E4074 Ministry of Health of Uzbekistan Central Project Implementation Bureau (CPIB) Project “Health-3� And Additional Financing Phase Framework Environmental Management Plan Prepared for: CPIB Office Tashkent 51, Parkentskya Street, Tashkent 100077 Uzbekistan Prepared by: Madina Khalmirzaeva NBT Environmental Engineer 14 Mavze Abdullaev, Suite 7, Yakkasaroy District Tashkent 100100 Uzbekistan www.nbt.uz November, 2010 TABLE OF CONTENT INTRODUCTION ..................................................................................................................... 4 1. EXECUTIVE SUMMARY ................................................................................................ 4 2. PROJECT DESCRIPTION ................................................................................................ 5 2.1. Project components ..................................................................................................... 5 2.2. Iinformation on medical equipment to be delivered and installed .............................. 7 2.3. Waste Management Practice in Uzbekistan ................................................................ 7 3. INSTITUTIONAL CAPACITY AND ARRANGEMENTS ............................................. 8 4. ROLES & RESPONSIBILITIES ....................................................................................... 8 5. STEP-BY-STEP PROCEDURE......................................................................................... 8 6. ENVIRONMENT MANAGEMENT FRAMEWORK ...................................................... 9 6.1. General content of FEMP............................................................................................ 9 6.2. Potential Negative Environment Impact and Mitigation Measure ............................ 10 7. Procurement and Use of Medical Waste Equipment .......................................................... 10 Medical Waste from Healthcare services ............................................................................ 10 7.1. Type of medical wastes ............................................................................................. 11 7.2. MITIGATION MEASURES TO DEAL WITH POTENTIAL NEGATIVE IMPACTS ............................................................................................................................ 11 8. CONSULTATION ........................................................................................................... 15 9. MONITORING AND ACTION PLAN ........................................................................... 15 ATTACHMENTS ................................................................................................................ 22 Attachment 1.Environmental Management Checklist for Small Construction and Rehabilitation Activities ...................................................................................................... 22 Attachment 3: ENVIRONMENTAL GUIDELINES .......................................................... 33 Attachment 3. Meetings with Project Stakeholders and Beneficiaries ................................ 35 Environmental Guidelines .................................................................................................... 36 Public Consultations on Health III Project .......................................................................... 37 2 ABBREVIATION EA Environmental Assessment EMC Emergency Medical Care EMP Environmental Management Plan CPIB Central Project Implementation Bureau DCM Decree of Cabinet of Ministries of Republic of Uzbekistan FEMP Framework of Environmental Management Plan Goskompriroda State Nature Protection Committee of Republic of Uzbekistan GOU Government of Uzbekistan IBRD International Bank for Reconstruction and Development MOH Ministry of Health of Republic of Uzbekistan NCD Non-Communicable Diseases NGO Nongovernmental Organization SanPiN Sanitarian Rules and Norms SES Sanitarian Epidemiological Station RCM Resolution of Cabinet of Ministers RCSES Republican Center of Sanitarian Epidemiological Supervision RMU Rayon Medical Union RUz Republic of Uzbekistan WB World Bank WHO World Health Organization 3 INTRODUCTION Under the State Healthcare Reform Program, Republic of Uzbekistan (RUz) has undergone restructuring of Primary Health care by improving infrastructure and equipment, developing medical personnel, introducing new management and financing reforms that promote management innovations. The World Bank (WB) provided support to reforming primary of health care (PHC) system. The organization and providing of health care services in Uzbekistan are implementing based on such administrative units as rayons and provinces. District level and cities level inside of health organizations are responsible for providing primary and secondary level health care services. There are 200 health care facilities at the rayon level, of which 171 from them are located in rural areas and 29 located in urban areas. They provide services to 28 million population of country. With the support of WB financed Health I and Health II projects the Government of Uzbekistan (GOU) improved infrastructure and provided equipment in most of rural PHC facilities. A nationwide reforming of Primary Health care was conducted in rural area; it was based on PHC facilities’ per capita financing. The medical personnel from the reformed PHC facilities took extensive retraining on general practice/family medicine. Within the framework of cooperation strategy between the GoU and the WB, it is envisaged to direct intensive investment to inpatient health care services quality improvement at the rayon level and for this purpose there is being developed “Health-3� project. The total project cost is estimated at US$ 101 million equivalent, of which US$93.0 million in IDA Credit. Government will be responsible for all local taxes (estimated at US$ 8.0 million equivalent) associated to the IDA-financed expenditures. The intended investment envisages solution of problems on medical services quality improvement and population accessibility to inexpensive specialty care at the rayon level. In this respect, the priority issues of project preparation stage will be the hospital care strategic conceptualization, including health care manpower training. Currently the Ministry of Health (MOH) has developed the investment program for capital construction, reconstruction and rehabilitation of rural hospitals for 2010-2014. The project will support the State Welfare Improvement Strategy 2008-2010 of RUz. 1. EXECUTIVE SUMMARY Under Project “Health-3� the Framework of Environmental Management Plan (FEMP) was developed to provide guidelines on EMPs preparation for all project’s objects. The document consists of the following chapters:  Project description,  Institutional Capacity and Arrangements  Roles & Responsibilities  Step-by-Step Procedure  Description of Simplified Simplistic EMP  Waste Management for Medical Equipment to be Delivered and Installed  Medical Waste Management Plan This document presents summary of project information with description of its components and goals, description of WB and Uzbekistan Legislation related to conducting and approval procedure of environmental assessment (EA). The Framework of EMP (FEMP) was developed based on reviewed impacts on environment. FEMP includes recommended mitigation measures for all stages of project implementation – pre- construction, construction and operation. Recommended measures comply with WB Safeguards 4 Policy and local environmental legislation. Roles and responsibilities of institutions involved in the process of developing, implementation EMP and further monitoring of environmental norms related with project were defined. The project is not expected to have significant or irreversible negative environmental impacts neither at the construction, nor at the operation phases. Impacts of the construction phase will be typical for all medium scale rehabilitation/construction activities and limited to the project sites which are State owned land plots with user rights already granted to the medical institutions currently operating in these plots. Impacts of the operation phase will be typical for operating medical institutions. The medical waste management practices in hospitals were reviewed and issues related to medical waste management were analyzed. Based on finding and literature review best available and practicable practices recommendations on wastes disposal were developed. It was mentioned that most acceptable and secure practice for current situation in Uzbekistan is burning wastes in incinerators. The Check List and Guidelines for Ecological Planning during construction and rehabilitation activity for EMP in the form of checklist are presented in Attachment. During FEMP preparation consultant held a number of meetings with representatives of State Nature Protection Committee, Republican Center of State Epidemiological Supervision (RSCES), hospitals in Tashkent city, international consultants involved in Project “Health-3� preparation. 2. PROJECT DESCRIPTION 2.1. Project components The overall objective is improving health system performance in delivery of efficient and quality essential health services and its ability to address the pending epidemic of chronic non-communicable diseases. The specific objectives are: (i) improving quality of medical services in rayon medical unions; (ii) ensuring financial sustainability of upgraded rayon medical unions; and (iii) supporting health promotion and prevention programs targeting NCDs and improving the epidemiological surveillance of communicable diseases through piloting reorganization of the public health laboratory network. Preliminary design of the “Health-3� project covers 4 components, which include following activities1: Component 1: Improving Health Service Delivery (US$84.04 million equivalent). This component is aimed at improving the quality of care within selected priority clinical conditions responsible for the highest burden of diseases according to quality management principles. This involves the use of comprehensive clinical and public health approaches aimed at reducing the impact of these conditions on the health status of the population while improving outcomes. Sub-component 1.1: Hospital Services Improvement This sub-component aims at improving quality of medical services in rayon medical unions and access to specialized inpatient and consultative outpatient care in rayon hospitals through: (i) the provision of medical equipment for central rayon hospitals; (ii) the development and implementation of systematized medical equipment maintenance for these hospitals; (iii) the development, review and implementation of the new clinical standards and protocols of the MoH; (iv) the functional planning of health service delivery for participating RMUs/CMUs, (v) the development of health service referral guidelines and mechanisms. The Government will finance under parallel financing (i) 1 http://www- wds.worldbank.org/external/default/main?pagePK=64193027&piPK=64187937&theSitePK=523679&menuPK =64187510&searchMenuPK=64187511&entityID=000262044_20100317164934&cid=3001_177 5 upgrading of buildings and fixtures of the central rayon hospitals and laboratory facilities; and (ii) recurrent operating costs. The estimates amount of Government contribution is UDS 300 million. Sub-component 1.2: Primary Health Care Development This sub-component aims at providing further support to general practice-based Primary Health Care established and supported under the IDA-financed Health I and II projects. It will finance: (i) the expansion of urban primary care model through investment in medical personnel and equipment in urban PHC facilities (all policlinics) in three oblasts: Fergana, Syrdarya and Samarkand; (ii) the extension of training/retraining programs to an additional number of PHC providers from rural Primary Health Care Clinics (SVPs, Selski Vratch Punckt) and reformed polyclinics; (iii) establishment of well designed and sustainable equipment maintenance system for PHC facilities developed through Health 2 project; and (iv) provision of energy security technologies to the selected PHC facilities (SVPs and polyclinics). Sub-component 1.3: Human Resource Quality Enhancement The key aim of the component is to strengthen the quality of care at primary and secondary health care levels through improvement of the clinical skills and competence of health personnel. This includes: (i) completion of GP re-training for rural health facilities and urban polyclinics; (ii) training of RMU and CMU pediatric and internal medicine doctors and nurses in new Clinical Practice Guidelines (CPGs); (iii) training of trainers in clinical case management; (iii) the development and introduction of up to date relevant and practical guidelines/treatment standards for RMU/CMU internal medicine and pediatrics staff. Component 2: Strengthening Health Financing and Management Reforms (US$3.14 million Equivalent) This component aims at: (i) solidifying and institutionalizing per capita based rural Primary Health Care Financing and management reforms that were rolled out nationwide within Health 2, including changes in oblast fiscal allocations; and introducing results-based provider payment system in the hospitals and PHC facilities. It will finance : (i) the development of appropriate regulatory measures to ensure lead role of the oblast/rayon health organs in health budget planning; (ii) staff training in financial management of reformed PHC and hospital facilities; (iii) design and implementation of performance-based incentive scheme for the reformed PHC facilities; (iv) implementation and evaluation of a pilot case-based payment system for the multi-profile hospitals in one oblast: Fergana; (v) the review of the current system of user fee exemptions and a study on the causes for the low utilization of hospital services by middle aged and older population. Component 3: Improving Public Health Service Delivery (US$2.76 million equivalent) This component is aimed at improving selected essential public health functions related mainly to NCDs and also for which there is strong counterpart buy-in and support. The proposed activities could include: Sub-component 3.1: Health Promotion and NCDs Prevention. This sub-component would build on current efforts to improve health promotion. Specifically it would support the development and implementation of a comprehensive national level Health Promotion program focused on the promotion of healthy lifestyles and prevention of NCDs. Sub-component 3.2: Strengthening Health Surveillance Systems. The sub-component would encompass the strengthening of surveillance systems and of the capacity of the Institute of Health to use data for policy making and program planning, and for monitoring NCDs. 6 Component 4: Project Management (US$3.84 million equivalent) This component would finance project’s administrative and fiduciary requirements such as project coordination, monitoring, evaluation, procurement and financial reporting. 2.2. Iinformation on medical equipment to be delivered and installed Under the Project “Health-3� it is being designed Master Plan for conducting rehabilitation works in hospitals to improve their operation and their ability to adapt to new medical technologies, communication system improvement and enhance of power efficiency. The problem of handling with medical wastes is planned to be considered. In the framework of WB funds it is planned to procure equipments for diagnostic centers (X-ray cabinets, electrocardiograph, and ultrasonic scanning devices), and for laboratories (incinerators). 2.3. Waste Management Practice in Uzbekistan In Uzbekistan, the Rules of waste management is regulated by Law of the RUz “ On Wastes� (2000), where stated the agencies involved into the process of waste management, their authorities, obligations, as well as wastes category and by number of regulatory documents (Sanitary norms and regulations (SNR), Regulation documents (RD)) determining procedure of waste management and their classification. Also the GOU has initiated a new national program to address the management of wastes, under which it prepared a National Waste Management Strategy and identified an associated action plan adopted as government policy. It covers all forms of waste—from municipal to industrial, including hazardous substances—and includes options for source reduction/ minimization, collection, storage, treatment and disposal. The action plan will emphasize not only technical solutions but also a range of policy measures focused on identifying least-cost approaches to waste management, including the use of economic incentives. Medical Wastes Management Plan includes designed “Instruction on medical waste disposal� (Appendix No.12 to the Health Ministry’s Order No.600 issued on December 29, 2007), “Sanitary norms and regulations for wastes collecting, storing and utilizing in medical and preventive treatment institutions� – No.0149-04 issued on 12.05.04. Classifications of medical and hospital wastes are stipulated in the instruction, and according to their classification it is given the procedure of their utilization – instillation, burning, discharge into centralized sewerage system and treatment in special factories (plastic and paper wastes). However, the present practice of medic wastes treatment does not meet environment requirements and besides it may be hazardous for population health. Consequently, not all hospitals equipped with solid wastes burning facilities with proper technical performance. Existing outdated wastes burning muffle furnaces and equipments do not meet hygienic and environment standards. Exception is several hospitals and research centers in different provinces in Uzbekistan where there were installed modern incinerators2 within the frameworks of International Loan. Consequently, as there are lack of waste burning equipments, solid medical wastes either buried or wasted together with garbage. Before being utilized to the centralized sewage system, the liquid wastes are to be chlorinated (according to the above mentioned standards). However, due to the lack of proper control and financial difficulties, these wastes are not always disinfected and they are delivered to the sewerage system. After the practice of medical wastes management in Uzbekistan had been reviewed, it was ascertained the necessity in development and adaptation of efficient medical wastes management system, including minimization of wastes generation, seperative collection, the use of modern environmentally sound technologies and control for the process of their utilization. Due 2 WB Project E1681 “ Uzbekistan - Avian Influenza Control and Human Preparedness and Response Project� http://www- wds.worldbank.org/external/default/main?pagePK=64193027&piPK=64187937&theSitePK=523679&menuPK =64187510&searchMenuPK=64187283&theSitePK=523679&entityID=000011823_20070719172151&search MenuPK=64187283&theSitePK=523679 7 to the lack of proper control and equipments needed for safety medical wastes utilization, there are great risks first of all for the people, working directly with medical wastes. 3. INSTITUTIONAL CAPACITY AND ARRANGEMENTS The Ministry of Health (MOH) of the Republic of Uzbekistan is core agency of State Health Management and it is under the Cabinet of Misters of the RUz. Implementation of “Health – 3� Project will be made by Ministry of Health via Central Project Implementation Bureau (CPIB). For approaching the objectives, the CPIB will conduct bidding for selecting local and international consultants. It will include: preparation bidding documents for rehabilitation works and procurement of equipments according to the consultants’ recommendation; construction works control in accordance with developed specifications (including EMP) in cooperation with representatives of local Hokimiyats; organization and conducting training programs for medical and technical personnel development for mastering new equipments and providing their maintenance. The Local (district) Hokimiyats, which acts both as a client and a customer, will be obligated to conduct biddings for construction works with the participation of CPIB experts. 4. ROLES & RESPONSIBILITIES It is recommended to establish position of environmental-engineer (staff unit) under CPIB. The environmental-engineer will be responsible for:  development of EMP for each invented objects;  tracking of EMP involvement to the bidding documentation for conduction construction works;  providing the further monitoring on EMP implementation during construction works;  preparing six-monthly report on project implementation;  assisting in adaptation of medical wastes management system, developed together with International environment-engineer. For installing the incinerators, the managers of hospitals will be responsible for preparing EA as well as its approval in accordance with Environmental Legislation of the RUz, by involving appropriate project organizations. Contractor, who implements construction works, should ensure EMP execution, which will be the part of the TOR. After construction works and medical equipments being completed and installed, the hospital administration will be responsible for equipment operation and wastes treatment. External monitoring on medical wastes treatment will be conducted on established schedule by representatives of District Sanitary and Epidemiological Station (SES), District MOH and District Committees for Nature Protection. 5. STEP-BY-STEP PROCEDURE For indicating negative impact on environment and development measures for its mitigation, it is required to conduct environmental assessment (EA) on the stage of Project designing in accordance with WB policy for environmental safeguard (OP/BP 4.01) and the Environmental Legislation of the RUz. In accordance with WB regulations on OP 4.01, the project facilities belonging to Category B that requires preparation of EMP for each individual facilities, as far as rehabilitating works will be implemented within the existing hospital territory and there no land acquisition for construction is 8 provided. This framework is a guideline for development of EMP which responds to WB requirements on safeguard policy and designed in accordance with local environment law. There are various national Laws and Decrees for environmental protection in Uzbekistan that is valid for this project, these are: “On Nature Protection� (1992), “On Water and Water Use� (1993), “On Atmospheric Air Protection� (1996), “On Wastes� (2002), “On Environment Expertise� (2000), Decree of the Cabinet of Ministers of the RUz (DCM RUz) “On adoption of the Decree on State Environment Expertise� (No.491, issued from 31.12.2001). The Head Department of State Environment Expertise (Glavgosexpertiza) is responsible for conducting environment expertise (EE), and it belongs to the State Nature Protection Committee (Goskomprirodi) of Uzbekistan. The Law of the RUz “On Nature Protection� (1992) says that the State Environment Expertise is mandatory measure for nature protection, that precedes business decision-making. Without any new land allocation for construction works, in accordance with local legislation, rehabilitating works require no any local environment assessment within existing framework. However, as per Appendix No.1 DCM No.491, installation of new incinerators, as biological treatment technology of Class 2, requires development and submission of EA Project material to its agreement with Glavgosexpertiza under the Goskomprirodi (according to the procedure stipulated in this Decree). Thereby, EMP for each hospital should be prepared by environment-engineer of CPIB in accordance to the WB policy for Safeguards and Local Environment Law, Contractor who conducts construction works in the field will be responsible for its implementation. EA for installation of new incinerators will be prepared by design institute which will develop feasibility study on rehabilitation/construction works. The CPIB environment-engineer will be responsible for monitoring on EMP implementation. The Environmental Management Checklist for Small Construction and Rehabilitation Activities will be used if installation of new equipments requires refurbishment of the existing buildings and construction of new small buildings., (see the template provided in Attachment 1). 6. ENVIRONMENT MANAGEMENT FRAMEWORK 6.1. General content of FEMP 116 hospitals were selected for the Project “Health-3� involvement during the project preparation. From it 81 hospitals locate in the regions which will be full covered by project and 35 partly: # Province Project involved hospitals 1 Andijan 14 2 Fergana 15 3 Namangan 11 4 Kashkadarya 13 5 Samarqand 14 6 Karakalpakstan 14 7 Bukhara 6 8 Jizzah 4 9 Navoi 4 10 Syrdarya 4 11 Surhandarya 4 12 Khorezm 6 13 Tashkent 5 9 The project is designed for implementation over the period of 5 years. The project will support, rehabilitation work and equipping for selected hospitals. The scope of rehabilitation work will be reviewed separately for each case, but all works are planning to conduct on the existing sites belonging to hospitals without land acquisition and increasing number of serviced patient. The project will also support procurement of medical waste management equipment and capacity building of healthcare workers in occupational safety practices, healthcare waste management steps from source to disposal and equipment usage and maintenance. 6.2.Potential Negative Environment Impact and Mitigation Measure The project impact on environment during construction and operation hospitals stages was reviewed to develop EMP. Potential impacts during rehabilitation/construction work: Dust, exhaust, noise, increasing traffic. Dust and noise will generate during construction work, from vehicles used for construction and transport. During construction work increasing of traffic is expected. It could lead to inconveniences in resident’s everyday life and local shopkeepers may experience reduced income as a result. Also increasing of traffic will lead to intensity on road particularly near to schools and kinder gardens. Impact from Asbestos handling. Work with asbestos is possible during rehabilitation of hospitals. Asbestos had been used as constructional material for roofing. During construction (rehabilitation) work asbestos will not be used. This will be specified in bidding documents for the Contractors. Impact on soil Soil contamination by fuel and lubricants are expected during construction works. It could lead to ground water contamination as well. Impact on flora and fauna Some trees growing on the hospital territory probably will be cut. 7. Procurement and Use of Medical Waste Equipment Medical Waste from Healthcare services Liquid and solid wastes will be generated during rehabilitation/construction works. Inadequate waste handling can lead to soil, surface and ground water contamination. Solid wastes will be generated as removed concrete, bricks and other construction materials. 10 On operation stage the main impact of hospital will be through medical wastes. Medical waste management plan are presented in following sections. On the delivering and installing medical equipment generation of wastes are expected as packing materials – carton, foam plastic, cellophane and various plastic fasteners. . 7.1.Type of medical wastes In condition of lack of clear environmental procedures and standards on medical waste management, it exists the treat of contaminated diseases disposal with communal wastes which could be the reason of diseases spreading as well as soil and ground water contamination. As it was above mentioned, existing in the Republic waste disposal practice consists in burning some part of the wastes in mufflers or in local hand made burning facilities, burying, discharge to sewage network and disposal on the landfills. Inadequate handling and disposal of medical wastes may lead to transmission of HIV, hepatitis, meningitis and other infectious diseases through injuries caused by syringe needles contaminated by human blood. The groups most at risk are medical care workers, waste management operators and scavengers. The management of medical wastes requires diligence and care from a chain of people, starting with medical care staff, continuing through collection workers, and finishing with disposal operators. If any of these are lacking of knowledge and careless in their work, or allow scavengers or children access to the waste, the chain is broken and dangers of infection follow. In according to “Medical waste disposal guideline� developed by Ministry of Health of RUz from October 29, 2007, wastes generated in medical facilities divided on contaminated (infected) and non- contaminated. Medical wastes generated in hospital included in this project could be separate on following groups:  Infectious waste: Wastes which are suspected to contain pathogens (laboratory cultures, wastes from hospital isolation wards, tissues, materials or other belongings being directly in contact previously with infected patients, discharge);  Pathologic waste: Human tissues or liquids (parts of body, blood and other body liquids)  Sharps: Needles, infusion sets, scalpels, knifes, blades, broken glass  Pharmaceutical waste: Wastes containing drugs, items being in contact or containing drugs (vials, ampoules, boxes)  Chemical waste: Waste containing unused chemical reagents (lab reagents, X-ray film reagents, disinfecting expired or expiring liquids, solvents)  High pressure containers: (gas bottles, cartridges, containers and aerosol cans)  Heavy metals: Waste with a high content of heavy metals (batteries, broken thermometers, mercury thermometers 7.2.MITIGATION MEASURES TO DEAL WITH POTENTIAL NEGATIVE IMPACTS During Construction: No tree felling will be completed by the Contractor without the consent of the Environmental Engineer. Merchantable timber will be removed from site. Non-commercial species and smaller trees, shrubs, 11 branches and slash from the harvest will be cut and piled for disposal. After completing rehabilitation/construction works, replanting activity should be done on the place of removed plants. The slash could be disposed by different way: Grind or chip the slash into a mulch that can be used to amend topsoil for restoration and/or mixed with other spoil material within the disposal sites; or track- pack the slash with heavy machinery into the disposal pile in lifts small enough to ensure there is no loss of stability of the disposal pile as the material decomposes. No slash or debris will be disposed of within the riparian zone buffer strip (15 m from either bank of any watercourse). There will be no disposal of any material by burning During construction work particularly demolition of building’s parts special attention should be given to asbestos handling with using proper prevention equipment. The exposed workers and other personnel must ware protective gear. Asbestos containing waste should be handled and disposed off as prescribed by national legislation for managing hazardous material. The disposal of waste into surface waters or in the sites at their immediate vicinity is prohibited. Generated liquid wastes (domestic, oil spills and paints) will be properly disposed. Domestic sewage will be disposal to central sewage network, for case lack sewage network – to septic tanks. Biotoilets could be installed in accordance with hygienic norms on the constructions sites on demand. Spilled oil and fuel should be disposed in accordance with procedure described in previous section. Existing building elements (walls, foundations, ground cement slabs etc.) should be carefully demolished and the debris should be sorted and removed. Used concrete blocks could be crushed and reused as gravel substitute in road and construction projects. All valuable materials (doors, windows sanitary fixtures etc.) should be carefully dismantled and transported to the storage area assigned for the purpose. Valuable materials should be recycled within the project activity or sold. Debris should be stored on the special sites on the hospital’s territory, be covered and under agreement with hokimiyats regularly transporting for disposal on the rayon’s landfills. Crashing the disposed concrete blocks for reuse as gravel substitute is suggested.  All repair works and fueling operating of machinery should be done on specially equipped concrete sites to prevent oil occurring in soil;  Implement measures mentioned in Attachment 2 to prevent oil spills;  Provide adequate containment for fuel and oil products and ensure that all containers are properly labeled;  Place oil sorbent sheets and/or containers under vehicles and equipment parked in high risk areas i.e., adjacent to watercourses) for longer than 2 hours or immediately under any vehicle or equipment that is leaking;  Ensure that all fuel vehicles are parked only in designated areas on site with brakes applied and wheels chocked;  Ensure that any employees and/or contractors fuelling equipment understand the environmental risks of the area and are equipped with adequate spill prevention and response measures;  Locate emergency spill response kits in areas where oil and fuel filled equipment will be working and provide additional spill response materials in sufficient quantities on site to catch drips, minor leaks and spills;  Appropriate fuel storage facilities will be constructed ensuring a minimum containment volume of 120% of the fluids being stored. Managing Construction Waste: It is recommended to sprinkle water on construction site, control of vehicle’s speed limits (in accordance with Rules of Road) to decrease level of dust pollution. Soil, sand and other construction materials on transport vehicles shall be covered. Construction site should be fenced from hospital site in case hospital 12 operating during construction work. All heavy equipment and machinery shall be fitted every day in full compliance with the national (SNPC) and local regulations with regards to emissions. To address noise and vibration related issues, all work will be conducted within normal working hours (i.e. 07:00 – 19:00 hrs) unless otherwise appropriately authorized. To minimize impact from intensity on road using of bypass is recommended. In case if using of bypass is impossible residents should be informed about possible risks on roads. Occupational Safety for Construction Workers: The workers should use the special preventive measures (personal protection equipment) on asbestos handling and its proper disposal. These workers need training on asbestos handling. If asbestos is located on the project site, it shall be marked clearly as hazardous material. When possible the asbestos will be appropriately contained and sealed to minimize exposure. The asbestos prior to removal (if removal is necessary) will be treated with a wetting agent to minimize asbestos dust. Asbestos will be handled and disposed by skilled & experienced professionals. If asbestos material is being stored temporarily, the wastes should be securely enclosed inside closed containments and marked appropriately. Security measures will be taken against unauthorized removal from the site. The removed asbestos will not be reused Managing Equipment Installation and Usage Medical waste equipment will be procured as per the specifications recommended for specific types of waste. Installation will be as per design guidelines of the MOH and will be in compliance with all national environmental requirements. Incinerators to be procured must meet international standards for environmental pollution (Attachment 2 includes international guidelines for Incinerators for Medical Waste Management) Healthcare workers designated to operate these equipment should be trained by equipment expert or manufacturer/distributor of the equipment. The hospitals which obtain new equipment must have maintenance contracts for an extended duration of time and must allocate adequate resources (financial, physical and manpower) for effective operations of the equipment. Medical Waste Management Generally Medical Waste Management Practice should be conducting in accordance with Law on Wastes of RUz (2002) and Sanitarian Norms and Rules mentioned in section 2.3. To specify and assure effective medical waste management practice the following activities are required: Waste separation To compliance with developed guideline and assurance environmental approach to waste management it is necessary to provide segregation of wastes: medical and household. Medical wastes Medical wastes generated in hospital could be separated on sharp (syringes and needles, infusion sets) and non-sharps. The sharp wastes should be disposal during medical manipulation or immediately after that. Every room should be equipped with special puncture-proof containers for collecting sharps, syringes and needles after medical manipulations. When containers are filled-up to 75% of its capacity inlet is closed and either transported to burning place or after disinfection spread concrete, alabaster or clay over and disposal at the landfill. Alternatively, needles can be removed from the syringe immediately after use by a manual needle cutter, which cuts off the needle and the hub of the syringe (see equipment). After disinfection the syringe can be placed in the bin for household waste. The needle cutter technology is at present under investigation by the WHO. Liquid contaminated wastes (biological wastes) are discharged to sewage network. 13 Infected (contaminated) wastes are recommended to burn in incinerators with firing temperature no less than 1200 oC to prevent dioxins discharge which generated during organic matter burning with temperature lower 1200 o C. Also infected medical wastes (biomaterial) could be buried on the hospital’s territory in the special fenced waste pits with cover. Every time after using pit should be cover with 10-15 sm soil layer, when pit will be filled-up covering soil layer shouldn’t be less than 50-60 sm. But it has been noted that properly waste burning in the incinerators are more effective and safe method of medical waste disposal. Alternatively infectious waste can be disinfected or autoclaved and then placed in a container for household waste. Junior hospital stuff is responsible for medical wastes collection. Hospitals chief nurse supervises waste management in hospitals on compliance with requirements. General wastes General waste separated by organic, inorganic and recycled wastes should be collected in different special marked containers. Organic wastes (food debris) should be daily transporting from hospital territory. Inorganic household wastes should be collected in containers on sites with asphalt or concrete covering and transporting on landfills for further disposal. Wastes will collected from hospital territory regularly based on agreement between hospital administration and contractor waste disposal company under the local/municipal government (not less than two times per week). Occupational Safety for Healthcare Workers: The hospital management will ensure a meticulously planned sanitation system as this is of primary importance to avoid infections. Good occupational health and safety measures include:  proper training  personal protective clothing and equipment  effective occupational health programmes including immunisation (against hepatitis B) and post exposure prophylaxis along with medical surveillance  conveniently placed hand washing facilities. Each hospital will develop a system for response to injuries that will include: a) immediate first aid measures; b) reporting of needle stick injuries; c) proper surveillance; d) adequate prophylactic treatment available within stipulated time. An Infection Control Committee must be established in each hospital to review occupational safety issues, supervise and monitor implementation and ensure training and retraining of staff in good practices and also be responsible for good healthcare waste management. Training program Training courses on wastes management and related risks will be conducted for all involved in the project “Health-3� hospitals. Training will include occupational good practices and procedures for the segregation, treatment, disposal and management of medical wastes as well as emergency procedures in the event of accidental exposure (e.g. needle stick injury). Facility staff will also receive training on other aspects of environmental management Training on occupational safety and waste management will also be provided to laboratory technicians. The training courses will be organized by the Ministry of Health in association with Central Bureau Project Implementation. 14 8. CONSULTATION During project design and implementation, a consultation plan will be developed to include local communities and non-governmental organizations (NGOs) in the development of the project. The site-specific EMPs will be shared with NGOs and local communities. Environmental Engineer of CBPI will be responsible and reporting for conducting these consultations. Consultation activities will also include community and NGO participation in facility design, scheduling construction hours, traffic management, effects on local businesses, and establishing a system for the public to register complaints related to project activities. The plan should include an approach to public liaison so that NGOs and communities are engaged with the facilities throughout their operating life. Communities adjacent to the proposed activities will be provided with an opportunity to request information about the proposed project and provide feedback during the project’s progress. The contractor under CPBI Environmental Engineer guidance will develop a process for public consultation appropriate to the scale of the proposed activities. 9. MONITORING AND ACTION PLAN Evironmental Construction Engineer hired by the CPIB will review, assess and supervise environmental aspects of all construction, including site-specific EMPs and Consultation activities. Site-specific reports will be prepared by the consultant and provided to the CPIB. These reports will be compiled and reviewed annually by CPIB and also by the World Bank. During Mid-term Review, CPIB will undertake an independent detailed survey of construction, installation of medical waste equipment and their operations. The review will also include operational and occupational practices within hospitals, from source to treatment and disposal. A Training Plan for occupational safety medical waste management will be developed by CPIB for undertaking training in all RMUs and city hospitals. Training of equipment technicians and laboratory personnel will also be defined and monitored on an annual basis. Sub project environmental screening table Type of Environmental Documentation Required Applicable To: Category 1. Environmental Assessment (EA) prepared in I accordance with WB Safeguard Policy with New buildings Environmental Management Plans (EMP) for each Installation of incinerators individual construction (sub project) Installation of new medical waste 2. EA prepared in accordance with Law on equipment Environmental Expertise of RUz approved by Goscompriroda II Environmental Assessment (EA) with Environmental New buildings Management Plans (EMP) for each individual construction Installation of incinerators (sub project) III Site-specific EMPs for each hospital in form of a checklist Small extensions on existing buildings, small new construction, rehabilitation of existing buildings, and incinerators 15 Environmental Management and Monitoring Framework Responsibility Type Time Type of activity Expected input Mitigation measure (Methodology) of Responsible Agency carrying out /\Frequency of Monitoring agency monitoring Monitoring 1 2 3 4 5 6 7 CONSTRUCTION PHASE Site clean-up works Dust and noise Fence off the construction site. On-site inspection Contractor Permanent CPIB during the course of monitoring for Supervisor contractor Contamination of water Confine noise and vibration the whole the whole period Local government and soil generating activities to the construction of construction Design company (design daytime. process. company is responsible After completion for authorship supervision Notify neighbours or local of clean-up. during the entire community if work is going to rehabilitation/construction occur outside of those hours. process) Water usage should be monitored Ensure drainage permissions are agreed. Accumulate polluted water in septic tanks and special sewage water collection pits. Once filled up, discharge into the operating sewerage network existing at all the sites. Minimize waste generation of waste. Avoid waste disposal in the areas at the immediate vicinity of surface water. Ensure appropriate resources for waste collection and transportation. Groundwork Generation of dust Water the site minimum twice On-site inspection Contractor Permanent CPIB 16 Responsibility Type Time Type of activity Expected input Mitigation measure (Methodology) of Responsible Agency carrying out /\Frequency of Monitoring agency monitoring Monitoring 1 2 3 4 5 6 7 Damage to the existing daily. during the course of monitoring for Supervisor contractor engineering systems the whole the whole period Local government Vehicle transporting bulk construction of construction, Design company Damage to the existing should be covered process. vegetation Cover the exiting vegetation After completion with protective box-like grates. of recovery Damage to topsoil in works. affected areas around Removal of faded plants and the buildings. re-planting. Remove and store top layer of soil in designed places, cover to prevent water flushing and after finishing replace it. Limit all works to the Damage to designated work sites. In case cultural/historical of chance find of monuments. historical/cultural artifacts in the course of earth works, immediately suspend activity on the site and resume works only upon receiving written permission from the client. Disposal of excavated Waste is disposed strictly in the waste at uncontrolled area assigned by local dumping sites government. Building frame Potential damage Fence off safety zones at the On-site periodical Contractor Periodic CPIB development caused by the falling time of the lifting machinery. inspection monitoring Local government objects or loads Design company Place blockers. Tracking safety of workers during Provide safety belts and frame development 17 Responsibility Type Time Type of activity Expected input Mitigation measure (Methodology) of Responsible Agency carrying out /\Frequency of Monitoring agency monitoring Monitoring 1 2 3 4 5 6 7 helmets to the workers Demolition Dust Dampen down dry areas; cover Visual observation. Contractar The whole period CPIB trucks transporting debris while Control for the of works Supervisor contractor Generation of the traveling public highways; whole period of Local government construction blacktop temporary roads to demolition works. Design company waste/debris minimize dust. Damage to internal Carefully demolish existing engineering systems elements of buildings; pile up debris in the designated storage areas and remove periodically to avoid accumulation of vast amounts of waste. Disposal of Disposal of waste at Minimize volumes of generated Visual observation. Contractor The whole period Local government construction waste uncontrolled dumping waste. Crashing the disposed Control for the of works sites leading to soil and concrete blocks for reuse as whole period of groundwater gravel substitute is suggested. demolition works contamination Descend the construction waste in closed containers and transport in covered body trucks The demolition/construction waste is disposed strictly in the area assigned by local government. The disposal of waste into surface waters or in the sites at their immediate 18 Responsibility Type Time Type of activity Expected input Mitigation measure (Methodology) of Responsible Agency carrying out /\Frequency of Monitoring agency monitoring Monitoring 1 2 3 4 5 6 7 vicinity is prohibited. Ensure wearing of protecting gear by workers handling asbestos containing waste; switch off the internal supply of water, gas and electricity prior to commencement of demolition. Building and Accidental spillage of Work out accidental discharge Review of the Design company Careful review of CPIB renovation works fuel, machine-oil, preventing measures. Ensure design documents to Contractor the design Supervisor contractor lubricants, etc construction machinery is well avoid documents upon Design company maintained with regular check- environmentally design ups of possible sources (places) non-friendly completion. of discharge. construction Monitoring for Coordinate deliveries to avoid materials. the whole period peak traffic periods; agree site of works access/exit points with client Control during all /subcontractors /suppliers. period of the Make sure equipment is turned building and off when not in use. renovation works Select environmentally sound goods and services (described in Attachment 2 “Guidelines on Ecological Planning�) as much as possible. Use of toxic materials Exclude usage of asbestos containing construction materials. Avoid the use of PVC (Polyvinyl Chloride) in plumbing lines and waste lines. 19 Responsibility Type Time Type of activity Expected input Mitigation measure (Methodology) of Responsible Agency carrying out /\Frequency of Monitoring agency monitoring Monitoring 1 2 3 4 5 6 7 Use nontoxic material for the exposed plumbing and pipe insulation. Use lead-free solder for water pipes. Locate incoming cables underground. OPERATION PHASE Hospital in operation In adequate handling of Assign clear responsibility for Waste management Hospital Daily District Branches of hazardous waste water, waste management to members responsible person administration Periodic MOH waste gases and of management team. (senior nurse or Municipal Government inadequate handling of epidemiologist) Hospital administration medical waste during Developed a waste carries out daily District Branches of SES hospital operation. management plan for the monitoring of the Collection and co- project assisted hospitals, with healthcare waste disposal non-disinfected the emphasis on minimization management medical wastes with of waste -segregation, source system. household waste at reduction, treatment and proper uncontrolled dumping disposal Periodic evaluation sites leading to soil and and review of the groundwater Train hospital staff, including waste management contamination and risk health care professionals, who program of spread of diseases. produce waste. Envision waste disposal stores in hospital designs for full control of medical waste waiting for off- site transportation. Burn infected medical wastes in incinerators in compliance with specification (in case if incinerators are planning to 20 Responsibility Type Time Type of activity Expected input Mitigation measure (Methodology) of Responsible Agency carrying out /\Frequency of Monitoring agency monitoring Monitoring 1 2 3 4 5 6 7 install). Treat infectious waste prior to disposal. Dispose waste only in landfill areas assigned by the local governments (project hospitals do not implement on-site incineration of infectious waste). Ensure that adequate resources are allocated for health care waste management, including plastic bags, waste collection bins, sharp containers, trolleys, etc. 21 ATTACHMENTS Attachment 1.Environmental Management Checklist for Small Construction and Rehabilitation Activities General Guidelines for use of EMP checklist: For low-risk topologies, such as school and hospital rehabilitation activities, the ECA safeguards team developed an alternative to the current EMP format to provide an opportunity for a more streamlined approach to preparing EMPs for minor rehabilitation or small-scale works in building construction, in the health, education and public services sectors. The checklist-type format has been developed to provide “example good practices� and designed to be user friendly and compatible with safeguard requirements. The EMP checklist-type format attempts to cover typical core mitigation approaches to civil works contracts with small, localized impacts. It is accepted that this format provides the key elements of an Environmental Management Plan (EMP) or Environmental Management Framework (EMF) to meet World Bank Environmental Assessment requirements under OP 4.01. The intention of this checklist is that it would be applicable as guidelines for the small works contractors and constitute an integral part of bidding documents for contractors carrying out small civil works under Bank-financed projects. The checklist has three sections: Part 1 includes a descriptive part that characterizes the project and specifies in terms the institutional and legislative aspects, the technical project content, the potential need for capacity building program and description of the public consultation process. This section could be up to two pages long. Attachments for additional information can be supplemented when needed. Part 2 includes an environmental and social screening checklist, where activities and potential environmental issues can be checked in a simple Yes/No format. If any given activity/issue is triggered by checking “yes�, a reference is made to the appropriate secti on in the following table, which contains clearly formulated management and mitigation measures. Part 3 represents the monitoring plan for activities during project construction and implementation. It retains the same format required for EMPs proposed under normal Bank requirements for Category B projects. It is the intent of this checklist that Part 2 and Part 3 be included into the bidding documents for contractors, priced during the bidding process and diligent implementation supervised during works execution. 22 CONTENTS A) General Project and Site Information B) Safeguards Information C) Mitigation Measures D) Monitoring Plan 23 EMP Checklist for Construction and Rehabilitation Activities PART A: GENERAL PROJECT AND SITE INFORMATION INSTITUTIONAL & ADMINISTRATIVE Country Project title Scope of project and activity Institutional WB Project Local Counterpart and/or Recipient arrangements (Project Team Management (Name and contacts) Leader) Implementation Safeguard Local Counterpart Local Contactor arrangements Supervision Supervision Inspectorate (Name and contacts) Supervision SITE DESCRIPTION Name of site Describe site location Attachement 1: Site Map [ ]Y [ ] N Who owns the land? Description of geographic, physical, biological, geological, hydrographic and socio-economic context Locations and distance for material sourcing, especially aggregates, water, stones? LEGISLATION Identify national & local legislation & permits that apply to project activity PUBLIC CONSULTATION Identify when / where the public consultation process took place INSTITUTIONAL CAPACITY BUILDING Will there be any [ ] N or [ ]Y if Yes, Attachment 2 includes the capacity building program capacity building? 24 PART B: SAFEGUARDS INFORMATION ENVIRONMENTAL /SOCIAL SCREENING Activity/Issue Status Triggered Actions A. Building rehabilitation [ ] Yes [ ] No See Section A below B. New construction [ ] Yes [ ] No See Section A below Will the site C. Individual wastewater treatment system [ ] Yes [ ] No See Section B below activity D. Historic building(s) and districts [ ] Yes [ ] No See Section C below include/involve any of the E. Acquisition of land3 [ ] Yes [ ] No See Section D below following?? F. Hazardous or toxic materials4 [ ] Yes [ ] No See Section E below G. Impacts on forests and/or protected areas [ ] Yes [ ] No See Section F below H. Handling / management of medical waste [ ] Yes [ ] No See Section G below I. Traffic and Pedestrian Safety [ ] Yes [ ] No See Section H below 3 Land acquisitions includes displacement of people, change of livelihood encroachment on private property this is to land that is purchased/transferred and affects people who are living and/or squatters and/or operate a business (kiosks) on land that is being acquired. 4 Toxic / hazardous material includes but is not limited to asbestos, toxic paints, noxious solvents, removal of lead paint, etc. 25 PART C: MITIGATION MEASURES ACTIVITY PARAMETER MITIGATION MEASURES CHECKLIST 0. General Conditions Notification and Worker (a) The local construction and environment inspectorates and communities have been notified of upcoming Safety activities (b) The public has been notified of the works through appropriate notification in the media and/or at publicly accessible sites (including the site of the works) (c) All legally required permits have been acquired for construction and/or rehabilitation (d) The Contractor formally agrees that all work will be carried out in a safe and disciplined manner designed to minimize impacts on neighboring residents and environment. (e) Workers’ PPE will comply with international good practice (always hardhats, as needed masks and safety glasses, harnesses and safety boots) (f) Appropriate signposting of the sites will inform workers of key rules and regulations to follow. A. General Rehabilitation Air Quality (a) During interior demolition debris-chutes shall be used above the first floor and /or Construction (b) Demolition debris shall be kept in controlled area and sprayed with water mist to reduce debris dust Activities (c) During pneumatic drilling/wall destruction dust shall be suppressed by ongoing water spraying and/or installing dust screen enclosures at site (d) The surrounding environment (side walks, roads) shall be kept free of debris to minimize dust (e) There will be no open burning of construction / waste material at the site (f) There will be no excessive idling of construction vehicles at sites Noise (a) Construction noise will be limited to restricted times agreed to in the permit (b) During operations the engine covers of generators, air compressors and other powered mechanical equipment shall be closed, and equipment placed as far away from residential areas as possible Water Quality (a) The site will establish appropriate erosion and sediment control measures such as e.g. hay bales and / or silt fences to prevent sediment from moving off site and causing excessive turbidity in nearby streams and rivers. Waste management (a) Waste collection and disposal pathways and sites will be identified for all major waste types expected from demolition and construction activities. (b) Mineral construction and demolition wastes will be separated from general refuse, organic, liquid and chemical wastes by on-site sorting and stored in appropriate containers. (c) Construction waste will be collected and disposed properly by licensed collectors (d) The records of waste disposal will be maintained as proof for proper management as designed. (e) Whenever feasible the contractor will reuse and recycle appropriate and viable materials (except asbestos) B. Individual wastewater Water Quality (a) The approach to handling sanitary wastes and wastewater from building sites (installation or reconstruction) treatment system must be approved by the local authorities (b) Before being discharged into receiving waters, effluents from individual wastewater systems must be treated in order to meet the minimal quality criteria set out by national guidelines on effluent quality and wastewater treatment (c) Monitoring of new wastewater systems (before/after) will be carried out (d) Construction vehicles and machinery will be washed only in designated areas where runoff will not pollute natural surface water bodies. 26 ACTIVITY PARAMETER MITIGATION MEASURES CHECKLIST C. Historic building(s) Cultural Heritage (a) If the building is a designated historic structure, very close to such a structure, or located in a designated historic district, notification shall be made and approvals/permits be obtained from local authorities and all construction activities planned and carried out in line with local and national legislation. (b) It shall be ensured that provisions are put in place so that artifacts or other possible “chance finds� encountered in excavation or construction are noted and registered, responsible officials contacted, and works activities delayed or modified to account for such finds. D. Acquisition of land Land Acquisition (a) If expropriation of land was not expected but is required, or if loss of access to income of legal or illegal users Plan/Framework of land was not expected but may occur, that the Bank’s Task Team Leader shall be immediately consulted. (b) The approved Land Acquisition Plan/Framework (if required by the project) will be implemented E. Toxic Materials Asbestos management (a) If asbestos is located on the project site, it shall be marked clearly as hazardous material (b) When possible the asbestos will be appropriately contained and sealed to minimize exposure (c) The asbestos prior to removal (if removal is necessary) will be treated with a wetting agent to minimize asbestos dust (d) Asbestos will be handled and disposed by skilled & experienced professionals (e) If asbestos material is be stored temporarily, the wastes should be securely enclosed inside closed containments and marked appropriately. Security measures will be taken against unauthorized removal from the site. (f) The removed asbestos will not be reused Toxic / hazardous waste (a) Temporarily storage on site of all hazardous or toxic substances will be in safe containers labeled with details of management composition, properties and handling information (b) The containers of hazardous substances shall be placed in an leak-proof container to prevent spillage and leaching (c) The wastes shall be transported by specially licensed carriers and disposed in a licensed facility. (d) Paints with toxic ingredients or solvents or lead-based paints will not be used F. Affected forests, Protection (a) All recognized natural habitats, wetlands and protected areas in the immediate vicinity of the activity will not be wetlands and/or protected damaged or exploited, all staff will be strictly prohibited from hunting, foraging, logging or other damaging areas activities. (b) A survey and an inventory shall be made of large trees in the vicinity of the construction activity, large trees shall be marked and cordoned off with fencing, their root system protected, and any damage to the trees avoided (c) Adjacent wetlands and streams shall be protected from construction site run-off with appropriate erosion and sediment control feature to include by not limited to hay bales and silt fences (d) There will be no unlicensed borrow pits, quarries or waste dumps in adjacent areas, especially not in protected areas. G. Disposal of medical Infrastructure for medical (a) In compliance with national regulations the contractor will insure that newly constructed and/or rehabilitated waste waste management health care facilities include sufficient infrastructure for medical waste handling and disposal; this includes and not limited to:  Special facilities for segregated healthcare waste (including soiled instruments “sharps�, and human tissue or fluids) from other waste disposal; and  Appropriate storage facilities for medical waste are in place; and  If the activity includes facility-based treatment, appropriate disposal options are in place and operational H Traffic and Pedestrian Direct or indirect hazards to (b) In compliance with national regulations the contractor will insure that the construction site is properly secured Safety public traffic and and construction related traffic regulated. This includes but is not limited to pedestrians by construction  Signposting, warning signs, barriers and traffic diversions: site will be clearly visible and the public warned 27 ACTIVITY PARAMETER MITIGATION MEASURES CHECKLIST activities of all potential hazards  Traffic management system and staff training, especially for site access and near-site heavy traffic. Provision of safe passages and crossings for pedestrians where construction traffic interferes.  Adjustment of working hours to local traffic patterns, e.g. avoiding major transport activities during rush hours or times of livestock movement  Active traffic management by trained and visible staff at the site, if required for safe and convenient passage for the public.  Ensuring safe and continuous access to office facilities, shops and residences during renovation activities, if the buildings stay open for the public. 28 PART D: MONITORING PLAN What Where How When Why Cost Who (Is the (Is the (Is the (Define the (Is the (if not (Is Phase parameter parameter parameter frequency / parameter include responsible to be to be to be or being d in for monitored? monitored? monitored? continuous? monitored? project monitoring? ) ) ) ) ) budget) ) During activity preparation During activity implementatio n During activity supervision 29 ATTACHMENT 2 Stockholm Convention on Persistent Organic Pollutants New Guidelines on Best Available Techniques for Medical Waste Incineration: Error! Reference source not found.Under the guidelines, “single-chamber, drum and brick ncinerators� are not allowed. An incineration plant should consist of the following units: 1. Furnace or kiln as the primary combustion chamber 2. Afterburning chamber as the secondary chamber 3. Flue gas cleaning device system 4. Wastewater treatment plant if a wet flue gas cleaning system is used. The thermal treatment process used in the furnace or kiln could be one of the following: pyrolysis or gasification, rotary kiln, grate incineration specially adapted for healthcare waste, fluidized bed incineration, or modular excess air or controlled air incineration. Emission Limits For best available techniques, performance levels in air emissions of dioxins should not exceed 0.1 nanograms I-TEQ/normal cubic meter at 11% O2. Moreover, dioxins in the wastewater of treatment plants treating effluents from any gas treatment scrubber effluents should be well below 0.1 nanograms I-TEQ per liter. General and Organizational Measures When incinerating wastes that contain chlorine and heavy metals (as is generally the case for medical waste), a combination of primary and secondary measures, as described below, are needed to meet the emission limits. Health-care wastes should be incinerated only in dedicated incinerators or in larger incinerators for hazardous waste. If a dedicated incinerator is not used, a separate charging system should be used. Operation of the incinerator requires trained, qualified personnel. The personnel should wear protective clothing. Periodic maintenance should include cleaning of the combustion chamber and de-clogging of air flows and fuel burners. As part of secondary measures, frequent cleaning of those sections of the incinerator wherein flue gas passes especially at the critical temperature range is important. There should be regular and/or continuous measurement of pollutants, as well as auditing and reporting systems. Primary Measures The guidelines list the following primary measures to reduce dioxin emissions: 1. Introduction of the waste in the combustion chamber only at temperatures of 850 °C; the plant should have an automatic system to prevent waste feed before the above-mentioned temperature is reached 2. Installation of auxiliary burners (for start-up and shut-down operations) 3. Avoidance of starts and stops of the incineration process 4. Avoidance of temperatures below 850°C and no cold regions in the flue gas 5. Control of oxygen input depending on the heating value and consistency of feed material 6. Minimum residence time of 2 seconds above 850°C in the secondary chamber after the last injection of air, or at 1100°C for wastes containing more than 1% halogenated organic substances (as is generally the case for medical waste), and 6% O2 by volume 7. High turbulence of exhaust gases and reduction of air excess by injection of secondary air or re-circulated flue gas, pre-heating of the air-streams, or regulated air inflow 8. On-line monitoring for combustion control (temperature, oxygen content, CO, dust), and operation and regulation of the incinerator from a central console. 30 Cold starts, upset conditions, and shutdowns generally create the conditions for dioxin formation. Therefore, preheating and initial co-firing with a clean fossil fuel is recommended, and continuous operation (as opposed to batch processes) should be the method of choice. Upsets should be minimized through periodic inspection and preventive maintenance. Operators should not feed waste during severe combustion upsets or during a filter bypass (dump stack) operation. Secondary Measures In order to reduce dioxin emissions to less than 0.1 ng TEQ/m3, the secondary measures below (an appropriate combination of dedusting and other equipment to further reduce dioxins) should be applied as best available techniques. 1. Dedusting  Fabric filters used at temperatures below 260 ºC  Ceramic filters used at temperatures between 800 to 1000 ºC  Cyclones used for pre-cleaning of flue gases  Electrostatic precipitators used at temperatures of around 450 ºC  High-performance adsorption units with activated charcoal (electrodynamic venturi) 2. Techniques to further reduce emissions and PCDD/F  Catalytic oxidation  Gas quenching  Catalyst-coated fabric filters  Different types of wet and dry adsorption systems using mixtures of activated charcoal, coke, lime and limestone solutions in fixed bed reactors (adsorption with activated charcoal or open hearth coke), moving bed reactors, or fluidized bed reactors (entrained flow or circulating fluidized beds with activated coke/lime or limestone followed by the use of fabric filters). Notes: Fabric filters used at temperatures above the critical temperature range for dioxin formation can reduce emissions efficiently. However, the operating temperatures would depend on the type of fabric material used. Cyclones are efficient only in removing the larger particles. Note that electrostatic precipitators could promote de novo synthesis of dioxins especially if operated at the critical temperature range for dioxin formation. Electrostatic precipitators are inefficient for removal of fine particles and may result in higher NOx emissions. High- performance adsorption units with activated charcoal can be used for removal of fine dust. Disposal of Residues Fly and bottom ash, as well as wastewater, should be treated appropriately. Proper treatment of these residues includes:  Disposal in safe sanitary landfills (Note: Examples of disposal methods are land filling in proper double-walled containers, solidification and subsequent land filling, or thermal post- treatment)  Catalytic treatment of fabric filter dusts  Scrubbing of fabric filter dusts by the 3-R process (extraction of heavy metals by acids)  Thermal post-treatment (e.g., rotary kiln or Hagenmeier trommel followed by a fabric filter and scrubber; plasma technology)  Vitrification of fabric filter dusts and subsequent land filling  Immobilization methods (e.g., solidification with cement) and subsequent land filling. Bottom and fly ash should be handled, transported and disposed of in an environmentally sound manner, including the use of covered hauling and dedicated sanitary landfills. 31 Monitoring With regards to monitoring, carbon monoxide, oxygen in the flue gas, particulate matter, hydrogen chloride, sulfur dioxide, nitrogen oxides, hydrogen fluoride, airflows and temperatures, pressure drops, and pH in the flue gas should be routinely monitored. Periodic measurement or semi-continuous measurement (continuous sampling and periodic analysis) of polychlorinated dioxins and furans help insure that the incinerator is operating properly. Unfortunately, sampling and analysis of dioxins are difficult and expensive for most developing countries. In general, stack sampling requires 4 to 8 hours of continuous isokinetic sampling, and analysis is carried out using high resolution gas chromatography-high resolution mass spectrometry.i Stringent quality control procedures are required. For waste incinerators with a capacity of less than 2 tons per hour, simplified bioassay methods for dioxins could be used for periodic measurements.ii 32 Attachment 3: ENVIRONMENTAL GUIDELINES 3.1 Introduction The Environmental Guidelines section details the specifics to be addressed in the concept, design and planning of small-scale projects for the upgrading of health infrastructure. The guidelines cover the selection of construction materials and construction methods with limited impact on the environment, energy saving methods as well as the handling of medical and non-medical wastes under project supported activities. In selecting suitable construction methods and materials for the clinics, great attention should be paid to locally available traditions, skills and resources in the project sites. 3.3 Energy Efficiency, Insulation and Ventilation Insulation should be tailored to the seasonal impacts of climate, internal thermal load, and characteristics of exposure. Vapor barriers should prevent moisture intrusion in the roof insulation and outer wall cavities. Window location should be determined by view, ventilation, light, thermal gain, privacy control and interior space functions. Plumbing should be coordinated to minimize plumbing and also water service to toilets, kitchen and utility rooms. Water-saving faucets, ring mains and other devices also require consideration. All plumbing lines should preferably be copper, with waste lines in cast iron to avoid PVC outgassing. Exposed plumbing and pipe insulation should be of nontoxic material. 3.4 Filtration Electrostatic, activated charcoal, and high-efficiency filters can greatly improve the indoor air quality. Filters that remove particulates down to 0.3 microns are advisable for capture of microbial agents. Molecular absorbing filters can be used to remove toxic gases originating from internal and external sources. Self-actuating electrostatic filters are easy to clean, less expensive, and use no electricity. Electrical electrostatic filters should have an activated charcoal filter in order to subsequently remove ozone that can be generated by the particles on the filter. When sequential filtering for primary particles, HEPA (high efficiency particulate air filtration) is used, then the use of charcoal, potassium permanganate, or other molecular absorbers plus negative ionization at the delivery point of distribution are desirable. Smoking areas or rooms, if any, should be isolated by partitions and equipped with outside exhaust that creates a negative pressure in the space. Certain medical equipment, copy machines, as well as other reproduction equipment, should be adequately ventilated to remove their particulates and gases. Maintenance, including duct cleaning, filters cleaning and changes, and cleaning positive plate receivers and ionizing tips, should be routine and included in recurrent maintenance budgets. 3.5 Electrical Systems Incoming cables should be located underground. Main entrance feed and panel located away from places of work and waiting is prudent to avoid electromagnetic fields. Ground fault wiring near any plumbing fixture is a precaution. Selecting the most energy-efficient light fixtures, lamps, appliances and equipment will reduce energy demand but can introduce undesirable electromagnetic fields. Be aware that close proximity to table, floor and desk halogen, fluorescent and other high-efficiency fixtures and lamps can cause an exposure to harmful electromagnetic fields. 3.6 Cabinetry and Wood Nontoxic finishes are available but expensive. Selecting the least toxic finishes is advised. All materials should have appropriate permissions on quality and safety (appropriateness certificate and sanitary- epidemiologic conclusion). 33 3.7 Finishes Water-based interior nontoxic, no allergenic paint for drywall or plaster surfaces is preferable to latex or oil-based paints from a respiratory standpoint. Any enamel coating for doors or other surfaces that require a more durable finish is advised to be applied away from interior spaces and be fully aired for over a month before installation. Indoor space should not be occupied until odor and toxins of the paint or finish have been adequately aired. 3.8 Flooring Nontoxic grouts and methods of installation should be used. 3.9 Window Treatments Vertical blinds provide light control, are easy to maintain, and require minimal stacking room. Horizontal blind can in combination with a white or light ceiling reflect daylight more deeply into a room. Exterior roller blinds, operable from the interior, are particularly effective in controlling solar thermal gain and interior heat loss, and give the benefit of security. The choice will depend on climate and geographical conditions of hospital location as well as project funds. 3.10 Exterior and Interior Colors White or very light-colored ceilings and interior side walls allow for deeper reflective penetration of natural light. Doors between interior room spaces can act as reflectors. Gloss white lacquer or enamel doors in the path of incoming daylight can lighten adjoining spaces. Interior paints and finishes can affect patients and staff directly. Outdoor finishes with odorous and toxic emissions can also have an effect upon persons indoors through windows, doors and other openings. 3.11 Demolition work Existing building elements (walls, foundations, ground cement slabs etc.) should be carefully demolished and the debris should be sorted and removed as directed by the EMP. All valuable materials (doors, windows, sanitary fixtures, etc) should be carefully dismantled and transported to the storage area assigned for the purpose. Valuable materials should be recycled within the project or sold. 3.12 Selection of Construction Materials and Construction Methods Environmentally sound goods and services should be selected. Traditionally well-tried materials and methods should be chosen before new and unknown techniques. Construction sites should be fenced off in order to prevent entry of public, and general safety measures would be imposed. Temporary inconveniences due to construction works should be minimized through planning and coordination with contractors, neighbors and authorities. In densely populated areas, noisy or vibration generating activities should be strictly confined to the daytime. 34 Attachment 3. Meetings with Project Stakeholders and Beneficiaries Dr. Koroleva Nina State Nature Protection Committee Deputy Head, Environmental Expertise Department Dr. Agzamkhodjaeva Dilnoza Republican Scientific Cancer Center Deputy Head Doctor Dr. Gaffarov Said Ministry of Health Head, Sanitarian-Hygiene Department Republican SES Mr. John Malmborg Project “Health-3� Construction Engineer 35 Option 2 Environmental Guidelines All contractors are required to use environmentally acceptable technical standards and procedures during the implementation of construction works. All construction contracts will contain the following requirements:  Take necessary precautions against negative impacts on the environment, any environmental damage or loss through prevention or suppression measures (where it is possible), instead of liquidation or mitigation of negative consequences.  Observe all national and local laws and rules on environmental protection.  Identify officers responsible for the implementation of activities on environmental protection conforming to instructions and directions received from the construction and design or environmental protection agencies.  Minimize dust, smoke and particulate emissions to avoid or minimize negative impacts on air quality.  Provide pedestrian crosswalks and roads to ensure access to public places.  Prevent or minimize vibrations and noise from the operation of vehicles and machinery during construction activities.  Minimize damage to natural setting and vegetative cover and assure vegetation recovery.  Protect surface and underground water from pollution sources. Assure adequate water collection and distribution. 36 Minutes Public Consultations on Health III Project Venue: Tashkent Institute of Postgraduate Medical Education Within the framework of cooperation strategy between the Government of Uzbekistan (GOU) and the World Bank, it is envisaged to direct intensive investment to inpatient health care services quality improvement at the rayon level and for this purpose there is planned implementation of Health III project. The main objective of Health III project is to improve functioning of health care system in order to provide effective and qualitative health services and its capability on prevention of non-communicable chronic diseases outbreaks. Preliminary design of health III project consists of four (4) components that include the following types of activity: Component 1: Improvement of health care services quality Component 2: Strengthening of health financing and management reforms Component 3: Improvement of public health services delivery Component 4: Project management Public consultations as a part of Environmental assessment (EA) process In accordance with the WB policy on protective measures and ecological legislation of the Republic of Uzbekistan the process of public consultations is one of the important elements of EA procedure. Public consultations enable to solve simultaneously two tasks: to identify main ecological problems and to bring the results of preliminary environmental assessment to public; get comments regarding proposed activities on reduction of environmental impact. The public consultations on Health III project, as a part of the process for disclosure of information on the project, were conducted in a small conference hall of the Tashkent Institute of Postgraduate Medical Education (TIPME) on the 29th of November, 2010 at 15.00. The public consultations were advertised in the national newspaper “Uzbekistonda soglikni saklash – Zdravookhraneniye Uzbekistana (Healthcare of Uzbekistan)� #47 (808) dated November 26, 2010 (see Annex 1). Also there was published an article about planned Health III project. The document Environmental Management Plan was disclosed at the official web-site of the Ministry of Health. Alongside with the above mentioned publications and advertisements of the public consultations official invitation letters were sent to different agencies of the Republic. 58 persons participated the public consultations among them there were representatives of various medical institutions of Tashkent city and regions of the Republic, State Sanitary and Epidemiological services, State Nature Protection Committee and citizens of Tashkent. In his opening speech Mr. D.D. Maksumov, Deputy Executive Director of JPIB, shortly informed about objectives of Health III project and purposes of the public consultations. After that Ms. Madina Khalmirzaeva, environmental engineer of the project introduced the presentation opening principal provisions of the Environmental Management Plan. The presentation was followed by a number of questions and proposals on the subject of the public consultations. Roza G. Mukhamediyarova, IDA Project Coordinator, and the environmental engineer answered the questions. 37 Questions, asked by the participants of meetings № The questions and comments, suggested by the The answers of project employees participants of meetings 1 Z.Zh. Mutalova (Director of the Republican Institute of “No, under this project, conduction of such Health and medical statistics). “Is there supposed to conduct operations is planned at rayon level; such operations – incinerators installation in Tashkent? Tashkent city didn’t enter this project. 2 B.M. Mamatkulov (Director of School of Public Health of Multiple meetings with different specialists Tashkent Medical Academy) has proposed to include the (inclusive of personnel of your department) personnel of the department into the department specialists’ are planned to be held at the phase of projects group members. implementation. 3 Z.Yarulina (Chief specialist of the State Nature Protection As far as all construction/reconstruction Committee). “Will it be necessary to carry out the ecological works shall take place at the area of expert examination for the sites of reconstruction/construction hospitals, subsequently, according to local as well as for getting a favourable conclusion of legislation, there is no need in carrying out of Environmental Expertise? ecological expert examination. 4 S.Sotvoldiyev (Chief of MPTF (medical and preventive The Environmental Management Plan (EMP) treatment facility) department of SSES Center of Tashkent includes the activities on reduction of city). “Why did you entitle your document as Environmental negative effect, which may occur at handling Management Plan? Your works are related to medical wastes; of works on reconstruction/construction; the document’s title should be revised. medical wastes management turns up to be just a part of the whole plan. 5 T.B.Lee (Director of Ecology Department of Republican The following activities are planned to be SES). “Shall your work on medical wastes management lie implemented under the project: development only in incinerators installation? It won’t be enough to of strategy on medical wastes management, provide their steady operation. development of standards, regulatory documents. This shall allow improving on the situation in this area. 6 L.V.Kudasheva. “We have the experience in similar projects With a view to assure further stability of the implementation under the work with UNICEF on incinerators project, the training component is considered installation. However, not all of them are operating as we to be one of the important components. It would like it to be, in particular because of that the personnel includes training of medical facilities’ lacks the required skills�. personnel on operation and maintenance of new equipment, being delivered (inclusive of incinerators). 7 V.Zh.Baratova (Deputy Director of the Republican SES). “No, under this project, conduction of such “Shall the same works on local waste utilization be carried operations is supposed to be done at rayon out, specifically, installation of incinerators in the territory of level; where Tashkent city is not involved�. Tashkent city?� 8 A.N.Aripov (Head specialist on laboratory service of the I think that holding of such public Ministry of Health). consultations is very useful, as it allows attracting the specialists (who are facing directly this problem) to the issues of ecology, inclusive of medical waste utilization. I hope that such public consultations shall be held in future too. Public consultations were ended at 4.30 p.m. 38 Annex 1 O’zbekistonda sog’liqni saqlash Zdravookhraneniye Uzbekistana #47 (808) dated November 26, 2010 (see Annex 1). ADVERTISEMENT Within the framework of cooperation strategy between the Government of Uzbekistan (GOU) and the World Bank, it is envisaged to direct intensive investment to inpatient health care services quality improvement at the rayon level and for this purpose there is planned implementation of Health III project. Within the framework of this project there was developed Environmental Management Plan (EMP) to reduce possible negative environmental impact associated with the project implementation. Public consultations are planned to be conducted to discuss proposed EMP. The public consultations will take place on the 29th of November, 2010 at 15:00 in the office of Health II and Woman and Child Health Development Joint Projects Implementation Bureau, located in the building of the Tashkent Institute of Postgraduate Medical Education to the address: 51, Parkentskaya Street, Tashkent city All interested persons are invited to participate the public consultations. Health II and Woman and Child Health Development Joint Projects Implementation Bureau 39 Annex 2 List of Participants of Public Consultations on the Environmental Management Plan of Health III project November 29, 2010 # Name Position Signature 1 Mustanov A.N. Head physician signature 2 Sherkazarev F. Surkhandarya obl SSES signature 3 4 Abdullayev R Namangan obl SSES signature 5 Korayev B.B. Andijan obl SSES signature 6 Maminiv E. Ferghana obl SSES signature 7 Latipov H. Djizak SSES signature 8 Mamatkulov B.M. Director of SPH, TMA signature 9 Avezova G.S. SPH, TMA signature 10 Kosimova D.A. SPH, TMA signature 11 Urazaliyeva E.R. SPH, TMA signature 12 Normukhamedova N.A. TMA, Training Center # 1 signature 13 Mutalova Z.J. Institute of Health signature 14 Kosimova G.A. Family Polyclinic # 53 signature 15 Honkhodjayeva Sh.M. “ECOSAN� Intern. Foundation signature 16 Isamukhamedov H. B. Chief of Zangiota RMU signature 17 Yuldasheva M.Sh. Coordinator, Zangiota RMU signature 18 Baratova V.D. Deputy Head Physician, Republic signature SSES 19 Li T.B. Chair person, Department of signature Ecologyl 20 Gaffarov S.G. Head of Sanitary Department of signature Resp. SSES 21 Sativaldiyev E. Yu. Head of Dep. SSESC, Tashkent signature 22 Hoshimirzayev A.H. Associate Prof., Hygiene Chair, signature TIPME 23 Kalanov N.B. Head of Department signature 24 Abdujabbarov A.S. Civil engineer signature 25 Kudasheva L.V. Head of Epidemiological dep., Rep. signature SSES 26 Rajabov G.H. Deputy Director of Republican signature AIDS Center 27 Yarullina Z.R. Main specialist of State Nature signature Protection Committee 28 Yusupov B.Sh. Sanitary Physician Rep. SSES signature 29 Boymatov O.L. Head Physician of RMU, Kibrai, signature Tashkent oblast 30 Isamukhamedova M.A. JPIB Consultant signature 31 Mirshina O.P. MOH Main Specialist signature 32 Telichkin A.I. Uztibloyikha signature 33 Djalilov A.A. Director of Training center, TPMI signature 34 Djurayev I.O. Undergraduate of Irrigation signature Institute 35 Kosimov Sh. Z. Head of Chair on PME of GPs, signature TIPME 36 Konnova D.B. Undergraduate of Irrigation signature Institute 37 Tolipov J. H. State Nature Protection Committee signature 38 Zaylobiddinov G.B. JPIB Consultant signature 40 List of Participants of Public Consultations on the Environmental Management Plan of Health III project November 29, 2010 # Name Position Signature 1 2 3 Ergashev B.T. Head of MOH Operational signature Department 4 Kalanov N. B. Head of Department for signature Development of Material and technical base, MOH 5 Atabekov N.S. Director of Rep. AIDS center signature 6 Uldashev R. Sh. Head of Kashkadarya OHD signature 7 Hamriyev A.K. Minister of Health, Karakalpak signature Republic 8 Sharipov F.R. Head of Sirdarya OHD signature 9 Khakimov OHD signature 10 Bekjanov E.Z. Head of Khorezm OHD signature 11 Arzikulov T.S. Head of Surkh. OHD signature 12 Khusanbayev Sh. Y. Head of Ferghana OHD signature 13 Malikov Y. R. Head of Navoi OHD signature 14 Nariyev E. U. Head of Djizak OHD signature 15 Yuldashev R.Sh. Head of Kashk. OHD signature 16 Abdusattarov Head of Samarkand OHD signature 17 Coordinator, Zangiota RMU signature 18 Narziyev I. Head of Bukhara OHD signature 19 signature 20 signature 21 Djusubatova Director signature 22 Halilov M.A. Deputy Director signature 23 Muminov M. Deputy Head of Department for signature Development of Material and technical base, MOH 24 Normukhamedova N.A. TMA, Training Center # 1 signature 41 42 i See European Committee for Standardization Method EN 1948, U.S. Environmental Protection Agency Method 23, Association of German Engineers VDI Method 3499, Environment Canada Methods EPS 1/RM/2 and 1/RM/3, and Japan Industrial Standards Committee K0311. ii Possible bioassay methods include the CALUX Assay, P450 Human Reporter Gene System, AhR Luciferase Assay, and the Dio-Quicker enzyme immunoassay methods. 43