its significant environmental impact. Conventional sewage systems cannot handle these contaminants, emphasizing the need for advanced wastewater treatment plants. Specialized technologies are required to manage these complex pollutants and protect health and the environment.

Type of Contaminant	Average concentration in hospital wastewater	Potential effects on environment & human health
Pharmaceuticals	Varies depending on usage and discharge rates	– Environmental persistence leading to bioaccumulation in aquatic organisms.-Disruption of endocrine systems in wildlife and potential transfer to the human food chain.-Development of antibiotic-resistant bacteria in natural ecosystems
Biological (Pathogens)	High, especially in untreated or poorly treated wastewater	-Contamination of surface water bodies, posing risks of waterborne diseases to humans- Impact on aquatic ecosystems, leading to reduced biodiversity and ecosystem function
Chemical (Heavy Metals)	Varies depending on hospital activities and waste disposal practices	– Accumulation in sediments and soils, causing long-term toxicity to aquatic organisms.- Adverse effects on human health through ingestion of contaminated water or food.- Potential leaching into groundwater, compromising drinking water quality.

3. Top Wastewater Treatment Solutions for Hospitals

Sewage treatment systems for hospitals must address the unique aspects of medical wastewater, which includes pathogens, pharmaceuticals, and chemicals. Conventional wastewater treatment facilities (WWTPs) achieve different removal rates: 20-50% for primary, 30-70% for secondary, and over 90% for tertiary processes (Bhandari et al., 2023).

For managing hospital effluents (HWW), various methods—physical, chemical, and biological—are utilized. Notable techniques include ozonation (Souza et al., 2018), electrochemical oxidation (Ouarda et al., 2019), and chlorination (Guo et al., 2015). Advanced systems like activated sludge (ASP) and membrane bioreactors (MBR), especially when combined with ozonation, are very effective at removing micropollutants (Nguyen et al., 2019; Vo et al., 2019).

Integrated treatment methods are shown to be the most successful in removing complex contaminants from hospital wastewater (Pariente et al., 2022).

3.1. Primary Sewage Treatment Plants for Hospitals

Initial treatment of hospital wastewater involves a crucial mechanical process that removes solids and organic materials through screening and sedimentation, generating primary sludge (Ibiam and Igewnyi, 2012). This step effectively removes large debris, protects downstream equipment, and reduces the organic load. However, initial treatment alone is not sufficient for managing medical effluents, which often include pathogens and pharmaceutical residues.

While important, initial treatment should be part of a comprehensive wastewater management system for medical facilities, integrating advanced methods to thoroughly decontaminate hospital effluents.

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3.2. Secondary Sewage Treatment Plants for Hospitals

Secondary wastewater plants for medical facilities utilize biological processes, mainly bacteria, to break down and purify the waste. Methods such as the activated sludge process (ASP), membrane bioreactors (MBR), and constructed wetlands (CW) are widely used (Majumder et al., 2020). These systems effectively address organic matter, but their ability to remove pharmaceutically active compounds (PhACs) and antibiotic resistance genes (ARGs) depends on the complexity of these pollutants (McCarthy et al., 2021).

While biological systems like ASP, MBR, and CW efficiently treat organic substances, they often require additional steps to fully eliminate pharmaceuticals and meet environmental regulations.

3.3. Advanced Wastewater Treatment Solutions for Hospitals

Treatment Plant Type	Key Characteristics	Pros	Cons
Primary Treatment	Basic physical separation of solids from liquid wastewater	Simple and cost-effective	Limited pollutant removal,not suitable for advanced treatment
Secondary Treatment	Biological processes to remove dissolved and suspended solids	Effective for organic matter removal	Requires larger space, may not efficiently remove some pollutants
Tertiary Treatment	Advanced processes to further purify water	High removal efficiency for various pollutants	Expensive, energy-intensive, requires skilled operation
MBR (Membrane Bioreactor)	Uses membranes for solid-liquid separation in biological treatment	Compact design, high-quality effluent	High capital and operational costs, membrane fouling is a concern
AOP (Advanced Oxidation Processes)	Chemical processes to degrade pollutants	Effective for hard-to-treat contaminants, versatile	Energy-intensive, may produce harmful by-products
Electrocoagulation	Uses electrical charge to destabilize and remove contaminants	Efficient in removing various pollutants	Requires electricity, maintenance may be challenging
Nanotechnology	Uses nanoparticles to treat water pollutants	High removal efficiency for specific contaminants	Costly, potential environmental concerns about nanoparticles

Advanced treatment plants represent the most sophisticated technologies for processing medical facility effluent, using modern methods to enhance water quality. These processes target remaining solids, harmful microorganisms, and persistent organic compounds, ensuring compliance with environmental and health regulations.

Key techniques include UV disinfection, which effectively removes antimicrobial-resistant (AMR) bacteria and antibiotic resistance genes (ARGs), along with chemical methods like catalytic ozonation and chlorination (McCarthy et al., 2021). Ozonation combines ozone with hydroxyl radicals to neutralize pathogens, while chlorination addresses AMR bacteria, ARGs, and pharmaceutically active substances (Wang and Zhuan, 2020; Chen et al., 2019).

While highly effective, these advanced processes can be energy-intensive and require strategic planning in sewage treatment for hospitals.

4. Advanced Sewage Treatment Technologies for Hospitals

In sewage treatment for hospitals, addressing the unique challenges of medical wastewater (HWW) is essential. Today, advanced solutions like Advanced Oxidation Processes (AOPs) play a key role in removing antibiotics and harmful microbes, while enhancing pollutant biodegradability. Nanocomposites are also valuable, aiding in the photo-catalyticbreakdown of contaminants.

Technologies such as electrocoagulation and photo-catalytic methods achieve removal efficiencies over 99%, making them highly effective. Integrated approaches, combining biological methods with AOPs, have proven over 98% effective in eliminating pharmaceuticals and antibiotic-resistant genes (ARGs) (Bhandari et al., 2023). Membrane bioreactors(MBRs) paired with AOPs are emerging as promising full-scale pre-treatment options.

Despite their high efficiency, these methods are energy and cost-intensive, particularly with large hospital wastewater volumes, requiring further research for large-scale feasibility (Ryan et al., 2019).

4.1. Membrane Bioreactors (MBRs) for Hospital Wastewater

The Membrane Bioreactor (MBR) is an advanced solution for hospital effluent treatment, combining biological processes with membrane filtration to achieve efficient removal of organic matter and nutrients (Pariente et al., 2022). MBR technology is particularly effective in eliminating pharmaceutical compounds (PhACs), with its performance dependent on factors like sludge age, wastewater composition, and environmental conditions such as temperature, pH, and conductivity.

Compared to traditional methods, MBRs offer enhanced effluent quality, require less space, and generate less biosolids(Chiarello et al., 2016). However, these systems involve higher operational costs due to the need for continuous aeration and regular maintenance to prevent membrane fouling. Despite these challenges, MBRs are a powerful option for hospital wastewater treatment in healthcare settings.

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4.2. Advanced Oxidation Processes (AOPs) in Hospital Sewage Treatment

Advanced Oxidation Processes (AOPs) are a cutting-edge solution for treating hospital effluent, utilizing reactive oxygen species (ROSs) to degrade and remove contaminants in medical wastewater. These reactive compounds oxidize stubborn organic pollutants into less harmful substances through methods like light irradiation, electricity, or catalysts (Choudhary et al., 2021; Ao et al., 2021).

AOPs enhance the efficiency of bioremediation by reducing toxicity and pollutant levels, making them highly effective in removing pharmaceutical residues, pathogens, and other harmful substances (Pandis et al., 2022). Despite their high efficiency, AOPs can be energy-demanding, and their effectiveness depends on the specific composition of the wastewater. Therefore, optimizing operational costs and system performance is crucial for maximizing the benefits of AOPs in effective sewage treatment for hospitals.

4.3. Electrocoagulation for Hospital Sewage Treatment

Electrocoagulation is an innovative wastewater treatment method that utilizes electrochemical processes to remove pollutants. By applying direct current, this technique generates coagulants through the oxidation of an anode, which then interact with ionic species or metal hydroxides, aiding in contaminant removal (Dehghani et al., 2014; Holt et al., 2005).

This process is valued for its simplicity, effectiveness, and operational ease. Compared to conventional methods, it offers advantages such as better sludge settling, reduced sludge volume, and the formation of larger flocs. Additionally, electrocoagulation reduces the use of chemicals, making it an eco-friendly and cost-efficient alternative (Carmona et al., 2006; Onder et al., 2007; Wang et al., 2009). It is particularly efficient in eliminating heavy metals (Dehghani et al., 2014).

However, challenges such as energy consumption and electrode corrosion can affect the system’s overall cost-efficiency and maintenance (Carmona et al., 2006).

Technology Name	Description/ Benefits	Advantage for Healthcare Facilities	Reference
MBR (Membrane Bioreactor)	Utilizes membranes for solid-liquid separation in biological treatment	Compact design saves space in healthcare facilities,High removal efficiency toward organic compounds, Reduced need for secondary clarifiers and sludge handling	Zhao et al., 2022
AOP (Advanced Oxidation Processes)	Chemical processes to degrade pollutants	Effective in breaking down pharmaceuticals and pathogens, Versatile for treating a wide range of contaminants,  May help in addressing emerging pollutants in healthcare waste	(Pandis et al., 2022).
Electrocoagulation	Uses electrical charge to destabilize and remove contaminants	Efficient removal of heavy metals and pathogens, Applicable for decentralized treatment in healthcare settings, Potential for reducing sludge production in the process	(Dehghani et al., 2014)
Nanotechnology	Uses nanoparticles to treat water pollutants	High precision in targeting specific contaminants, Potential for addressing nanoscale pollutants in healthcare waste, High adsorption efficiency	Bagheri et al., 2016

4.4. Nanotechnology in Hospital Sewage Treatment

Nanotechnology is transforming wastewater treatment, especially in tackling pharmaceutical contaminants in hospital wastewater (HWW). By leveraging the unique properties of nanomaterials, highly efficient sorbents are developed to capture and eliminate pharmaceuticals (Tiwari et al., 2008; Afkhami et al., 2010; Bagheria et al., 2016).

Nanoscale membranes, nanoparticles, and nanostructured adsorbents enhance filtration, improving the removal of pathogens and drug residues. For instance, photocatalytic nanomaterials like titanium dioxide help degrade organic pollutants through advanced oxidation when exposed to light.

Furthermore, nano-enabled sensors offer real-time monitoring of water quality, streamlining treatment processes. Nanotechnology provides significant benefits, including improved efficiency, a smaller system footprint, and superior pathogen removal in effective sewage treatment for hospitals.

4.5. Smart Sewage Treatment Systems for Hospitals

Smart sewage treatment systems for hospitals utilize sensors, automation, AI, and remote monitoring to optimize operations for hospital wastewater (HWW). AI enhances wastewater treatment by improving process design, water quality monitoring, and performance prediction (Wang et al., 2023). These intelligent systems allow for real-time adjustments, increasing efficiency and effectiveness.

AI-driven analytics improve pattern recognition and predictive modeling, leading to better outcomes. Automated controls and predictive maintenance minimize downtime, while cloud-based platforms enable remote access to system data.

However, challenges include high costs, energy use, and concerns around cybersecurity and data privacy.

5. Successful Case Studies of Sewage Treatment in Hospitals

5.1. MLD Sewage Treatment Plant at Kozhikode Medical College Hospital, Kerala

Kozhikode Medical College Hospital operates a 2-MLD treatment facility utilizing electrolytic technology and 18 reactors, recently expanded to handle 5 MLD. This adaptable system optimizes efficiency by adjusting to wastewater volume. The plant processes toilet effluent from nearby wards, delivered by tankers, and channels waste through a 1,400-meter pipeline network connecting campus buildings. Currently, treated effluent is discharged into the Conolly Canal, with future plans for reuse in gardening and flushing, underscoring a commitment to sustainable water management. This case illustrates the integration of advanced technologies, strategic capacity planning, and innovative reuse initiatives in effective sewage treatment for hospitals.

5.2. MBR-Based Wastewater Treatment Plant at Kamakshi Hospital, Visakhapatnam, Andhra Pradesh

Kamakshi Hospital met the demand for high-quality treated effluent in critical areas, such as the dialysis unit, by installing an MBR-based treatment system. This facility, equipped with dual filtration layers, ensures compliance with environmental standards and provides clean recycled water for hospital use. Additionally, an Energy-Efficient Heat Pump was installed to supply temperature-controlled water, enhancing both comfort and sustainability while promoting energy savings.

5.3. Al-Mauany Hospital Sewage Treatment Plant in Basrah City, Iraq

The Al-Mauany Hospital in Basrah Governorate implemented an MBR-based wastewater treatment system, showing significant environmental benefits. A study by Khafaji and colleagues (2023) assessed its efficiency, revealing changes in key parameters such as COD, BOD, DO, and nitrogen compounds. The system reduced COD by 80% in the summer and 79% in the winter, while BOD5 levels dropped by 74% and 69% for the same periods. The BOD5/COD ratioindicated good bio-treatability.

The removal of NH3-N reached 86% in summer and 83% in winter, meeting required standards. Turbidity reductionwas also significant, with 70% removal in summer and 66% in winter. Though suspended solids removal was less efficient due to biofilm accumulation in the aeration basin, overall results showed effective sewage treatment for hospitals in addressing most contaminants.

6. How to Choose the Right Sewage Treatment Plant for Your Hospital

Selecting the right sewage treatment system for your hospital is essential for efficient wastewater management (Cetkovic et al., 2023). Key factors to consider are:

• Daily wastewater volume: Assess average output.
• Effluent composition: Analyze contaminant levels.
• Available space: Ensure sufficient space for installation.
• Budget: Consider both setup and operational costs.

Technologies include:

• Membrane Bioreactors (MBRs): Provide high-efficiency treatment but come with higher operational costs.
• Advanced Oxidation Processes (AOPs): Effective for complex pollutants but are energy-intensive.
• Electrocoagulation: Requires low chemical use but needs regular upkeep.

Evaluating long-term sustainability, energy efficiency, and maintenance requirements is critical to meeting hospital goals and environmental standards.

Fig 3: Energy savings related to proposed measures in 47 wastewater treatment plants in Germany [Kaste, 2003]

6.1. Technology Options for Hospital Sewage Treatment

When selecting wastewater solutions for hospitals, prioritize technologies that meet regulatory standards and offer cost-effective solutions. Conventional municipal systems often fall short in removing micropollutants and antibiotic-resistant genes (ARGs), making advanced treatment essential for environmental protection and public health (Beier et al., 2011; Khan et al., 2020).

Key technologies to consider:

• Membrane Bioreactors (MBRs): Space-efficient, low-maintenance, and effective in organic matter removal and high-quality effluent production (Biasea et al., 2019).
• Advanced Oxidation Processes (AOPs): Effective for degrading complex pollutants like pharmaceuticals and pathogens.
• Electrocoagulation: Cost-effective and versatile, suitable for various facility sizes, removing contaminants through electrochemical reactions.
• Nanotechnology: Enhances filtration and catalytic properties with nanoscale membranes and photocatalytic materials.
• Smart Treatment Systems: Utilize sensors, automation, data analytics, and AI for real-time monitoring and optimization.

Tailor the technology to your hospital’s needs for optimal performance and cost-efficiency.

Treatment	Efficiency	Initial Cost	Operational Cost	Space Required	Suitability for Hospitals
MBR	High removal efficiency for various pollutants	Moderate to high	Moderate to high	Compact Design	Suitable for medium to large hospitals
AOP	Effective for hard to treat contaminants	Moderate to high	Moderate to high	Depends on specific AOP	Applicable to various hospital sizes
Electrocoagulation	Efficient removal of heavy metals & pathogens	Moderate	Moderate	Requires moderate space	Suitable for small to medium hospitals
Nanotechnology	High precision in targeting specific contaminants	High	High	Requires minimal space	May be suitable for various hospital sizes
Primary Treatment	Limited pollutant removal,basic separation	Low to moderate	Low to moderate	Moderate space	Suitable for small hospitals
Secondary	Effective for organic matter removal	Moderate	Moderate	Moderate to large space	Suitable for medium to large hospitals
Tertiary	High removal efficiency for various pollutants	High	High	Requires substantial space	Suitable for large hospitals

6.2. Environmental Impact of Hospital Sewage Treatment Systems

Hospital effluents contain complex, hazardous pollutants such as pharmaceutically active compounds (PhACs), endocrine disruptors, hormones, heavy metals, disinfecting agents, cytotoxics, and radioisotopes (Khan et al., 2021). Hospital wastewater (HWW) is typically high in Biochemical Oxygen Demand (BOD), Chemical Oxygen Demand(COD), Total Dissolved Solids (TDS), Total Suspended Solids (TSS), Total Organic Carbon (TOC), Total Nitrogen(TN), nitrites, nitrates, and Total Phosphorus (TP) (Majumder et al., 2021), and often contains infectious microbes, multi-drug-resistant organisms, and antibiotic resistance genes (ARGs) (Parida et al., 2021). Effective sewage treatment for hospitals is crucial to mitigate environmental impacts.

Sustainable sewage treatment technologies can significantly reduce hospitals’ environmental footprint:

• Membrane Bioreactors (MBRs): Offer space-efficient solutions and high-quality effluent with reduced waste byproducts.
• Advanced Oxidation Processes (AOPs): Address complex pollutants, minimizing harmful byproducts and enhancing water quality.
• Smart Treatment Systems: Optimize processes and resource use, contributing to energy efficiency and waste reduction.

Integrating these technologies helps hospitals meet regulatory standards and supports environmentally responsible practices, promoting a healthier future for the community and planet.

7. Cost Analysis of Hospital Sewage Treatment

Conducting a sewage treatment plant cost analysis for hospital systems involves evaluating both startup and ongoing expenses:

Startup Costs:

• Acquisition and Installation: Includes purchasing and setting up technologies like Membrane Bioreactors (MBRs), Advanced Oxidation Processes (AOPs), and Smart Treatment Systems, along with necessary infrastructure and technology setup.
• Infrastructure Requirements: Costs for building or modifying facilities to support the selected treatment technology.

Ongoing Expenses:

• Energy Consumption: Costs for powering processes such as electrocoagulation, advanced oxidation, and membrane filtration.
• Maintenance: Regular costs for cleaning, repairs, and replacement of parts or membranes to ensure system efficiency.
• Labor: Staffing costs for operating and managing the treatment plant.
• Waste Disposal: Costs for disposing of residual sludge and other byproducts.

Assessing these factors helps hospitals choose a sewage treatment solution that is both cost-effective and compliant with regulations, ensuring long-term operational efficiency and sustainability.

Fig 4: Initial costs for primary and secondary treatment plants both equipment and construction costs (Ozgun et al., 2021).

7.1. Comparing Hospital Sewage Treatment Technologies

When assessing sewage treatment technologies for hospitals, it’s crucial to evaluate both startup and ongoing expenses, alongside design and engineering considerations (Ahmad, 2019). Here’s a comparison of different technologies based on their costs and features:

• Sequential Batch Reactor (SBR): Moderate startup and running expenses. Effective for batch treatment with flexibility, though it can be complex to operate.
• Activated Sludge Process (ASP): Moderate costs, well-established for efficient organic matter removal but requires considerable space and management.
• Moving Bed Biofilm Reactor (MBBR): Moderate initial and ongoing expenses. Compact design with effective organic matter removal, though regular monitoring is needed.
• Upflow Anaerobic Sludge Blanket (UASB): Low startup and running costs, energy-efficient with high organic load handling, but produces large volumes of sludge.
• Membrane Bioreactors (MBRs): High initial and ongoing costs due to membrane use. Offers excellent efficiency and compact design, but membrane fouling can be an issue.
• Waste Stabilization Pond (WSP): Low-cost with minimal operational expenses, effective in warm climates, but requires large land areas.
• Advanced Oxidation Processes (AOPs): High startup and running costs due to advanced equipment. Highly effective for removing persistent contaminants, though maintenance can be costly.
• Electrocoagulation: Moderate initial costs with low running expenses. Cost-effective with less sludge production but involves energy consumption and electrode wear.
• Nanotechnology: Costs vary significantly. Enhances filtration and catalytic properties but can be expensive.
• Smart Sewage Treatment Systems: Moderate initial investment with ongoing costs related to energy and maintenance. Offers optimization and long-term efficiency but can be complex and costly.

Selecting the right technology involves balancing hospital needs, efficiency improvements, energy use, and long-term sustainability goals to meet environmental and budgetary requirements.

Table 2: Comparison of Operation & Maintenance cost of various technologies for STP (Tare V., 2010)

7.2. Hospital Sewage Treatment Financing Options

Financing wastewater management, especially for wastewater treatment plants (WWTPs), can be challenging but is crucial for successful operation and environmental enhancement (Juszczyk et al., 2020; Perez et al., 2014). Effective financing strategies are essential for aligning financial and environmental objectives.

Modern economic cost-benefit analysis (CBA) incorporates both financial and environmental impacts, such as health improvements, reduced disease rates, and decreased mortality (Dixon, 2011; Dixon, 2012; Dixon, 2013).

Key financing options include:

• Government Grants and Subsidies: Help cover initial costs.
• Public-Private Partnerships (PPPs): Share financial responsibilities.
• Environmental Bonds: Raise capital for projects.
• Loans and Credit Facilities: Spread out costs.
• Carbon Credits: For projects aimed at reducing greenhouse gases.
• Cost Sharing and User Fees: Distribute financial responsibilities.

A diverse financing strategy aligns financial management with environmental and public health goals.

8. Regulatory and Environmental Factors in Hospital Wastewater Treatment

When selecting sewage treatment plants for hospitals, complying with environmental regulations is essential. These regulations ensure responsible wastewater management, legal compliance, and protection of public health.

Assessing the environmental impact of sewage treatment technologies is critical. This includes evaluating their effects on ecosystems, water resources, and air quality. Key factors involve the system’s ability to meet effluent quality standards, minimize energy use, and handle waste byproducts efficiently.

Hospitals must align regulatory compliance with environmental sustainability. Achieving this ensures effective wastewater management and reflects a commitment to both legal and environmental responsibilities.

Fig 5 : Percentage reduction of the pollutant indicators in subsequent sewage treatment stages (Dariusz et al., 2020).

8.1. Local and National Wastewater Regulations

Globally, nations have established various regulations for managing pollutants in aquatic bodies, including:

• WHO Guidelines
• US Clean Water Act (1972)
• USEPA Standards
• Indian Biomedical Waste (Management and Handling) Rules (1998)
• EU Water Framework Directive (1991)
• China’s Discharge Standards for Water Pollution from Medical Institutions

However, enforcement remains inconsistent in many regions (Majumder et al., 2019). In India, the Bio-medical Waste (Management & Handling) Rules, 1998, enforced by the Ministry of Environment & Forests (MoEF) under the Environment (Protection) Act, 1986, mandate oversight by State Pollution Control Boards (SPCBs) or Pollution Control Committees (PCCs) (Verlicchi, 2018).

Despite regulations like the EPA’s Effluent Guidelines and WHO’s Safe Management of Wastes from Healthcare Activities, there is often a lack of specific standards for pollutants such as pharmaceuticals (PhACs) and personal care products. This results in varied characteristics of effluent worldwide (Kumari et al., 2020; Majumder et al., 2021).

Regulation/Standard	Summary of Requirements	Potential Penalties for Non-Compliance
Central Pollution Control Board (CPCB) Guidelines for Hospital Waste Management	Defines standards for hospital wastewater treatment, including specific parameters and permissible limits	Fines, legal actions, closure of facilities for non-compliance
Water (Prevention and Control of Pollution) Act, 1974	Regulates water pollution, sets standards for wastewater discharge, including from healthcare facilities	Fines, legal actions, closure of facilities for non-compliance
Environment (Protection) Act, 1986	Provides a framework for environmental protection, mandates compliance with wastewater treatment standards	Fines, legal actions, closure of facilities for non-compliance
Biomedical Waste Management Rules, 2016	Specifies requirements for biomedical waste management, which may include wastewater from healthcare facilities	Fines, legal actions, closure of facilities for non-compliance
National Ambient Air Quality Standards (NAAQS)	Sets air quality standards indirectly influencing wastewater treatment practices in healthcare settings	Fines, legal actions, closure of facilities for non-compliance
State Pollution Control Boards (SPCBs) regulations	State-specific regulations complementing national standards for wastewater treatment in healthcare facilities	Fines, legal actions, closure of facilities for non-compliance

8.2. Green Initiatives for Sewage Treatment

A Green Hospital prioritizes both public health and environmental sustainability by reducing its impact on disease burden and enhancing eco-friendly practices (Azmal et al., 2014). Key initiatives include:

• Efficient Water Use: Implementing rainwater harvesting, water-saving fixtures, and wastewater treatment and recycling systems.
• Green Design: Incorporating green roofing and managing stormwater releases.
• Renewable Energy: Integrating renewable energy sources to minimize reliance on non-renewable resources.
• Nature-Based Treatments: Utilizing natural treatment approaches for improved wastewater management.
• Resource Recovery: Adopting systems for recovering valuable resources from waste.

By exceeding environmental standards and regulatory requirements, Green Hospitals manage sewage responsibly and contribute positively to the environment (Kumari and Kumar, 2020).

9. Conclusion: Effective Wastewater Management in Hospitals

Establishing efficient hospital wastewater treatment systems requires a comprehensive strategy that balances regulatory compliance, technological innovation, and sustainability. By choosing the right wastewater treatment technology tailored to their needs and environmental impact, healthcare institutions can manage sewage effectively while promoting responsible resource use.

Green initiatives emphasize adopting eco-friendly practices to support sustainability goals. Adhering to local, state, and federal regulations ensures legal compliance and demonstrates a commitment to environmental and public health responsibilities.

As the healthcare industry progresses, integrating smart technology, renewable energy sources, and effective water management will shape the future of wastewater treatment. Embracing these innovative solutions enables hospitals to address wastewater management challenges and set a standard for sustainable and ethical healthcare practices.

10. “References and Further Reading”

H. Zhou., D. W. Smith., 2002.  Advanced Technologies in Water and Wastewater Treatment, J. Environ. Engg. Sci. 1, 247-264.

Mike Williams, Rai, S., Kookana., 2018. Chapter 3 – Fate and Behavior of Environmental Contaminants Arising From Health-Care Provision. Elsevier.  21-40.

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