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Medical waste refers to those hazardous waste materials generated by healthcare activities, including a broad range of materials, and remains as an issue on both public health and environment. In China, there was inadequate information on the implementation of management systems in hospitals based on the national regulatory framework. The objectives of this study were to assess the current situation of medical waste management and to identify factors determining the implementation of a management system based on the national regulatory framework in hospitals. We investigated 23 general hospitals in both urban and rural areas of Shandong Province, China, by both quantitative and qualitative approaches. The medical waste generation rate was 0.744, 0.558 and 1.534 kg bed(-1) day(-1) in tertiary hospitals, urban secondary hospitals and county hospitals, respectively. There is a wide disparity between implementation in tertiary, secondary and county hospitals. With increasing financial, technological, and materials investment, a management system has been established in tertiary and secondary hospitals. Financial support and administrative monitoring by the government is urgently needed to build a sound management system in hospitals located at remote and less-developed areas. In those areas issues in the financial, administrative and technical aspects should be further examined.