59936 HEALTH IMPACT ASSESSMENT AND PUBLIC HEALTH ACTION PLAN FOR TRUNG SON HYDROPOWER PROJECT Prepared by Ly Ngoc Ha MD, MPH National Public Health Consultant And Surinder Kaul MBBS, MFPHM, FFPHM (UK) International Public Health Consultant July 10, 2010 Table of Content ABBREVIATIONS USED IN THE DOCUMENT........................................................ 3 EXECUTIVE SUMMARY .............................................................................................. 5 PART 1: HEALTH IMPACT ASSESSMENT OF THE PROJECT ........................... 8 HEALTH IMPACT ASSESSMENT ............................................................................. 12 BASELINE STUDIES .................................................................................................... 13 AFFECTED AREAS ....................................................................................................... 16 SOCIO-ECONOMICS OF THE PROJECT AREA ................................................... 18 HEALTH SITUATION IN THE AFFECTED AREAS .............................................. 19 DISEASE PATTERNS ................................................................................................... 20 HEALTH DETERMINANTS IN THE AFFECTED AREAS .................................... 24 THE LOCAL HEALTH SYSTEM ............................................................................... 27 CURRENT SITUATION OF LOCAL HEALTH SYSTEM ...................................... 28 HEALTH SERVICES PROVIDED, USED AND NEEDED ...................................... 33 USE OF HEALTH SERVICES AT DIFFERENT LEVELS...................................... 34 KNOWLEDGE AND ATTITUDES ON PROJECT HEALTH IMPACTS ............. 39 HEALTH CHECKS AND SURVEY ............................................................................ 41 HEALTH IMPACTS DURING LIFE OF THE PROJECT ....................................... 43 AFFECTED GROUPS ................................................................................................... 47 LONG-TERM IMPACT ................................................................................................ 49 PART 2: HEALTH PLANS FOR TRUNG SON HYDROPOWER PROJECT ...... 51 INTRODUCTION........................................................................................................... 51 THE PUBLIC HEALTH ACTION PLAN ................................................................... 53 THE PROGRAM ............................................................................................................ 54 INSTITUTIONAL ARRANGEMENTS FOR PHAP IMPLEMENTATION .......... 56 BUDGETS AND FINANCING ...................................................................................... 60 PUBLIC HEALTH ACTION PLAN ­ BUDGET IN USD ......................................... 61 MONITORING AND SURVEILLANCE..................................................................... 62 CAPACITY BUILDING AND TRAINING ................................................................. 62 SERVICE PROVIDERS ................................................................................................ 65 CONSTRUCTION WORKER'S HEALTH PROGRAM .......................................... 66 CONCLUSION ............................................................................................................... 69 REFERENCES................................................................................................................ 71 ANNEX 1: PUBLIC HEALTH ACTION PLAN ......................................................... 74 ANNEX 2: PROJECT HEALTH MANAGEMENT TEAM ...................................... 84 ANNEX 3: PUBLIC HEALTH PROGRAMS ............................................................. 87 ANNEX 4: DETAILS OF THE TEN HEALTH PRIORITIES ................................. 95 ANNEX 5: SURVEY INSTRUMENT - 1 ................................................................... 100 ANNEX 6: SURVEY INSTRUMENT - 2 ................................................................... 104 ANNEX 7: HEALTH CHECKS AND SURVEY ....................................................... 107 ANNEX 8: DEMOGRAPHIC CHARACTERISTICS OF RESETTLERS ............ 113 ANNEX 9: NATIONAL INFRASTRUCTURE STANDARDS................................ 114 2 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 Abbreviations Used in the Document ADB Asian Development Bank LLIBN Long-Lasting Impregnated Bed Net AFB Acid Fast Bacilli MA Medical Assistant ANC Antenatal Care MCH Mother and Child Health ARI Acute Respiratory Infection MDG Millennium Development Goal Behavioral Change Ministry of Agriculture and Rural BCC MARD Communication Development BS Blood Smears (Slide for Malaria) MOE Ministry of Education Communicable Disease Centre, CDC MOH Ministry of Health (Atlanta, USA) CHC Commune Health Centre NGO Nongovernmental Organization Construction Worker's Health CWHP OPV Oral Poliomyelitis Vaccine Program DH District Hospital PAP Project Affected People DHF Dengue Hemorrhagic Fever PECC4 Power Engineering Consulting JSC 4 DHC District Health Centre PH Provincial Hospital Directly Observed Therapy Short- DOTS PHA Public Health Action term DPT Diphtheria-Pertussis-Tetanus PHAP Public Health Action Plan DPT-Hep Vaccine against Diphtheria, PHC Primary Health Care B Pertussis, Tetanus, and Hepatitis B Development Research and DRCC PHMT Project Health Management Team Consultancy Center DSS Dengue Shock Syndrome PHO Provincial Health Office EHA Environmental Health Area PIA Potential Impact Areas of Concern EMP Environmental Management Plan PMB Project Management Board EIA Environmental Impact Assessment PMU Program Management Unit Extended Program for EPI PNC Postnatal Care Immunization WHO/CDC Free Statistical EPI-INFO RAP Resettlement Action Plan Package Resettlement and Livelihood EVN Electricity of Vietnam RLDP Development Plan GDP Gross Domestic Product RSA Resettlement Area GIS Geographical Information Systems RTA Road Traffic Accident GOV Government of Vietnam SDP Social Development Plan GWh Gigawatt Hour STD Sexually Transmitted Disease HC Health Centre STH Soil transmitted Helminthes HC&S Health Checks and Survey STI Sexually Transmitted Infection HH Household TB Tuberculosis HIA Health Impact Assessment TBA Traditional Birth Attendants Human Immunodeficiency Virus/ HIV/AIDS Acquired Immunodeficiency TS Trung Son Syndrome HP Health Program TSHP Trung Son Hydropower Project IBN Impregnated Bed Nets TSHPMB Trung Son Hydropower Project 3 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 Management Board Information-Education- IEC TT Tetanus Toxoid Communication Integrated Management of IMCI URI Upper Respiratory Infections Childhood Illnesses IMR Infant Mortality Rate ITN Insecticide-Treated Bed Net UFMR Under Five Mortality Rate IRS Indoor Residual Spraying VCT Voluntary Counseling and Testing Vietnam Household Living Standards JE Japanese encephalitis VHLSS Survey KAP Knowledge, Attitudes, Practice VHW Village Health Worker Lao PDR Lao People's Democratic Republic VNHS Vietnam Health Survey LDP Livelihood Improvement Plan WHO World Health Organization 4 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 Executive Summary THE PROJECT The Trung Son hydropower project is a multipurpose project. The project creates a new 88 Mt. high dam creating a reservoir with total volume of 348 million m3 at full supply level of 160 Mt. With a capacity of 260 MW, the project will provide on average 1056 GWh per year to the national electricity grid, thus alleviating power shortages and supporting economic growth. The dam will regulate the Ma river basin water regime in Thanh Hoa Province. This will reduce the occurrence of floods in the downstream section of the river basin. The dam will also supply water to meet demand from industry, agricultural development, tourism, navigation and aquaculture. A 22 Km access road from Co Luong in Hoa Binh Province to the dam site will be built that will reduce travel time to and from Hanoi to 4 hours. Power lines will be constructed to supply electricity to the site during construction and evacuate power during operation. About 6000 people will be resettled, from 1600 households. Of these, some 478 households, or around 2500 people will be relocated, all of whom will move within their current commune to elevated resettlement sites. Those households, which are affected but do not have to relocate and lose land and other assets mainly because of the impacts of the reservoir and road will be compensated. The number of those affected by the power lines is not included in these figures and will be determined later. Based on experience of other projects, few if any households affected by the power lines will have to relocate and impacts are expected to be minor. HEALTH IMPACT ASSESSMENT A comprehensive health impact assessment has been carried out. Baseline health studies were conducted through a survey of 190 people representing households to be resettled from the reservoir area and 250 people in the project area not being resettled. The questionnaires were administered in eleven communes: Trung Son, Thanh Son, Phu Thanh, Trung Thanh, Trung Ly, Muong Ly Tam Trung, Mai Hich, Van Mai, Xuan Nha and Tan Xuan. These communes fall in four districts, Quan Hoa and Muong Lat (in Thanh Hoa province) Mai Chau (in Hoa Binh province) and Moc Chau (in Son La province). They were supplemented by in depth interviews and group discussions, desk studies and field observations. Basic health indicators show that the area has higher crude birth, death and infant mortality rates than the country as a whole, but somewhat lowers than the North-West region which the project area borders. The most common diseases or conditions in the region are malaria, tuberculosis (TB), road traffic accidents and HIV. The affected districts ­ for which information is somewhat sketchier ­ suggest respiratory, food, soil and water borne diseases, nutrient deficiencies, especially among children and mental 5 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 disorders are also prevalent. Environmental hygiene is also an issue with clean water, improved sanitation and solid waste disposal all requiring attention. The local health system at the district level consists of District Hospitals (DHs), District Health Centers (DHCs), and District Health Offices. These provide both acute care, with DHs having capacity for outpatient and inpatient care with 50-100 beds, a laboratory, X- ray/ultrasound and general surgical facilities. Preventative care through DHCs and polyclinics focus on mother and child health services, goiter control and TB as well as the ten national health priorities, namely: TB prevention, elimination of leprosy, malaria and dengue fever prevention, HIV/AIDS prevention and treatment, expanded immunization, child malnutrition prevention, community mental health care, cancer prevention reproductive health care and integrated military/public health care. Each commune in the project area has a Commune Health Center (CHC) and nearly all villages have a village health worker (VHW). CHCs are variously staffed with about six qualified people in each. Only one CHC has a medical doctor. In general staffing of the CHCs is somewhat lower in the project area than in the region as a whole. The focus of efforts of CHCs and of VHWs are first aid, care of common diseases, information, education and communication, especially on hygiene and disease prevention, maternal and child health care and family planning and implementation of the national health program. Resettlers and others in the project area identify concerns about their health as a result of the project to be about their own health, access to the commune health centers and lack of health workers and transmission of new diseases by incoming construction workers. The HIA identifies the main project impacts in two stages: during construction and during operation. Environmental health issues, from noise, dust, emissions by vehicles and contamination are all noted, as well as the risk of accidents and injuries. Environment hygiene and waste management, the impacts of crowding are noted as increased health risk factors. In addition the arrival of construction workers may also increase stress levels, drugs and alcohol related violence and sexually transmitted infections (STIs) including HIV/AIDS. Commissioning, reservoir filling and operations bring threats of water borne illnesses including malaria, schistosomiasis and leptospirosis. There is also an increased risk of water-related accidents. Local communities, construction workers and camp followers - opportunists who follow big construction sites to make money ­ are identified as groups at risk. HEALTH PLANS To mitigate the project impacts, Trung Son Hydroelectric Program Management Board (TSPMB) will develop two main health plans, the Workers Health Program and the Public Health Action Plan. The Workers Health Program will be exclusive responsibility of the TSPMB supported by the government hospitals for referral purposes. The service will include adequately 6 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 staffed 24 hour health clinic for any health needs of the workers and additional on site aid posts in strategic places. The health and safety program will include preventive and educational programs for the workers throughout the project life, including rules and regulations to control irresponsible driving and the misuse of alcohol and drugs. A special program for control of sexually transmitted infections, including HIV/AIDS, will be implemented for the workers. The public health action plan (PHAP) is aimed at mitigating negative impacts on the population's health due to the construction of the dam. To ensure sustainability, the health service provision in the impacted area remains the primary responsibility of the government health infrastructure. On the part of TSPMB, this entails providing adequate financial and technical support to the existing government health services so that implementation of all national health plans related to the primary health care is carried out uninterrupted and secondary health services are available on a referral basis to the impacted population. The strategies used will be to ensure that the ten national health priorities are implemented by the MOH institutions through district and commune health services. This support will include capacity building including training of all health workers at commune and district level health staff, infrastructure, equipment, transport needs of the both resettled people and the other impacted populations. A reliable referral system will be in place to adequately deal with any emergencies. The support will also focus on improving the routine data collection for use in monitoring the progress of the project. A base line survey will be conducted in the impacted population before or soon after the start of the construction program. The information thus obtained will be used for monitoring the progress of the PHAP at regular intervals. A mid-term survey will be conducted after four years of the start of the project. This will provide further understanding of the health impacts of the population from the project. The TSPMB will have a memorandum of understanding with the provincial health administration for the provision of health services to the impacted populations. The TSPMB will appoint a small health team to work with the district and provincial health services that will facilitate the implementation of the PHAP. The health team will be supported by a public health expert for specialist advice remotely. 7 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 Part 1: Health Impact Assessment Trung Son Hydropower Project 1. INTRODUCTION Trung Son hydropower project will be constructed on the Ma River, in the territory of Trung Son commune, Quan Hoa district, Thanh Hoa province. The proposed project aims to provide low-cost electric power to support Vietnam's further economic development and improvement of living standards through the development of hydropower resources in an environmentally sustainable and socially responsible manner. The proposed project will provide support for EVN's development of one of the country's medium-sized hydropower development projects. The goal is to provide a "good practice" case of sustainable hydropower development in this core part of Vietnam's power sector. Trung Son Hydropower project with its installed capacity of 260 MW and mean annual energy of 1056 GWh is a multipurpose project, providing both power generation and flood control benefits,. The proposed dam is about 40Km downstream from Lao PDR, with the reservoir head about 10Km from the border. The roller compacted concrete dam will be 88Mt high and have a crest length of 353 meters. Full supply level is 160 meters. The total reservoir volume will be about 348.50 million m3 including a flood control volume of about 112 million m3. It will cover an area of about 13.175 km2, inundating mixed forest and agricultural land. The construction work consists of the main dam, including the spillway, intake gate, penstock, powerhouse and discharge channel. A switchyard at the dam site and a 220kV transmission line about 65 Km long will evacuate power from the plant and connect it to an existing 220kV in Tan Lac district in Hoa Binh province. An access road about 22Km long connecting the all weather road at Co Luong with the dam site will be constructed, as will about 13km of road within the construction area. Four hydropower turbines and generators, control and other equipment will be installed, as will mechanical equipment including the spillway gates. The project area consists of the communes bordering the reservoir above the dam and the river below the dam to the confluence with the Luong River approximately 65Km below the dam site. In addition the project area includes the communes through which the transmission line is proposed to run. Table 1 lists the communes and the districts and provinces in which they fall that are considered to be in the project area and Map 1 shows these in relation to one another. 8 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 Table 1: List of Communes in the Project Area Commune Impacted by Hoa Binh Province Mai Chau District Chieng Chau Power lines Mai Chau town Power lines Mai Ha Power lines Mai Hich Road, power lines Thung Khe Power lines Tong Dau Power lines Van Mai Road, power lines Tan Lac District Dich Giao Power lines Phu Cuong Power lines Thanh Hoi Power lines Tu Ne Power lines Tuan Lo Power lines Son La Province Moc Chau District Tan Xuan Reservoir Xuan Nha Reservoir Thanh Hoa Province Muong Lat District Muong Lat Town Reservoir Muong Ly Construction site, reservoir Pu Nhi Reservoir Tam Chung Reservoir Ten Tan Reservoir, upstream impacts Trung Ly Reservoir Quan Hoa District Hoi Xuan Downstream impacts Phu Son Downstream impacts Phu Thanh Downstream impacts, road Phu Xuan Downstream impacts Thanh Son Downstream impacts, power lines, road Trung Son Construction site, downstream impacts, power line, reservoir, road Trung Thanh Downstream impacts 9 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 Map 1: Trung Son Hydropower Project Area 1.2 PROJECT STRUCTURE The project will consist of the following four components: Dam construction. This will include the construction of the main dam, including the spillway, intake gate, penstock, power house and discharge channel, supply and installation of the electromechanical equipment and of the hydro mechanical equipment. Auxiliary investments including the access road and bridges, internal roads and construction camp will be included in this component, as well as the consulting services for supervision of construction. Construction of two power lines, one for supply during construction, at 110/35kV and one to evacuate power from the switchyard to the connection point into the existing 220kV system. Impact mitigation and compensation, which will include the implementation of resettlement, livelihoods restoration, ethnic minorities, environment management and public health management plans. Technical assistance. 10 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 Total costs are estimated at $380 million, of which about $1.5 million is for environmental management and $26 million for resettlement and restoration of peoples' livelihoods. Vietnam Electricity (EVN) has applied to the World Bank for a loan of $330 million. 1.2 RESETTLEMENT An estimated 544 households, totaling about 2,500 people are expected to have to be relocated, and a further 3,500 people in 1,100 households will lose land or productive assets. Most of these people are of Thai, Muong or H'mong minority descent. Relocation of people will take place in Hoa Binh, Son La and Thanh Hoa provinces. Eleven resettlement sites are planned for 4 communes: 4 villages in Trung Son Commune, 3 in Tan Xuan, 2 in Trung Ly, 2 in Muong Ly. The resettlement sites were identified in 2004 and modified in 2008 on the basis of feedback received through local consultation (Table 4&5). All planned resettlement sites are within the affected communes so that relocated households will be able to continue to manage their remaining land and other properties outside of the project affected areas, and maintain social relationships. Average distance from affected site to resettlement site is 2 Km. The capacity of the planned resettlement sites takes into account the forecast of households to be relocated in 2011, and the 40 households that would be isolated by the reservoir. The current area of agricultural land and forestry land in resettlement sites is preserved. Overall, other lands (unused land) will decrease to allow the creation of residential land and new paddy fields. Each relocating household moving to the resettlement sites will be assigned with a house site plot not smaller than 400 m². Depending on the availability of residential land in the resettlement sites, relocating households might be assigned with larger plot. The project will be responsible for ground leveling to ensure house construction as planned. The area of home garden is not less than 300 m² per household. The agricultural land is not smaller that 1.5 hectare per household. Each back-and-up relocating household will be assigned with a home plot not smaller than 400 m². Depending on the availability of residential land in the resettlement sites, relocating households might be assigned with a larger plot. The project will either do the ground leveling for displaced persons (DPs) or pay them so that they can do it themselves, at the DPs' choice. If a DP prefers to do the ground leveling, the DP has to comply with technical requirements as necessary for safety purpose as agreed in the project. 1.2 PROJECT TIMETABLE Key dates for project implementation are given in Table 1. 11 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 Table 1: Time Frame of Trung Son Hydro Project Activities and of Resettlement Activities Period Procurement and construction of resettlement sites January 2011- April 2013 Construction of auxiliary works October 2010 ­ February 2012 Construction of main works - electrical mechanical December 2011 - equipment March 2016 Main works ­ hydraulic mechanical equipments December 2011- November 2015 Reservoir filling October 2015 Livelihood restoration December 2010- December 2016 Environmental management plan June 2010-October 2016 Overall October 2010- October 2016 1.3 HEALTH IMPACT ASSESSMENT Health Impact Assessment (HIA) is a tool that provides decision-makers with information on how a policy, program or project may affect the health of people1. Health effects are generally poorly assessed within Environmental Impact Assessments (EIA), if at all. This is evident from the EIA conducted for the Trung Son Hydropower Project and approved by MoNRE, where health was merely touched2. However, in keeping with the global trend of introducing HIAs in all major projects, an HIA was conducted with the following objectives. 1.3.1 Key objectives of HIA: to establish the baseline of existing health conditions in a project area to evaluate the potential health impacts on individuals and communes influenced by a project, programme or policy to employ qualitative and quantitative data for assessment of health impacts, where impacts can be neutral, positive or negative to provide a formal mechanism for engaging relevant stakeholders in discussions regarding prevention and mitigation of negative effects on health to provide a basis for developing formal mitigation action plans 1 WHO HIA website. http://www.who.int/hia/en/ accessed on 13 April 2009. 2 Environmental Impact Assessment Report. Trung Son Hydropower Project. May 2008. 12 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 Large infrastructure developments invariably trigger the need for some type of HIA. Construction of dams for power production usually inundates large areas of land, previously without water, necessitating the need for resettlement of small or large communes in the affected areas. It also impacts land generally used by these communes for agricultural purposes and other livelihood activities, affecting the health of those living in the area in a number of ways. The Trung Son Hydropower Project Management Board (TSHPMB) wishes to ensure good health of the workforce, as well as mitigating impacts and promoting positive improvements in the health of the host communities. The overall public health management approach focuses on incorporating workforce and community health considerations systematically and cooperatively into project planning and management. The HIA is an important core element of this public health strategy. 2 Baseline Studies To establish a baseline of existing health conditions in the project area, a number of activities were arranged and a process of consultation carried out with all stakeholders to collect required information. 2.1 GENERAL OBJECTIVE The general objective of the baseline health study was: To assess the impacts of the Trung Son Hydro Project on the health of local communes, particularly resettled populations, and to propose a public health action plan to minimize these impacts. 2.2 SPECIFIC OBJECTIVES The specific objectives of the baseline health study were: To assess the current health status and determinants of health of communities which will require relocation due to inundation To assess the health of those living in the project intervention areas and in the corridor of construction activities To assess people's access and use of health care services at different levels, and the capacity of the local health care system To assess status of national health programs being implemented within the project intervention areas and making it the basis of the public health action plan; To identify health impacts on the workforce and outline measures for TSHPMB to consider when looking for contractors to provide health service for their workforce. To propose a public health action plan incorporating all above. 13 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 2.3 PARTICIPANTS AND DATA COLLECTION METHODOLOGY A sample survey was conducted among those who would require relocation and those who would stay but would experience impacts of the project. The survey was conducted from April to June, 2008. The instrument used is in Annex 5&6. The survey was not exhaustive as time and expertise were not easily available. However, useful information was obtained and deficiencies recognized from the results have identified a need for a much more comprehensive survey. Such a survey has been planned for the resettled population. A sample survey of other project impacted people is planned and will be carried out at the start of the project. This methodology, in the absence of detailed baseline information is feasible without compromising the quality of the information, as the major impacts of the project on the population will take some time to manifest after the start of construction. Annex 7 describes the methodology and the plan. 2.3.1 Sites Eleven communes from four districts of Thanh Hoa, Son La and Hoa Binh provinces are impacted as detailed earlier. 2.3.2 Participants and methods of data collection Both quantitative and qualitative methods were applied to collect data from different sources. Methods and techniques for data collection are as follows: Questionnaire survey for the resettled population and those impacted but not due for relocation In-depth interviews with all the communities Group discussions with impacted communities and health service providers Desk study from literature and available reports General observations. 2.4 SURVEY The population was divided into two groups. In all 440 local people were selected for interviews: 190 from the 2,500 due for relocation and 250 from other impacted populations. Random sampling was not possible due to lack of time and expertise. In the absence of this, the first five contactable households were interviewed in each village. 2.4.1 Group 1: Households interviewed This group included 190 people who were representatives of resettled households from five communes in Quan Hoa, Muong Lat and Moc Chau districts. Eleven individuals from Phu Thanh were also included in this group. Although they may not move eventually, Phu Thanh commune is affected by Trung Son operation road. 14 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 Table 2: Survey of communes due for Relocation Commune Number interviewed Trung Son 88 Phu Thanh 11* Trung Ly 12 Muong Ly 10 Tan Xuan 69 Total 190 * Impact due to road construction 2.4.2 Group 2: Impacted households not due for relocation This group included 250 people who were considered representatives of households living in 10 communes around the project intervention areas. Table 3: Sample of impacted communes not due for resettlement Commune Number interviewed Trung Son 40 Thanh Son 40 Phu Thanh 24 Trung Thanh 25 Trung Ly 15 Tam Trung 22 Mai Hich 25 Van Mai 25 Xuan Nha 26 Tan Xuan 8 Total 250 The interviewers were not able to reach Muong Ly commune in group 2 due to poor condition of the access road therefore only people from group 1 were interviewed. 2.4.3 In-depth interview and group discussion In-depth interviews: 12 leaders and staff of provincial health services, district preventive medicine centers and hospitals, and community health centers were selected for group discussions and in-depth interviews. Group discussion: There was one group discussion in each province. Each group discussion included 10 leaders and staff of provincial health services, district preventive medicine centers and hospitals, and community health centers. 2.4.4 Desk Study A desk study of national health programs being implemented locally was made. It included reports of studies conducted in the project intervention sites, the capacity of the local health system, health behavior and lifestyle and check lists provided by provincial health services. 2.4.5 Observation 15 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 Observations were made within the sites to further obtain complementary information. 2.4.6 Assessment Period The assessment was conducted from 19/04/2008 to 30/06/2008 and again in September 2009. 2.4.7 Data analysis The following data analysis protocols were employed: EPI-INFO software was employed for data entry. These data sets were cleaned and analyzed using SPSS software. Qualitative data has been coded and analyzed using N-Vivo software. 2.5 Affected Areas 2.5.1 Son La province The Hydropower project affects two communes of Moc Chau district i.e. Tan Xuan and Xuan Nha. They are the most remote being 45 Km from the district center. These communes were established in 2007 (Original Xuan Nha commune was divided into three namely, New Xuan Nha, Tan Xuan and Truong Xuan). Xuan Nha has continued using the existing infrastructure facilities while Tan Xuan has to set up completely new ones. The project will result in the re-settlement of 177 households in Dong Ta Lao and Tay Ta Lao villages 2.5.2 Hoa Binh province Hoa Binh province has two communes, Mai Hich and Van Mai which will be affected by the road. These communes have favorable conditions in terms of geography and transportation systems. The distance from the two communes to the district centre is only 15 Km. This will bring them concrete advantages of social and economic development in the area. 2.5.3 Thanh Hoa province Two districts, Muong Lat and Quan Hoa in Thanh Hoa province are affected by the project. Muong Lat district The affected communes are Tam Trung, Trung Ly and Muong Ly. Centre of Trung Ly commune is 40 Km from the district centre and locates on the main route to the district health center and is easily accessible by motor vehicles. However, the resettled villages are as far as 25-30 Km from the district center and can only be approached by foot or motorcycle on a difficult path. It takes 2-3 hours to reach these villages from the commune center. They are situated next to the bank of the river and will be resettled within the same village, to higher ground, close to adjacent villages. The resettlement location is not geographically far from the former ones. The resettled area of Muong Ly is opposite to Trung Ly through the river. It is walking distance but the road is in poor 16 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 condition. The Commune People's Committee and Commune Health Center are close, just 200-300 meters from the bank of the river. Quan Hoa District The project will affect three communes including Phu Thanh, Thanh Son, and Trung Son. Trung Son will be at the heart of the hydropower plant, consisting of the hydropower dam and part of the reservoir area. Resettled villages are Ta Ban and Xuoc. Phu Thanh is located on the main route to the dam site of Trung Son Hydropower. It lies along Route 15A from Co Luong. Seven households (in Uon village) are subject to resettlement because of the road construction. There are 25 households of Thanh Son communes affected who will be resettled. Basically, the main impacts on these communes are almost similar to Phu Thanh except that construction camps will be located here. 2.6 DEMOGRAPHIC AND SOCIO-ECONOMIC CHARACTERISTICS OF AFFECTED AREAS Table 4: Number of households impacted by the main project Number of Households Impacted (2008 Survey) No. Places No. of Households Population Affected Total 509 2283 A Thanh Hoa province 327 1484 I Quan Hoa District 183 765 1 Trung Son commune 183 765 II Muong Lat district 144 817 1 Muong Ly commune 87 422 2 Trung Ly commune 49 261 3 Tam Chung commune 8 36 B Son La province 182 799 I Moc Chau District 182 799 1 Tan Xuan commune 177 768 2 Xuan Nha commune 5 31 17 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 Table 5: Number of people resettled by construction of access road to the project site Number of Households Impacted (2008 Survey) No. Places No. of Households Population Affected Total 66 268 A Thanh Hoa province 57 228 I Quan Hoa District 57 228 1 Trung Son commune 25 103 2 Phu Thanh commune 7 28 3 Thanh Son commune 25 97 B Hoa Binh province 09 40 I Mai Chau District 09 40 1 Mai Hich 2 11 2 Van Mai 7 29 According to the Health Statistics Yearbook 2006, the population of Son La is 1.007.500; Hoa Binh is 820.400 and of Thanh Hoa 3.680.400. Further information on the population of 11 communes in the project site has been collected from the 2007 summary report of communes, the report on Comprehensive Resettlement Planning, the report on Environment Impact Assessment and is presented in Table 4. Trung Son hydropower project affects three provinces, namely Thanh Hoa, Hoa Binh and Son La. A total of 575 households with 2551 people are affected with Thanh Hoa province affected most as detailed below: Thanh Hoa province: 384 households affected (accounting to 66,7%) Son La province: 182 households affected (accounting to 31,6%) Hoa Binh province: 9 households affected (accounting to 1,6%) There are four ethnic groups in the project area: Thai, Muong, H'Mong, and Kinh. Kinh people make up a small proportion and are mostly engaged in small business. In each commune, the workforce accounts for approximately 50-80% of all people, of whom 98% work in agriculture and forestry and only 2% work in non-agriculture occupations. 2.7 SOCIO-ECONOMICS OF THE PROJECT AREA The project area is mountainous and socio-economic development is poor. The economy is based on agriculture and forestry, with agriculture accounting for over 98% of the total income of the commune. 2.7.1 Household incomes 18 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 The main activity of households is subsistent farming producing staple crops for food, approximately 338kg/person/year on average. Households obtain additional income from gardening, breeding, and non-timber forest products as well. The income of each household is, on average, VND 6-15 million per year of which 3-5 million comes from agriculture and 3-10 million is contributed by forest products. It should be noted that the Northwest region is the poorest in Vietnam and the affected areas are the most difficult and poorest in the Northwest. Muong Lat is one of the poorest districts in Vietnam. According to the 2005 Government guidelines, which places the poverty line at an income under 200.000 VND/month, 91% of households in Trung Ly commune in Muong Lat district are categorized as poor, of which 34% suffer from hunger at some time during the year. 2.7.2 Living conditions According to the survey of five communes in Quan Hoa, Muong Lat, and Moc Chau districts, 90% of households have houses on stilts, of which 56.5% are on wooden and 32.5% are on bamboo stilts. Solid and semi-solid houses are mainly situated near major roads and centers but account for only 1% of the total. Approximately 10% of households are living in a one or two story house. Roughly 97% of households use water for daily activities from streams naturally flowing close to the villages. The number of households utilizing water from dug wells is very small. Approximately 60% of households have a simple wooden enclosure for a toilet and 40% have no toilet at all. 2.8 HEALTH SITUATION IN THE AFFECTED AREAS 2.8.1 Basic health indicators Health issues in the Northwest in general, and the affected areas in particular, are of concern. Vietnam has achieved considerable improvement in health compared with other countries with comparable incomes. The crude death rate per 1000 population is used as a measure but this measure is sensitive to age structure. This means that the death rate is higher in the very young and the elderly and lower in the younger and the middle age groups. Hence it is not a good indicator to reflect the health situation of the community or the country as a whole. The Infant Mortality rate (IMR), or deaths in the first year of life per 1000 live births, is a better indicator as it reflects living standards and social conditions, education, management and quality of health services, especially mother and child health care. According to the Ministry of Health (MOH), IMR in Vietnam dropped from 55 per 1,000 live births in 1983 to 20 per 1,000 live births in 2004. Table 5 demonstrates the comparison between project sites, the Northwest region and Vietnam on crude birth rates, crude death rates, and IMR. Thanh Hoa is compared with the Northwest because Muong Lat and Quan Hoa are adjacent to the border. All indicators for the three project provinces, especially IMR, are considerably higher. 19 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 Nationwide IMR in 2006 was 16 per 1,000 live births, which was considerably lower than that of the Northwest, 22 per 1,000 live births, and half of that of Son La (Table 5). Table 5: Death and birth rate in 2006 Hoa Thanh Indicators Vietnam Northwest Son La Binh Hoa Crude Birth Rate (%o) 17,4 22,6 21,7 18,2 15,3 Crude Death Rate (%o) 5,3 5,.5 6,0 5,6 6,9 IMR under 1 year old (%o) 16,0 22,0 32,0 26,6 24,0 Source: Health Statistics Yearbook 2006, Ministry of Health 2.9 DISEASE PATTERNS 2.9.1 Provincial level The most prevalent diseases in the Northwest provinces are tuberculosis, malaria, HIV, road traffic accidents, and mental disorders like schizophrenia and epilepsy. Table 6 indicates the high prevalence of malaria in three provinces. The most prevalent diseases are tuberculosis and mental disorders in Thanh Hoa, traffic accidents in Hoa Binh, and HIV in Son La. Table 6: Prevalence of common diseases 2006 (Rate/100,000 Population) Common Diseases Vietnam Northwest Son La Hoa Binh Thanh Hoa Reported number of tuberculosis cases 98284 (116,7) 1143 (43,8) 367 (36,4) 509 (62,0) 3832 (104,1) Total malaria cases 91 635 (108,9) 10 713 (410,9) 1003 (99,5) 1140 (138,9) 3587 (97,5) HIV/AIDS 116 565 (138,5) 117 565 (129,0) 2242 (200,8) 555 (66,1) 2245 (51,0) Total number of traffic accident deaths 14 360 (17,7) 392 (15,0) 148 (14,7) 162 (19,7) 216 (5,9) Schizophrenia morbidity rate per 100 000 population 148,4 37,8 1,4 40,3 164,1 Epilepsy morbidity rate per 100 000 population 85,2 18,7 2,9 17,3 67,4 Source: Health statistics yearbook 2006, Ministry of Health 20 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 Figure 5: Prevalence of common diseases Prevalance Rate for Malaria Prevalance Rate for TB Son La Son La 2005 2006 2007 2005 2006 2007 Hoa Binh Hoa Binh Thanh Hoa Thanh Hoa North West Region North West Region Vietnam Vietnam 0 50 100 150 200 250 300 350 400 450 30.00 50.00 70.00 90.00 110.00 Rate per 100,000 people Per 100,000 hab Death Rate due to accicdents Incidence Rate for HIV Son La 2005 2006 2007 Son La 2004 2005 2006 Hoa Binh Hoa Binh Thanh Hoa Thanh Hoa North West Region North West Region Vietnam Vietnam 40.0 50.0 60.0 70.0 - 50.00 100.00 150.00 200.00 250.00 300.00 Rate per 100,000 hab Rate per 100,000 The most common diseases are: Malaria: Although malaria is declining across Vietnam, its prevalence in the Northwest region remains considerably higher. 21 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 Tuberculosis(TB): Thanh Hoa seems to have the highest prevalence of tuberculosis and the disease levels seem to be stable and do not show any rising or falling trends. Accidents: Road traffic accidents are on the increase in all areas except in Hoa Binh. This is consistent with the economic growth Vietnam has demonstrated in recent years. All areas show higher levels of accidents compared to the national average. This is one of the important project impacts that will be felt in these areas. It requires special considerations and measures of prevention. HIV Infection: This is another area of concern as infection rates are increasing in all areas, but more so in the Northwest region, especially in Son La District. The area has been known for some time for drug trafficking. 2.9.2 District level The most common diseases are flu, food poisoning, diarrhea and traffic accidents. As in the Northwest, TB, malaria, and goiter are common, especially in Mai Chau where the number of goiter cases is 378 (Table 7). HIV infections are also high and will require special attention for control. Data collection and its availability are variable from district to district and drawing firm conclusions is difficult. This area will be revisited during the health checks and survey at the start of the project Table 7: Disease profile of affected districts 2007 Disease Quan Hoa Mai Chau Moc Chau Muong Lat Flu 4183 1940 2615 NA Food poisoning 2830 NA 0 NA Pneumonia 821 NA NA NA Diarrhea 434 719 906 NA Traffic accident 285 142 NA NA Bronchitis 216 NA NA NA Dysentery 85 26 219 NA Tuberculosis 34 34 NA 22 Malaria 33 152 134 228 Goiter 10 378 150 72 Mental disorder 25 83 NA 68 HIV/AIDS 50 188 425 77 Source: The report of District Preventive Medicine Centers, 2007 N.B. These figures apply to the entire population and may not be representative of the impacted population; however, they provide an indication of general health problems in the area. 2.9.3 Commune Level According to the report of the Commune Health Centers, the most prevalent diseases in Mai Hich and Van Mai communes in Hoa Binh province are TB, diarrhea, pneumonia, occupational and traffic accidents. The disease pattern of communes in Moc Chau district in Son La province focuses on flu, diarrhea, pneumonia, neuralgia, and tonsillitis. In the 22 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 affected communes in Quan Hoa and Muong Lat districts, the most common diseases are sore throat, tonsillitis, bronchitis, diarrhea, TB and arthritis. The morbidity data shown here are largely from those who visit health facilities, generally a self selected group. In the absence of data from smaller areas and communes, the Vietnam Household Living Standards Survey 2006 (VHLSS 2006) provides some useful information. The average household size in the project area is 5,1 compared to the national poorest quintile rural average of 4,6 (VHLSS 2006). The population from the impacted area has higher infant mortality as shown in Table 5. The survey also shows higher fertility, higher under nutrition among children below five years of age and comparatively lower uptake of contraceptive methods for family planning. According to VHLSS 2006 71% of people living in the rural poorest quintiles had health insurance compared to 75,5% in the project area, indicating the impacted population is poorer. In 2004, 8,6% of people reported illness or injury in the past four weeks in the Northwest region. The figure has doubled in 2006 to 15,7%. It is not clear if this increase is due to increased morbidity or the increased utilization of health services. Women reported higher illness rates than men in all regions and categories. Total expenditure on health, according to the VHLSS, had gone down in the Northwest region from 444,900 VND in 2004 to 342,700 VND in 2006. Table 8: Health status of community adjacent to intervention area Thanh Hoa Hoa Binh Son La Quan Hoa District Muong Lat Mai Chau Moc Chau District District District Trung Thành Phú Trung Trung Tam Mai Vn Xuân Tân Total Sn Sn Thanh Thành Lư Trung Hch Mai Nha Xuân n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) Possess a health 30 32 24 25 14 17 8 6 26 7 189 insurance (75,0) (80,0) (100,0) (100,0) (93,3) (77,3) (32,0) (24,0) (100,0) (87,5) (75,5) card Got sick 14 11 8 8 3 5 7 10 17 1 87 within last (35,0) (27,5) (33,3) (32,0) (20,0) (22,8) (28,0) (40,0) (65,4) (14,3) (34,8) year Health problem in 20 27 16 10 2 11 4 13 18 5 126 last 2 (50,0) (67,5) (66,7) (40,0) (13,3) (50,0) (16,0) (52,0) (69,2) (62,5) (50,5) weeks Source: Interviews in Trung Son Hydropower Project area, May 2008 & Summary Report 2007 Table 8 shows that proportion of people covered by a health insurance scheme accounts for 80% in six of the ten communes. In resettled communes, 90% of people have a health insurance card; particularly in Phu Thanh and Trung Thanh communes where 100% of total population is covered by health insurance. This figure is reliable as all these 23 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 communes are in the list of poor communes subsidized by Government under national programs, such as Program 135 for Hunger Eradication and Poverty Alleviation and program 139 for health care for the poor. These programs are highly beneficial for the poor. However, the proportion of people with a health insurance card in Mai Hich and Van Mai communes are relatively lower than other communes, 32% and 24% respectively. The lack of health insurance cards in these communes will create difficulties in obtaining health care for these people. This will be verified again during the health checks and survey (HC&S) before the start of the project. Over 30% of total interviewed people reported a health problem during the previous four weeks and within one year. 27,3% of Phu Thanh's population and 76,1% of Trung Son's reported health related problems which negatively interrupts their daily activities for one year. Over 60% of people in five communes reported health related problems in the last four weeks (Table 9). The most common diseases are dizziness, backache, headache, flu, fever, and diarrhea. The results are the perceptions of people, and are difficult to interpret as health problems affecting productivity. This is another area which will be verified during the HC&S at the start of the project. Table 9: Recent health issues of resettled communes Tan Trung Phu Muong Xuan Son Trung Ly Thanh Ly Total n (%) n (%) n (%) n (%) n (%) Have a health 67 80 12 11 10 180 insurance card (97,1) (90,9) (100,0) (100,0) (100,0) (94,7) Got sick within 30 67 8 3 5 113 last year (44,1) (76,1) (66,7) (27,3) (50,0) (59,8) Health problem 44 79 10 8 7 148 in last 2 weeks (63,8) (89,8) (83,3) (72,7) (70,0) (77,9) Source: Interviews in Trung Son Hydropower Project area, May 2008 and Summary report 2007 2.10 HEALTH DETERMINANTS IN THE AFFECTED AREAS 2.10.1 Drug use The Northwest area in general and the four project districts in particular, are "hot spots" of illicit drugs. Drug use is of particular concern to the local authorities. Muong Lat and Quan Hoa are located in the `drug triangle' which receives drugs and transports them towards Hoa Binh-Hanoi-Ha Dong-Nam Dinh. Muong Lat is known to be not only a drug selling and transporting area but also has a rehabilitation center with 284 drug users managed by border guards. More importantly, Trung Ly and Muong Ly, situated in the hydropower construction area, are arterial venues of drug transportation. 2.10.2 Environmental Hygiene This evaluation targeted the impacts of safe water and environment hygiene in the affected communes. This evaluation shows the consistent findings with existing reports 24 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 that the majority of people use water for daily activities from ponds, lakes, rivers, and streams (41,0%) and 36,2% use water channeled by bamboo semi-circular pipes from springs to household (Máng ln water). Only in Phu Thanh commune do all households receive water from an electricity-powered water pump by World Vision. In all, only 9% of households are using safe water. Table 10: Water and Sanitation in adjacent communities Thanh Hoa Hoa Binh Son La Muong Lat Mai Chau Moc Chau Quan Hoa District District District District Trung Thành Phú Trung Trung Tam Mai Vn Xuân Tân Sn Sn Thanh Thành Lư Trung Hch Mai Nha Xuân Total n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) Water sources Pond, lake, 20 26 3 14 11 5 0 15 1 7 102 river, stream (50,0) (65,0) (12,5) (56,0) (73,3) (24,5) (0,0) (60,0) (3,8) (87,5) (41,0) 3 0 0 1 0 3 6 10 1 1 25 Natural well (7,5) (0,0) (0,0) (4.0) (0,0) (14.0) (24.0) (40.0) (3.8) (12.5) (10.1) UNICEF's 0 0 0 0 1 0 0 0 0 0 1 (0.5) pumping water (0,0) (0,0) (0,0) (0,0) (6.7) (0,0) (0,0) (0,0) (0,0) (0,0) Bamboo 14 25 0 14 0 8 0 5 23 1 90 channeled (35,0) (62,5) (0,0) (56,0) (0,0) (37,0) (0,0) (20,0) (88,5) (12,5) (36,.2) water 5 3 0 0 0 1 1 13 2 0 25 Rain water (13,0) (7,5) (0,0) (0,0) (0,0) (4,5) (4,0) (52,0) (7,7) (0,0) (10,1) World Vision's 0 0 21 0 0 0 0 0 0 0 21 water (0,0) (0,0) (100,0) (0,0) (0,0) (0,0) (0,0) (0,0) (0,0) (0,0) (8,4) Toilets 6 3 0 3 1 4 2 22 0 0 41 Septic tank (18,0) (9,7) (0,0) (9,7) (3,2) (18,2) (6,5) (71,0) (0,0) (0,0) (16,5) One 10 5 0 4 1 3 12 2 9 6 52 compartment (25,0) (12,8) (0,0) (10,3) (2,6) (15,0) (3,1) (5,) (23,1) (75,0) (20,7) latrine Two- 1 0 0 0 1 0 2 0 0 0 4 compartment (2,5) (0,0) (0,0) (0,0) (33,3) (0,0) (66,7) (0,0) (0,0) (0,0) (1,6) latrine One-time 30 32 24 18 12 8 9 1 17 2 153 used* (75,0) (27,8) (100,0) (15,7) (10,4) (45,0) (7,8) (0,9) (14,8) (25,0) (61,2) Source: Interviews in Trung Son Hydropower Project area, May 2008 & Summary report 2007 25 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 2.10.3 Waste Disposal Household and other wastes are disposed of without much care and it is common to see plastic bags and other discarded rubbish lying around communities. A small number of people may collect waste and dispose it, often by burning. The waste is managed, if at all, at individual level and no community action is in place. The same applies to human excreta. Toilets, if any, are just enclosures often at the edge of a stream or the river. As detailed in Table 10, only 16,5% of houses had septic tank toilets. Majority of people use bush for defecation. 26 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 3. The Local Health System Within the scope of this evaluation, the health system from the lowest level to the provincial health system was reviewed as these facilities will directly ensure and support health care delivery for local people and secondary level of care to the construction workers. Overall information of health systems of the three provinces is discussed first followed by further detailed analysis of roles and responsibilities of health systems at all levels in the project area. 3.1 BASIC INFORMATION ON THE LOCAL HEALTH SYSTEM District Hospitals (DHs) in Vietnam provide outpatient and inpatient care with 50-100 beds, a laboratory, X-ray/ultrasound and general surgical facilities. Preventive activities are managed by the District Health Centers (DHCs) conducting primary health care including mother and child services, goiter control, TB directly observed short term (DOTS) therapy and the ten national preventive programs (Annex 4). The DH is well equipped to deal with most medical emergencies. Any emergencies not managed in DH are referred to the provincial hospital. Village health workers (VHWs) are responsible for preventive activities and carry out all preventive programs under the supervision of the Commune Health Center (CHC). The CHC supervises the VHWs in all villages under a commune. The CHC provides outpatient and inpatient services to its population and is supervised by the DHC. Emergencies are referred to the district hospital. Table 11 represents the number of health facilities in the three provinces from provincial to lowest level, including provincial and district general hospitals, general polyclinics, and CHC. Among the three project provinces, Thanh Hoa has the highest number of health facilities and patient beds at all levels because of its size and population, with capacity approximately three times that of Hoa Binh or Son La. Table 11: Health facilities and patient beds Inter commune Communal Health Provincial hospital District hospital Polyclinic center Facilities Bed Facilities Bed Facilities Bed Facilities Bed Son La 4 620 11 850 19 270 201 1005 Hoa Binh 4 420 11 805 23 115 209 836 Thanh Hoa 7 1660 26 2760 29 491 627 3600 Source: Health statistics yearbook 2006, Ministry of Health Table 12 indicates the number of health staff in three provinces compared with that of Northwest region and the nation. 27 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 Table 12: The average number of health staffs per administrative unit Hoa Vietnam Northwest Son La Binh Thanh Hoa Commune 5,4 5 5 5 4 District 100 92 101 64 112 Province 1308 636 936 517 2072 Source: Health Statistics Yearbook 2006, Ministry of Health and VLHSS 2006 It should be noted that there is no difference in the number of health staff at communal level between project sites, the Northwest region and the nation. At district level, there is a significant difference, in which Hoa Binh is recorded to have the lowest number of health staff at 64 people per district. Further information of human resource is presented in Table 14. Table 13: Health budget per capita, 2006 - Unit: VND Category Vietnam Northwest Son La Hoa Binh Thanh Hoa Average health budget per 87.000 107.900 107.800 88.900 63.500 capital Costs for health care providers 75.907 89.321 90.402 72.672 51.810 Budget for health program 3.147 5.173 3.940 4.599 2.317 Source: Health Statistics Yearbook 2006, Ministry of Health The national budget for health care was compared between project provinces, the Northwest region and the nation. Based on the Health Statistics Yearbook 2006, the per capita health budget for each category was computed. The national budget per capita of the Northwest region is relatively higher than that of Vietnam. However, average health budget per capita of Hoa Binh and Thanh Hoa is lower than that of Northwest region. In particular, average health budget per capita of Thanh Hoa is even lower compared with the national level Table 13. 3.2 CURRENT SITUATION OF LOCAL HEALTH SYSTEM 3.2.1 Provincial level The provincial health service is the lead agency managing health services in the province. It is responsible to the Provincial People's Committee for health care provision and directly manages all health facilities such as provincial hospitals and preventive medicine centers. At the provincial level, medical facilities include the provincial general hospital and specialized traditional hospitals and obstetric hospitals. According to data available, Hoa Binh and Son La, each have four provincial hospitals while Thanh Hoa has seven provincial hospitals. 28 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 Figure 7: Provincial Health Care Structure Provincial People Committee Provincial Health Bureau District Health District Health District People Unit Center Provincial Committee Hosp. (included Specialized Hosp. District Preventive Health Center Provincial Commune Preventive People Health Center Committee District Hospital Other specialize he alth centers Commune Health Centers Provincial Pharmaceutical Inter-commune Company Polyclinic Secondary Medical VH Ws School To reform the organizational structure of the basic healthcare network through decentralization, the government enacted Decree 171/2004/ND-CP and Decree 172/2004/ND-CP on September 29, 2004, Joint Circular 11/2005/TTLT-BYT-BNV of the Ministry of Health and Ministry of Interior (April 12, 2005). These decrees defined the new organizational model for health services at the district level, including the District General Hospital and District Preventive Medicine Center that are directly under the Provincial Health Service, and the District Health Office under the District People's Committee, responsible for managing the CHS. Provincial governments are implementing the new organizational model at the district level. The districts, however, are encountering major difficulties in restructuring because of the change from a unified system of district health centers responsible for preventive and curative medicine and managing commune health services. Many advantages of the former district health center model are being lost and mechanisms have yet to be developed to overcome these problems. For example, the former model stressed the integration of curative and preventive care between the district and communal levels, but under the new model many districts have not yet found effective coordinating mechanisms. The data show that Moc Chau, Mai Chau and Quan Hoa have all three organizations as regulated in the Decree, including a district general hospital, a district preventive 29 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 medicine center, and a district health office. Only Muong Lat has not yet set up a district health office. Although much effort has been paid to supervising and controlling national health programs, communicable diseases and reproductive health, limited achievements have been made in preventive medicine due to large areas and lack of health workers. The district health office has only 2-3 staff with governmental management responsibilities. "There are still some villages where children have never been immunized because health workers could not transport vaccine there" In-depth interview with head of District preventive medicine District hospitals have in general been doing well, are independent and can perform intermediate surgical procedures. In general, they meet standards set for district hospital performance. Common health problems managed at district hospital are related to general medicine, pediatrics, first line surgical interventions including obstetrics, gynecological, injuries and traffic accidents. Support services like laboratory and radiological services are also available at district hospitals. Human resources in district hospitals are presented in Table 14. Table 14: Human resources of district hospitals in affected areas District Doctor Nurse Midwife Pharmacists Total Mai Chau 12 24 37 5 78 Moc Chau 20 50 27 7 104 Muong Lat 6 28 18 2 54 Quan Hoa 10 23 19 3 55 Source: Interviews Trung Son Hydropower Project area, May 2008 & Summary report 2007 30 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 Figure 8: Mai Chau Interdistrict Hospital Distances from the intervention area (Trung Son commune) to Mai Chau district is 40 kilometers, to Moc Chau is 100 kilometers, and to Muong Lat and Quan Hoa are 80 kilometers. Mai Chau general hospital is the nearest hospital from the construction site. Fortunately, Mai Chau district general hospital has been newly built with modern equipment for diagnosis and treatment and will serve as a referral point for the impacted populations. 3.2.2 Regional polyclinics Regional polyclinics under the district hospitals mainly provide health services to selected communes/wards in the district. Before Doi Moi, regional polyclinics were established to ease the burden on public hospitals, which had a shortage of beds. Polyclinics made it easier for people to seek health care, early diagnosis and timely treatment. Regional polyclinics also assisted commune health centers to improve their professional capabilities. Since Doi Moi, regional polyclinics have continued to play a role in reducing the burden on DHs in their areas, taking on many of the responsibilities of a district hospital. In 2005, Vietnam had 880 regional polyclinics, a decrease of 56 units compared to year 2000. According to the master plan for Vietnam's health system development by 2010, the health sector will maintain and develop regional polyclinics under DHs in mountainous and remote districts to ensure basic health services for local residents. 3.2.3 Commune health center The CHC is the primary unit for delivery of health care in the public health system. The CHCs are well placed for delivering primary health care and basic health services, as well as supporting the operational management and goals of village health programs. In 2005, 31 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 Vietnam had 10,613 CHC, and the number continues to increase annually so that newly established communes/wards have primary healthcare facilities. From 2000 to 2005, Vietnam added 342 new CHCs. By December 31, 2005, 100% of communes had health workers and 98% of villages had VHWs. Table 17: Number of health workers in CHCs in affected areas Medical Elementary Mid- No Commune Doctor Assistant Nurses pharmacist wife Total 1 Trung Son 0 2 5 0 1 5 2 Thanh Son 0 1 2 0 0 4 3 Phu Thanh 0 3 1 1 0 5 4 Trung Thanh 0 1 4 0 0 5 5 Trung Ly 0 5 0 1 0 6 6 Muong Ly 0 1 2 0 0 3 7 Tam Trung 0 1 2 0 0 3 8 Xuan Nha 0 1 1 0 0 2 9 Tan Xuan 0 1 0 0 0 1 10 Mai Hich 1 2 0 0 3 6 11 Van Mai 0 2 1 0 1 4 Source: Interviews in Trung Son Hydropower Project area, May 2008 & Summary report 2007 Table 17 sets out human resource of the CHCs impacted by the construction works and operations of Trung Son hydropower project. Only one out of 11 (9,0%) CHCs here have a medical doctor. This figure is much lower than other areas in Son La (23,4%) Hoa Binh (38,8%) and Thanh Hoa (61,7%). Further, the average number of health workers per CHC in the impacted area is four, lower than the national average of 5,4 (VHLSS). Except Xuan Nha and Tan Xuan, newly established communes in 2007, all remaining communes have at least three health workers. The Trung Son health center has six health workers. 3.2.4 Village health network Village health is the extended arm of commune health, focusing on information, education and communication. During the Doi Moi reform process, the village health network in many localities disappeared due to lack of resources but the network is being revitalized in recent years. Village health workers have been assigned specific tasks as stipulated in Decision 3653/QD-BYT of the Health Minister on November 15, 1999: Health information, education, and communication Instructions on hygiene and disease prevention Maternal and child health care and family planning First aid and care of common diseases Implementation of national health programs 32 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 Village health workers are under the direct management of the CHC and village leaders and they coordinate between the community and social organizations in the villages. Strengthening the knowledge and skills of the VHWs will be important for implementation of primary health care in the impacted villages. 3.2.5 Private health facilities Apart from state health facilities, private facilities are available in districts and communes. Since the Standing Committee of the National Assembly issued the Ordinance on Private Medical and Pharmaceutical Practice in 1993, private facilities including modern medicine, traditional medicine, and pharmaceutical practices have been established and are gradually expanding. According to the Ministry of Health, by the end of 1999, Vietnam had 41,000 private medical and pharmaceutical facilities in operation. By 2004, the total number of private facilities rose to about 65,000 facilities. The project health program, in conjunction with the district health service management, will be liaising with the private sector to ensure basic standards of health care are maintained, especially for the ten areas listed under the National Health Priorities. 4 Health Services Provided, Used and Needed 4.1 NATIONAL HEALTH PROGRAMS According to Decision number 108/2007/QD-TTg dated 17/7/2007 by the Prime Minister on National Health Programs for 2006-2010, the aim of these programs is "to reduce the morbidity and mortality rates, promote quality of health, prolong life and try to ensure universal access to primary health services." The program identifies ten national health programs shown in Table 15 linked to the ten national priorities under the responsibilities of the CHC. For practical purposes and ease of implementation of the Public Health Action Plan (PHAP) the order has been rearranged. Table 15: Ten National Health Priorities and some additional CHC responsibilities No. Ten National Health Priorities Some additional relevant health issues 1. TB prevention Including respiratory diseases integrated 2. Elimination of leprosy management of childhood infections (IMCI) approach 3. Malaria and Dengue prevention Vector-borne and pest related diseases 4. HIV/AIDS prevention and treatment Including STIs 5. Expanded Program of Immunizations (EPI) Integrated with Mother and Child Health (MCH) program 6. Child malnutrition prevention, including Nutrition and micronutrients related issues (under Iodine deficiency program MCH program) 7. Community mental health care Including psychosocial problems 8. Cancer prevention program Education and awareness of cancer risk factors e.g. smoking 9. Reproductive health care program Fertility control and spacing 33 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 10. Integrated medicine military-public program Not applicable to the project area These national health programs have been implemented under the central Vietnamese government with support from international organizations. All programs provide services free of charge, all the way from central to local levels in order to "solve the most pressing and urgent issues in preventing ill health and disease in Vietnam". The objectives, and some selected interventions are reviewed, focusing at grassroots levels. The ten national health programs during 2006-2010 and are provided in Annex 2. Table 16: CHCs delivering national health programs 2001­2002 Program Percent of districts Percent of communes Program of Immunization 99.4 95.3 Tuberculosis control and prevention 93.2 83.0 Malaria control and prevention 73.4 79.7 HIV/AIDS control and prevention 84.0 50.0 Fresh water and environmental and sanitation 21.6 28.9 Food hygiene and safety 25.0 25.2 Diarrea prevención 95.4 91.6 Acute Respiratory Infection Prevention 96.0 94.6 Malnutrition prevention 82.4 78.9 Population and family planning 90.7 83.2 Anaemia prevention 80.4 70.3 Community mental health care 11.2 8.7 Source: VNHS 2001­2002 According to the Vietnam National Health Survey (VNHS) report, CHCs implement 12 national health programs focusing on preventive medicine (Table 16). The proportion of CHCs carrying out these programs is relatively high, except for water and sanitation, food hygiene and community mental health care. Within the affected areas, almost all communes have been doing well in terms of controlling and preventing communicable diseases and epidemics. National health programs have been implemented relatively well at commune level, including malaria prevention, reproductive health, and EPI. However, some CHCs are facing difficulties caused by a lack of health workers and unfavorable geographical conditions. Transportation is extremely difficult in the rainy season and populations are scattered, with many not speaking Vietnamese well. It is anticipated that project support will enable provision of health services to reach remote areas because road construction will ease access. Moreover, additional resources available from the project will facilitate the implementation of the national priorities. 4.2 USE OF HEALTH SERVICES AT DIFFERENT LEVELS 4.2.1 Provincial level The comparative use of provincial health services in the Northwest region and Vietnam is shown in Table 18. In general, the number of outpatients is two to four times higher than 34 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 inpatients. Hoa Binh has a much higher number of inpatients compared to other provinces. Table 18: Use of health services at provincial level Vietnam Northwest Son La Hoa Binh Thanh Hoa Number of hospital visits 187,950,562 3,577,062 1,315.087 642, 640 4,718,167 Number of inpatients 8,834,530 270,997 99, 612 81,473 428,357 Number of outpatients 23,027,890 1,238,548 573,154 114,239 1,444. 545 Source: Health Statistics Year Book, 2006 4.2.2 District level Total number of visits and hospitalizations in district hospitals within the affected area during last three years is listed in Table 19. Although the numbers have been gradually increasing, significant differences over time have not been recorded. Table 19: Total number of patients visiting district hospitals Number of visits Number of hospitalized patients District Year 2005 2006 2007 2005 2006 2007 Mai Chau 50.460 51.460 45.892 3.978 6.196 5.771 Moc Chau 34.581 35.581 40.503 7.501 7.597 7.049 Muong Lat 12.950 13.950 21.464 2.307 2.262 3.184 Quan Hoa 49.517 57.463 61.722 5.970 5.748 6.103 Source: District health reports, 2007 Limited information related to national health priorities was collected from district departments of health and is tabulated in Table 20. MCH indicators showed good coverage although there were marked differences in the four districts. Immunization coverage could be improved in some of the districts. Maternal health facilities were poorer in Muong Lat and Moc Chau districts. Malnutrition and under nutrition among children under five was arguably the most worrying among MCH indicators. Food supplementation after six months exclusive breast feeding and up to three years of age will require close attention. The IMR was generally low but this needs to be assessed over a longer period for a clear picture. Muong Lat district is the most disadvantaged in the Northwest and had the highest IMR. Close monitoring of childhood morbidity and mortality will be essential. While malaria cases were higher in Moc Chau and Mai Chau, TB was also a problem in the area. The number of HIV+ cases was quite high for this comparatively small population and identifies a major area for intervention. 35 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 Table 20 Selected information on Ten National Health Priorities Health Service Provision and Quan Hoa Muong Lat Moc Chau Mai Chau Other Categories District District District District Maternal and Child Health Immunization coverage (Percent) 98 86 88 88 Women in Reproductive Age for TT (Percent) 96 86 93 88 Antenatal care coverage (Percent) 83 92 77 75 Supervised delivery by Health Worker (Percent) 95 87 93 92 Child births at recognized health facility 95 72 74 86 Under/malnourished children under 5 (%) 35,4 34,0 24,9 23,6 Total number of births/year 672 582 2078 775 Maternal deaths 0 1 0 0 Infant deaths 1 10 12 7 Infant Mortality Rate/1000 live births 1,5 17,2 5,8 9,0 TB/Leprosy Number of diagnosed TB patients under treatment 25 13 8 35 Number of diagnosed Leprosy patients under treatment 8 0 0 1 Sexually Transmitted Infections (STIs) Number of HIV cases 293 157 530 76 Number of HIV/AIDS cases on treatment 80 0 9 0 Vector borne diseases Malaria cases/year 27 66 125 99 Dengue cases/year 0 0 0 0 Accidents RTA numbers/Year 32 40 49 47 RTA fatalities/Year 0 2 2 0 Drowning/year 0 0 1 1 Psychosocial cases Suicides numbers by year 12 10 15 8 Attempted suicides by year 22 15 18 14 Road traffic accident patients were reported by all the four districts in comparable numbers. The fatality rate for accident victims was 2,4%. Attempted suicides and suicides were quite high in the impacted districts. This indicates a serious social problem and will require close monitoring during the implementation of the PHAP. Although these health statistics relate to the whole population of the district, it can reflect on the health situation in project impacted area. 4.2.3 Commune level The number of patients visiting CHCs has been stable over the last three years, at an average of less than 3.000 patients per year. Table 20 gives trends at the level of communes most affected by the project. 36 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 Table 20: Number of patients visiting Commune Health Centers Commune Average for Year 2005 2006 2007 3 years Trung Ly 3214 3215 2744 3058 Muong Ly 2952 2953 3233 3046 Xuan Nha 6915 6916 7721 7184 Trung Thanh 2500 2501 3250 2750 Thanh Son 1814 1815 1129 1586 Trung Son 1305 1306 1568 1393 Phu Thanh 1331 1332 1031 1231 Mai Hich 3019 3020 3225 3088 Tam Trung 2875 2880 3100 2952 Van Mai 1840 1841 1934 1872 Avg./Commune/Yr 2777 2778 2894 N.B. Data for Tan Xuan is unavailable as it was separated from Xuan Nha in 2007 Source: Commune health reports, 2007 4.2 WORK LOAD OF THE CHCS The workload of CHCs with a staff ratio of four to five per population of 2.500-5.250 is shown in Tables 20&21. Considering higher fertility levels compared with national figures and taking the birth rate as 20/1000 population, the number of mother and child health (MCH) activities can be worked out. The figures are arbitrary and can be used and recalculated according to more realistic rates to local areas. The workload calculated in the table demonstrates feasible management of the entire population for primary health care activities. Table 21: CHC health work load No. Category Total Work Per Week Remarks Load/Year (Min-Max) 1. Births 50-105 1-2 Average Pop. 3000 x 20 (Birth 2. ANC 50-105 1-2 women rate) /1000 3. PNC 50-105 1-2 mothers 4. Immunizations 200-310 2-4 children and Mother and Child Women in reproductive age 5. Family Planning 500-600 women in 0.5 day/week reproductive age 6. Outpatient 3000 60 patients/week 10-15/day 7. BCC activities 150 3 days/week HIV/AIDS & control of other +village visits diseases (Group sessions) 8 Administration/ 0.5 day/week Reporting duties data collection etc. 9. In service training 0.5 day/week Includes visits, supervision and special sessions of training 37 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 Four to five staff at CHC with advisory and supervisory support from the district can easily carry out this work load, provided they manage their time efficiently and distribute responsibilities among themselves. Health seeking behavior in the affected area Table 22: Health seeking behavior in the affected area Thanh Hoa Hoa Binh Son La Quan Hoa District Muong Lat Mai Chau Moc Chau District District District Total Trung Thành Phú Trung Trung Tam Mai Vn Xuân Tân Sn Sn Thanh Thành Lư Trung Hch Mai Nha Xuân n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) 15 2 0 0 0 7 0 5 4 0 29 Private health (37,5) (7,4) (0,0) (0,0) (0,0) (0,0) (0,0) (38,5) (22,2) (0,0) (11.6) Commune 20 17 2 7 2 15 1 2 13 1 78 health centre (75,0) (63,0) (12,5) (70,0) (100,0) (64,6) (25,0) (15,4) (72,2) (20,0) (47.4) District 2 5 1 4 0 1 1 6 12 2 34 Hospital (5,0) (18,5) (6,0) (40,0) (0,0) (26,2) (25,0) (46,2) (66,7) (40,0) (32,6) No 0 5 13 0 0 0 0 0 0 3 21 consultation (0,0) (12,5) (54,2) (0,0) (0,0) (0,0) (0,0) (0,0) (0,0) (37,5) (11.2) (Source: Interviews in area of Trung Son Hydropower Project in May 2008 and Summary report 2007 The majority of people interviewed would seek health care services at different facilities when they have a health problem. However, 11,2% of all people interviewed did not seek any consultation within the existing health system. The survey also included a question on health seeking behavior of resettlers in order to provide recommendations for this group. Table 23 represents their response. Over 50% of total resettlers living in Trung Ly, Phu Thanh, and Muong Ly do not visit health facilities when having a health problem. Reasons given were a long distance from home to health facilities, unfavorable transportation system especially during rainy season, and poor knowledge. It is evident that improvement of health education, information and communication program is necessary. Moreover, a new CHC built near the community will increase health access. Table 23: Health seeking behavior among resettlers Facility/commune Tan Xuan Trung Son Trung Ly Phu Thanh Muong Ly Total n (%) n (%) n (%) n (%) n (%) n (%) Commune health 14 30 0 1 2 47 center (31,8) (38,0) (0,0) (12,5) (28,6) (31,8) 6 20 0 0 0 26 District hospital (13.6) (25.3) (0.0) (0.0) (0.0) (17.6) 0 2 0 0 0 2 Provincial hospital (0,0) (2,3) (0,0) (0,0) (0,0) (1,0) Private facility 9 0 3 0 0 12 38 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 (20,5) (0,0) (25,0) (0,0) (0,0) (8,1) 18 28 7 7 5 65 Not seeking (26,1) (31,8) (58,3) (63,6) (50,0) (34,2) Source: Interviews in Trung Son Hydropower Project area, May 2008 4.3 Knowledge and Attitudes on Health Impact of the Project 4.3.1 Health workers Health workers had different levels of knowledge regarding the health impacts of the hydropower project on some specific groups such as construction workers living in camps, settlers and camp followers. Communicable diseases would be an issue due to a sudden increase of the population: "Exposure to HIV, tuberculosis and malaria would increase because of influx of population within a limited area. Environmental pollution, food poisoning, outbreak, injuries, and STDs would also increase" said a health worker at Mai Chau preventive medicine center. Others highlight the danger of environment pollution: "Attention should be paid to rising environment pollution such as smoke, dust, wastes, and noise" said the leader of the Moc Chau preventive medicine center " ...Smoke, dust, chemical would cause respiratory infections," agreed a health worker at the Quan Hoa health center. 4.3.2 Resettlers Moving to a new place with changes in environment, weather, and living conditions may affect access to health care. Resettlers would be infected with new local diseases: "New places with different weather conditions could affect physical and mental health. Resettlers can be exposed to communicable diseases such as malaria, typhoid. The resettlement process may affect access to health care due to changes in addresses," said a health worker at Mai Chau preventive medicine center. "Changes in the living environment may affect health of the population, for instance, resettlers might have to change cultivation practices that will affect income and community health..." said a worker at Trung Son Health center. The resettlers living in five communes including Tan Xuan, Trung Son, Trung Ly, Phu Thanh and Muong Ly answered questions on their knowledge and attitude on the health impact of the project. Their key concerns of resettlers are reflected in Table 24: 84,7% of people were worried about their health, 67,2% were concerned about access to CHCs and 20,0% thought there will be difficulties in finding health workers to work in the area. Among interviewees in Phu Thanh commune, 80% expressed concern about transmission of new diseases by newcomers. 39 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 Table 24: Resettlers and their Concerns about Health Trung Trung Phu Muong Tan Xuan Son Ly Thanh Ly Total n (%) n (%) n (%) n (%) n (%) Know the construction of 69 85 12 10 10 186 the plan (100,0) (96,6) (100,0) (90,9) (100,0) (97,9) 61 78 9 5 8 161 Concern about their health (88,4) (88,6) (75,0) (45,5) (80,0) (84,7) Less access to commune 41 6 2 0 0 49 health center (67,2) (7,4) (22,2) (0,0) (0,0) (29,5) Transmission of new 17 31 6 4 0 58 diseases by newcomers (27,9) (38,3) (66,7) (80,0) (0,0) (34,9) 21 9 2 0 1 33 Lack of health worker (34,4) (11,1) (22,2) (0,0) (10,0) (19,9) Source: Interviews in Trung Son Hydropower Project area, May 2008 Tabulated key demographic characteristics of the resettlers can be found in Annex 10. 4.3.3 Construction workers The majority of construction workers move in from other localities making them vulnerable to diseases endemic in the intervention area. As mentioned earlier, the prevalence of malaria and tuberculosis is high in the project area. Moreover, construction workers live far from their families, adding the risk of drugs and Sexually Transmitted Infections (STIs) to the occupational injuries. "This group could be infected with communicable diseases circulating in the locality. Living far from family for a long time, they might have unprotected sexual contact with prostitutes which can result in infections. Moreover, they can also be exposed to traffic accident, food poisoning etc," said a health worker at Mai Chau preventive medicine center. 4.3.4 People living adjacent to the intervention areas Of the 250 people living adjacent to the intervention areas interviewed, approximately 70% knew that a dam and power house will be built near where they are living. However, only 26.7% in Trung Ly and 26.9 % in Xuan Nha were aware of the project. It is clear that need for communication is great. Their knowledge and attitude is presented in Table 25. Their demographic information such as gender, education attainment and marital status is detailed in Annex 9. Health concerns of local people due to construction of the hydropower project are: the outbreak of communicable diseases; non-communicable diseases; occupational accidents; food poisoning; and traffic accidents. Social problems were also mentioned by over 50% of interviewees with illicit drugs, prostitution, theft, communal violence and gambling as behavioral risks. Therefore, close cooperation between local administration agencies and health facilities in implementing Information, Education and Communication (IEC) and planning for emerging issues will be necessary. 40 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 Table 25: Knowledge and attitude of local people Thanh Hoa Hoa Binh Son La Quan Hoa District Muong Lat Mai Chau Moc Chau District District District Trung Thành Phú Trung Trung Tam Mai Vn Xuân Tân Sn Sn Thanh Thành Lư Trung Hch Mai Nha Xuân Total n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) n (%) Knowing the 27 39 24 12 4 16 21 15 7 8 173 construction (67,5) (97,5) (100,0) (48,0) (26,7) (72.7) (84,0) (60,0) (26,9) (100,0) (69,1) plan 16 26 22 3 1 10 14 8 3 2 105 Noise (40,0) (65,0) (91,7) (12,0) (6,7) (45,4) (56,0) (32,0) (11,5) (25,0) (42,0) 20 33 22 8 3 13 11 13 6 2 131 Dust (50,0) (82,5) (91,7) (33,3) (20,0) (59,0) (44,0) (52,0) (23,1) (25,0) (52,4) Risk of 33 35 23 11 6 11 19 13 19 4 174 Migrants (82,5) (87,5) (95,8) (45,8) (40,0) (50,0) (14,6) (52,0) (73,1) (50,0) (69,5) Risk of 35 23 19 7 1 15 9 8 8 4 129 communicable (87,5) (63,9) (95,0) (6,6) (33,3) (68,2) (36,0) (40,8) (61,5) (100,0) (51,8) diseases Risk of non- 16 14 3 3 0 8 1 1 5 0 51 communicable (40,0) (38,9) (15,0) (27,3) (0,0) (36,4) (4,0) (5,0) (38,5) (0,0) (20,5) diseases 18 22 18 6 15 9 12 9 2 113 Accidents 2 (66,7) (45,0) (88,9) (90,0) (54,4) (68,1) (36,0) (60.0) (69,2) (50.0) (68,2) 18 16 6 1 0 10 2 2 4 1 60 Food poisoning (45,0) (44,4) (30,0) (9,1) (0,0) (45,4) (8,0) (10,0) (30,8) (25,0) (24,2) Occupational 23 19 12 0 0 10 17 9 3 0 93 accident (57,5) (52,8) (60,0) (0,0) (0,0) (45,4) (68,0) (45,0) (23,1) (0,0) (45,5) 32 35 24 16 11 16 16 18 25 7 200 Illicit Drug use (80,0) (87,5) (100,0) (64,0) (73,3) (72,2) (64,0) (72,0) (96,2) (87,5) (80,9) 21 34 17 6 3 11 10 12 10 4 128 Prostitution (52,5) (85,0) (70,8) (24,0) (20,0) (50,0) (40,0) (48,0) (38,5) (50,0) (51,1) 27 33 24 8 4 14 19 18 24 5 176 Theft (67,5) (82,5) (100,0) (3,0) (26,7) (66,6) (76,0) (72,0) (92,3) (62,5) (71,8) 23 27 22 7 4 12 11 13 21 2 142 Violence (57,5) (67,5) (91,7) (28,0) (26,7) (54,6) (44,0) (52,0) (80,8) (25,0) (56,9) 30 31 21 6 4 12 20 1 22 7 171 Gambling (75,0) (77,5) (87,5) (24,0) (26,7) (54,5) (80,0) (72,0) (84,6) (87,5) (68,6) Source: Interviews in Trung Son Hydropower Project area, May 2008 4.5 Health Checks and Survey Data collection from the surveys conducted among the impacted populations and the health service providers was quite extensive; however some important information is missing from the data already collected. Examples are information regarding reproductive health including the number of children born and number alive at the time of the interview. Information on contraceptive use, antenatal and post natal care, place of delivery and supervision by a skilled health worker, disability among the impacted populations and social problems will be collected soon after the start of the project through the health checks and survey (HC&S). The survey will also include some 41 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 measurements such as weight and height of a sample population to establish baseline levels of malnutrition and stunting among children and adults. Certain laboratory tests may also be carried out to determine levels of some health problems in the community. The methodology and details of the HC&S are detailed in the Annex 4. 42 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 5 Health Impacts during Life of the Project 5.1 POTENTIAL IMPACTS OF DAM CONSTRUCTION Health issues related to major phases of construction work are shown in Table 26. For purpose of the current HIA, a more project-specific set of phases has been selected. It includes the following time periods: baseline pre-construction transition and mobilization active construction commissioning and reservoir filling early operations/post reservoir filling standard operations The table provides a check list of changes during the life of the project. Each phase can have its own impacts on health, varying in intensity as the project proceeds from preparation to construction to operation. The matrix also provides an indication as to what needs to be done at what time to mitigate impacts. 5.1.1 Impacts by project stages The baseline period is especially important as it provides a snapshot of the health status of populations prior to the commencement of the project and it remains important throughout the life of the project. The data informs the implementers of planning for the health services and possible mitigation required. It will continue to be relevant in demonstrating how the project impacted the population's health over a long period of time. Pre-construction, transition and mobilization may lead to poor water quality and add dust and fuel emissions to the atmosphere, affecting the health of the people. The influx of workers often increases the prices of essential commodities and food, affecting local population more than the migrant workers. Increased traffic enhances the risk of accidents and injuries, all adding to increased stress levels in the community. During active construction, these problems are exacerbated with increased risk of STIs and HIV/AIDS, drugs and alcohol related violence, while stress and anxiety increases in the host populations. Commissioning and reservoir filling brings new threats of water borne illnesses like malaria, schistosomiasis, leptospirosis etc. Loss of land to the reservoir brings new problems with reduced land for agriculture and pastures for domestic animals, creating new financial difficulties for the people. A large water body poses a danger of drowning, especially for children, who seldom realize the dangers of vast body of water. 43 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 Table 26: Potential Health Issues during Phases of the Trung Son Hydroproject Communicable Non- Nutrition- Accidents and Psychosocial Period diseases communicable related health injuries issues diseases issues Baseline Studies at Studies at Studies at Studies at Stress, anxiety province, district province, district province, district province, district and village level and village level and village level and village level Preconstruction, Diseases related Dust- and Food inflation Increased Stress, anxiety transition and to lack of clean emissions- with secondary traffic-related mobilization water and induced poor diets accidents and improved respiratory injuries sanitation problems Active construction STIs, including Dust- and Loss of Construction Uncertainty HIV/AIDS, and emissions- subsistence related, traffic malaria induced farming respiratory problems Commissioning and Changes in Dust- and Changes of Drowning Stress, anxiety reservoir filling vector-borne emissions- agricultural disease patterns induced production respiratory problems Early operation and Water-related Increased use of Loss of river Drowning, and Displaced post-reservoir diseases (e.g. pesticides and garden crops traffic-related communities filling malaria, dengue) fertilizers and altered accidents and lose coherence fishery injuries Standard operation New steady- Pesticide Loss of Drowning, Changes in (3-5 years post- state of vector- contamination agricultural traffic traditional filling) borne diseases lands medicine practices Source: Adapted from Nam Theun 2 HIA. 2004 Early operations, post reservoir construction and finally decommissioning phases pose increased risk of water borne diseases. The workers are gone and have possibly left their mark by introducing new disease strains in the population, such as STIs, including HIV infection. 5.1.2 Planning required However, this gloomy scenario also provides an opportunity for planning and mitigating negative impacts. Communities can be prepared to adapt to their new surroundings and some clearly positive impacts are likely including employment, better access to markets, tourism, ease of movement and improved infrastructure and housing. Preparations for these changes are the focus of the social and development programs in large projects. The organizers are responsible for educating and preparing people to make the best use of the benefits emerging from the project, including essential services to mitigate loss caused by the project. Housing can be provided but its optimum use is what 44 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 will benefit the occupants. Similarly, simple provision of a modern toilet to a rural family is not enough as families must understand why it should be used at all and the best way to do so. All this requires sincere efforts on the part of the owners of the project and government agencies supporting the project. The project will provide an opportunity to improve environmental health issues along with disease specific morbidity and mortality. There are significant positive impacts associated with better housing, safe water, food, sanitation, transportation facilities and information communication in improving the health of the people. 5.1.3 Timing of Impacts From a health perspective, the Trung Son hydropower project can be considered to take place in two phases. The preparation and construction phase will last about five years and the operational phase will start from 2017. This section covers the impacts of the preparation and construction phase (called immediate impacts). A section described later covers the impacts of the operational phase (called Long-term impacts). 5.2 IMMEDIATE IMPACTS The construction of the coffer dam, diversion tunnel and the main dam itself will immediately start impacting the environment of the project area. People will start experiencing changes due to construction including noise, increased traffic, and dust. Changes to the river may affect the fish supply almost immediately. River water may not be available or suitable for irrigation because of excess amounts of solid matter in the water and the change in the course of the water will deprive certain sections of the agricultural land. The immediate negative impacts on health may include: accidents and injuries associated with construction labour camp issues associated with construction vector-borne disease issues surrounding construction social/societal ramifications, positive and negative, of mass media access through television and radio. 5.2.1 Changes in infrastructure The infrastructure of the affected region will change dramatically. The investor will upgrade Route 15 from Co Luong to Co Me, where the dam will be built. Other rural roads will also be newly built. All routes in the resettlement areas will be built to national standards: routes from resettlement areas to the main road will be 4 Mt. in width while the internal routes within resettlement areas will be 3.5 Mt. in width. Local populations will benefit from this development. Several villages will soon receive electricity and resettlement areas will be provided with both electricity and running water. Improvement of infrastructure will make it possible for people to access health services, especially secondary health services such as district and provincial hospitals. Time for traveling will be shortened considerably, and improved living conditions at home and access to information through radio and TV should also have a positive impact on health. 45 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 5.2.2 Air environment During the construction phase, Trung Son will be a large building site with thousands of workers and tons of heavy machinery and trucks adding noise and dust pollution. Although, the environment assessment report showed that the air environment would be affected within a small scale and will not be continuous, construction workers' health will not be left untouched. Such interventions as making the air more humid especially in the dry season and providing safety equipment for workers to reduce noise and dust during the construction phase will be necessary. 5.2.3 Wastes and environmental hygiene Pollution of water source and poor environmental hygiene would be pressing issues in the construction phases. Both industrial and daily waste will increase in the intervention area. Waste water originates from daily routines of construction workers and local populations. According to the environment impact assessment (EIA) report an estimated discharge of 300.000 liters per day from the construction workers is expected. Waste water contains microorganisms, organic waste and solid matter and requires skillful treatment before discharge to avoid any harm to the public. Industrial waste will be produced by facilities directly involved in the construction process. For example, a large amount of used lubricating oil will be discharged by vehicles and other machines. According to EIA each truck, on average, needs 18 liters of lubricating oil changed four times a year. With hundreds of trucks on the site, a significant amount of lubricating oil will be discharged annually. A lack of appropriate collection and disposal of this waste has the potential of creating major pollution affecting the local populations. Moreover, hundreds of tons of solid waste will be discharged from the construction site so it is encouraging to note that plans for waste management are included in the overall construction plan. 5.2.4 Urbanization Currently, urbanization in the affected area is low. The most urbanized district is Moc Chau where 24% of total population resides in Moc Chau town. In Quan Hoa, the proportion of population living in urban areas is only 7,6%. This proportion is even lower in Muong Lat. As stated earlier, urbanization will speed up when Route 15 is finished exposing local populations to different health risks. 5.2.5 Employment The Trung Son project will create substantial job opportunities for locals. Many of them, depending on ability and skills, will be employed in construction work. In addition, locals will also be hired by the entertainment industry, where illegal activities like drug use may flourish, affecting health of the workers and the local people. Cheap child labor may be one of the problems in small businesses such as restaurants and needs to be controlled. These opportunities represent considerable changes from the existing lifestyle and people's livelihoods, which may introduce stress and anxiety, particularly among the elderly. 46 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 5.3 Affected groups Three groups can be identified likely to be most impacted by the project. First, the local communities living in and around the proposed construction site which includes the directly impacted people (resettlers) and those who are indirectly impacted. The second category is the workers themselves. The third group consists of people who follow construction sites, so-called the camp followers. At all times people are subject to a combination of exposures rather than only one risk and most risks are interconnected. 5.3.1 Local communities Local communities are the most vulnerable because many are exposed to outsiders and to new health risks for the first time. They must adapt the most and potentially have least resources with which to do so. Nonetheless, many households in the area do have access to local health facilities and are covered by the state insurance. The new life style that outsiders bring is both fascinating as well as likely to give rise to concerns. Over time local communities will learn new things. They may be exploited by outsiders as well as benefit from new opportunities. They may be exposed to dangers of increased traffic, dust and pollution, or certain diseases but they will benefit from the roads opening up access to markets, towns and the facilities within them. Young women may be an attraction to outsiders and there are possibilities of exploitation. If local communities have been exposed to drugs, unscrupulous people may use this opportunity for marketing drugs for making quick money. Business of these activities the economic development will accelerate. People would move to live closer to main roads. It is quite likely that Phu Thanh commune would become an eating and entertainment area where drivers can stop over and construction workers can enjoy these places during their free time. Living closer to roads with high volumes of traffic may increase road traffic accidents and pollution from dust and emissions. It should be noted that Mai Chau has a relatively high traffic accident rate already. During 2007, there were 142 deaths and injuries caused by traffic accidents. Resettlement and relocation may trigger envy within communities because of real or perceived unfairness. Moreover, resettlers and those not being resettled alike may have to change their customs and routines, adapting to new settings, leading to stress. The impacted people in the project area do not have to move far from where they are living at present. Many will move to higher ground within the same village and resettlers will stay within their own communes and communities of ethnic minorities, with whom they share common customs. However, social cohesion and existing relationships will be impacted to some extent. Each relocating household will either have a new house built for them or be financially supported to move their own house, or build a new one, be it a house on stilts or a brick house, depending on their customs. New houses will meet a minimum standard and will include kitchen, bathroom and a separate toilet. It will have a cistern to store water 47 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 because in resettlement areas, both freshwater and electricity will be provided. Moreover, a water drainage system will be constructed following the local terrain or it will be integrated into the road drainage system. Appropriate design of bathrooms will help improve personal hygiene though it will be important to educate households about cleanliness as some may have never used such facilities. Better housing will provide protection from exposure to insects, rodents and reptiles. Indeed, if modern housing is used effectively, the burden of vector-borne diseases can be reduced considerably. Provision of sufficient clean and safe water will help to improve health of the population by reduction in diarrheal diseases. However, the need for a properly designed sewage system is essential for the containment of disease and epidemics. 5.3.2 Camp Followers Camp followers are opportunists who follow big construction sites to earn a living. Estimates based on international experience, show that for each worker there are likely to be two camp followers. The situation in Vietnam may be a bit different. In Son La project there are 8.000 workers and an estimated 500 camp followers. Similarly, in Ban Chat project there are 200 camp followers for 3.000 workers and in Tuyen Quang 600 for 9.000 workers. According to these figures it is estimated that the numbers of camp followers in Trung Son may be anything from 400 to 1000. Camp followers usually have initial problems of crowded housing, poor waste management/sanitation and lack of safe water. They are also exposed to vector borne diseases and STIs and HIV/AIDS. Camp followers will also be exposed to communicable diseases that are endemic in the intervention area such as malaria and dengue fever. The spread of tuberculosis is also facilitated in overcrowded conditions. Stringent measures will be required to limit the numbers of camp followers in the project area and to keep these diseases under control. Most camp followers arrive despite restrictions from local authorities who try to avoid undue pressure on already thin local services. But they come to provide services for which there is a demand from the construction workers. They will foster expansion of the entertainment industry leading to possible alcohol and drug abuse, prostitution and risk of the spread of STIs and HIV/AIDS. At the Son La hydropower plant, entertainment facilities such as karaoke, cafés and mini-hotels soon sprang up. A similar trend is likely to be repeated in and around Trung Son construction camps. In addition, Muong Lat is a known area for illicit drug trade in Thanh Hoa and social problems are more likely to appear in this area. This sudden population increase will create an increased demand for health services. Although they may earn their livelihoods at the construction site, camp followers may not be covered for health insurance but will have access to local facilities albeit on payment. The local health care system should prepare to meet this demand which will also put pressure on other services like housing, public services such as water and sanitation and other essential services, including law and order. 48 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 5.3.3 Construction Workers Most construction workers are outsiders, as skilled labor is usually not available locally. Most are keen on making money to support their families. They generally have limited choices and live in crowded conditions and at times are under stress from overwork to meet contract deadlines, at the same time they are away from home. Most of construction workers are under contracts with construction companies and are covered by health insurance. They also earn higher wages and have expendable income at hand. Most workers make good use of their earnings and save for future use. Experience shows that there are some who are likely to spend money rather recklessly on alcohol, drugs and in the sex industry, exposing themselves and others to health hazards, such as alcoholism, drug dependency and STIs including HIV/AIDS. Furthermore, living in camps and eating in collective kitchens makes construction workers vulnerable to food poisoning, if stringent hygiene is not maintained in camp kitchens. 5.4 Long-term impact 5.4.1 Reservoir formation and inundation of land In time, the combination of new roads and water transportation will cut down travel time from one village to another. Experience from other projects shows that initially, soon after inundation, there will be a significant increase in aquatic life, in particular fish, because of increased amount of semi-digested vegetable matter. Once the decomposing vegetable matter reaches such heights as to consume most of the oxygen in the water, the fish starts dying. Removal of vegetable matter from the reservoir site before inundation will decrease the extent of deterioration of the water quality. Within a few years the water quality will stabilize and aquatic life regenerates, providing plenty of fish and other aquatic life for harvesting. This may provide new business opportunities for people and high protein diet for the local people. However, during the interim period, there may be need for some supplementation of proteins to the impacted populations. 5.4.2. Development of travel and tourism industry Tourism is another business opportunity that is likely to emerge. Adjacent to the project is a tourist area in Mai Chau. Trung Son reservoir is likely to become another tourist area in future, attracting both domestic and international tourists. This influx may also have its negative health impact by increasing social problems such as spread of drug use, sexually transmitted infections including HIV/AIDS and prostitution. 5.4.3 Infrastructure In addition to housing, water, sanitation and roads discussed earlier under short term impacts, the physical structures required for communications/information and transmission line distribution can be associated with multiple and long term impacts. Information technology used within the project area will bring telephone, especially cell phones, internet and telecommunication, enabling business and other services to thrive. 5.4.4 Association of health issues Acute and chronic health issues 49 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 Changes of infrastructure, resettlement of inhabitants, social changes, impacts on environment and sanitation and prospects of socio-economic development are forecast. Risk factors brought by construction workers and camp followers Cramped conditions and makeshift physical facilities for daily life, complicated relationships among construction workers and camp followers as well as with the local people are favorable conditions for diseases to emerge and spread. Most construction workers and camp followers are persons who have lived and worked far from their home for long periods compromising their living conditions. Quite contrary to the usual trend of migrant workers being a health threat to local communes with regards to STIs including HIV/AIDS, the northwest region of Vietnam, has a disproportionately high incidence and prevalence of HIV/AIDS, exposing workers to HIV infections, both through intravenous drug use and unprotected sex. A great responsibility lies with contractors to educate workers about these dangers. There are vector-borne diseases such as malaria and dengue fever and other behavioral risks such as alcohol abuse, road traffic accidents, drug addiction, violence and some zoonotic diseases, animal diseases that can be transmitted to humans from animals such as tapeworm from pig or beef to man by eating undercooked meat. According to the literature, Vietnam has some incidence of schistosomiasis in the south, the Mekong Delta. However, there is no evidence of this infection in the Northwest. Close monitoring of this disease and the intermediate host (specific snails) is essential to keep watch on the spread of the infection, especially if workers bring this disease into the area. It is necessary to examine and screen construction workers for schistosomiasis before employment. 50 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 Part 2: Health Plans for Trung Son Hydropower Project 1 Introduction 1.1 THE PUBLIC HEALTH ACTION PLAN The Public Health Action Plan (PHAP) covers Resettlement and Regional Health Plan. The plan is responsible for preventing and mitigating the adverse effects of the Trung Son Hydro Project on resettlers, recipient communities, workers and others in the project affected areas. This PHAP is the logical result of the HIA. The health needs identified under the ten national health priorities along with the primary functions of the CHCs, will be the focus of the PHAP so that a nationally applicable health infrastructure provides the primary health care at the delivery point. It is customary to consider the health needs of those being resettled, and the wider public in separate resettlement health and regional health programs. The resettlement of people in Trung Son Hydropower project is limited to a comparatively small number moving to higher ground, mostly within the same village and in no case outside the commune. The health status and health service provision for both impacted communities is exactly the same. Considering this, the two programs are joined together for this project under the PHAP. The objective of the PHAP is to strengthen the existing government health infrastructure and facilitate full implementation of the national health programs in the impacted areas to mitigate the health impacts of the Trung Son Hydropower project. The Resettlement and the Regional Health plans have common objectives, activities and time frame but with slight differences in target groups and budget. This is essential for the sustainability of the health program after the completion of the hydroelectric project. The implementation of the PHAP will be through the government public health infrastructure. For these reasons, the Government's and the PMB's health teams must work very closely during planning, implementation and evaluation. This should result in synergies, cost-effectiveness and avoid duplication. For planning purposes the Regional and Resettlement HP are used to identify the geographical areas as such defining where specific activities should take place. Each period generates its own health impacts. While identifying the EIA and their risks, the HIA looked at them separately. 1.2 THE CONSTRUCTION WORKERS HEALTH PLAN The Construction Worker's Health Plan (CWHP) is also provided in this chapter but only in its outline. The intention is to list all aspects of health required to be implemented by the main construction contractor to provide health services for all those working on the 51 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 project. The CWHP is for the use of TSHPMB in specifying the requirements in the bidding documents for the construction work. 1.3 CONSULTATION PROCESS The HIA and health plans have been developed by a taskforce in consultation with authorities of three provincial health departments and four district health centers. The stakeholders were: Village authorities District authorities District Health Offices Provincial Health Offices Development organizations active in health in Vietnam During meetings with the stakeholders the taskforce presented the likely impacts on the populations in the project area. The preliminary action plans with their proposed mitigating activities and discussions followed. The different groups reviewed and commented on the plans. Communities and other stakeholders did share their worries and proposed some supplementary activities as solutions. The PHAP has incorporated most comments and recommendations made at these meetings. The MOH officials proposed that the inputs for promotional, preventive and curative activities required for limiting and mitigating the impacts of the Trung Son hydropower project be covered by enhancing existing health programs. This includes rehabilitation, construction, provision of equipment and operational costs related to the improvements of the DHs and CHCs of the project districts. Further discussions were held in August 2009 with the provincial health authorities and the four impacted districts to ensure government health services were in agreement and were prepared to provide the full range of health services to the affected populations. A one day meeting was then held on 7th September 2009, with the representatives from the four districts affected by the construction areas and the reservoir. The meeting was organized by the TSHPMB. The national and the international health consultant participated in the meeting highlighting the possible impacts. The participants were briefed on the project and details of the construction of the dam and other project constructions. The impacted areas were again defined and districts were well aware of the impacted areas and populations. This was followed by the detailed explanation of the PHAP by local and international consultants. A question and answer session led to a healthy discussion of the project and any concerns from the districts were addressed. There was unanimous acceptance of the 52 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 program and the district officials looked forward to the implementation of the plan with support from the TSHPMB. The TSHPMB will further have an agreement of implementation of the PHAP with the two provinces under which the four districts are operating before the start of the project. This Memorandum of Understanding will have two main clauses: 1. That the provincial health center agrees to continue to provide health services through the four districts in the project area under the national health program to both resettled and regionally impacted populations 2. That the PMB provides additional resources as detailed in the PHAP to the districts enabling them to implement the plan. 2 The Public Health Action Plan The PHAP is planned to cover a ten year period. The first five years, corresponding to the construction of the dam, will address the immediate project health impacts. The second five year period will address the longer term health impacts and ensure the sustainability of improved health outcomes in the project area. 2.1 PLAN OBJECTIVES The PHAP has the following objectives for those affected by the resettlement: Prevent and mitigate health effects of resettlement Improve the health status of the resettled population Build the capacity of public health institutions for addressing their target populations' health needs It has the following objectives for those living in the project areas, who are not resettled: Prevent and mitigate adverse effects of construction and operation of the project activities on the local populations Prevent and mitigate effects of the population influx (workers & camp- followers) on the local population Improve the health situation of the local population Build the capacity of public health institutions for addressing their target populations' health needs 2.2 STRATEGIES Several strategies will be used to address the whole chain of services required for obtaining health program objectives. They are as follows: The Prevention and Mitigation activities addressing the ten national health priorities will be implemented by the MOH institutions, mainly at the DHCs and the CHCs; 53 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 The PHAP will thus support improvement of public health institutions and programs. This support will include: Capacity building, infrastructure, equipment, transport, medicine and medical supplies and operational costs. Implementation and planning of the mitigating activities will be carried out in an integrated manner for both resettled and regional populations. In order to assure comprehensive curative care, a referral system will be developed integrating the CHCs, District and Provincial Hospitals Capacity building is recognized as a major component A Monitoring and Surveillance system will collect, process, analyze, interpret and communicate data coming from different data collection systems (routine and surveys, existing and newly developed). The project area will be covered under the national "Infectious Disease Outbreak Rapid Response Preparedness" plan. A contingency fund, to be used in case of an outbreak, will be available and easily accessible. 2.3 THE PROGRAM The matrix in Table 27 provides an outline of the PHAP corresponding to the national health priorities that have been identified by MOH. Some of the national priorities have been merged because of similarities in the interventions, frequency and activities to be undertaken and additional categories have been added considering the health impacts. Detailed description including monitoring and surveillance and indicators can be found in Annex 1. 54 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 Table 27: PHAP Activities Health Issue Promotion and Diagnosis and Treatment Capacity Agencies Prevention Detection Building involved VHWs/CHC/ DHC staff Respiratory Information, IMCI for Management DOTS program, DHC & CHCs Diseases Education and respiratory of ARI IMCI, in Muong Lat, BCC on risks of infections in DOTS Laboratory skills Trung Son, ARI and TB, children program for and BCC Trung Thanh Immunizations Sputum testing TB patients and Thanh Son and contact and contact tracing tracing Vector Borne Information, Rapid test at Nationally Rapid testing and DHC & CHCs Diseases Education and CHCs and blood approved blood smear in Muong Lat, BCC on risks of smear Malaria and preparation and Trung Son, Malaria and preparation and dengue reporting Trung Thanh Dengue reporting at treatment BCC and Thanh Son DHCs regimes Sexually Information, Simple tests for Syndromic STI Syndromic DHC & CHCs Transmitted Education and common STIs approach to Approach in Muong Lat, and Blood BCC on STIs and and VCT for the treatment treatment Trung Son, Borne HIV/AIDS to HIV of common Management of Trung Thanh Diseases general public, Contact tracing STIs. HIV+ case and Thanh Son high risk groups Referral of BCC and teenagers in HIV + cases to schools the DHCs Food, Soil Information, Stool Management Management of DHC & CHCs and Water Education and examination for of dehydration severe in Muong Lat, Borne BCC on drinking parasites due to diarrhea dehydration and Trung Son, Diseases water and use of Diagnosis of and worm other diarrheal Trung Thanh latrines and types of diarrhea treatment diseases and Thanh Son fecal/oral Management of contamination parasitic infections and IMCI. BCC Nutrition and Information, Diagnosis of Prevention and Correct weaning DHC & CHCs Micronutrien Education and anemia, management practices of in Muong Lat, ts and BCC on undernutrition of infants and Trung Son, Related nutritional needs and micro- malnourished adequate food Trung Thanh Issues of Infants, Under nutrient children and intake and Thanh Son Fives, Pregnant deficiencies anemia. Prevention and and Lactating treatment of mothers anemia. BCC 55 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 Accidents, Information, Diagnosis and Shock Management of DHC & CHCs Injuries, Education and categorization of treatment patient in shock in Muong Lat, Chemical BCC on all types type of injury Stabilizing of and stabilizing Trung Son, Exposures of accidents and patient and the victim and Trung Thanh and safety fractures referral and Thanh Son Poisoning Speeding, alcohol Referral if Dos and Don'ts and other drugs required BCC Psychosocial Information, Detecting Advice and Prevention DHC & CHCs Disorders Education and psychosocial referral strategies for in Muong Lat, BCC on problems early psychosocial Trung Son, psychosocial and their problems, Trung Thanh impacts, alcohol, management and Thanh Son drugs, family violence 2.4 INSTITUTIONAL ARRANGEMENTS FOR PHAP IMPLEMENTATION This section deals with the institutional arrangements for PHAP implementation, including assigning responsibilities, coordination with other programs and budgets. 2.4.1 Critical preconditions for success The following are critical factors for the success of the PHAP: The district and provincial health services ensure that the CHCs staffing in the project area will meet the national guidelines set for the country. Training for CHC and MCH district hospital staff takes place and ensures they meet required standards. This includes the selection of the participants, the targeted content of the training and the methodology which should be as participative as possible. Retention of staff trained by the programs in the project districts and communes. Health service providers are able to communicate, if necessary in minority languages, with the resettled and other impacted communities. The preparation work (construction, rehabilitation, equipment, trainings) for the improvement of the health institutions is finished before the commencement of the works and influx of workers. The Primary Health Care (PHC) program, including Maternal and Child Health (MCH), is fully implemented in the project area. The project area continues to get support on the Extended Program of Immunization, Family Planning, Condoms, STIs and HIV/AIDS and the Tuberculosis Control Program from the existing support organizations. The health and environmental regulations (sanitation, food hygiene, dengue control, waste management, dust control, etc.) are developed and respected by the contractors, the workers, the camp-followers and the local communes. 56 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 2.4.2 Organization and Reporting The organizational functioning of the PHAP and reporting relationships between the main entities is illustrated in Figure 1. The functioning of the PHAP will be largely the responsibility of the District health services with the overall guidance and support from the provincial health services. The TSPMB will provide the agreed resources through the PHMT, for the implementation of the PHAP. The PHMT will support the facilitators at all levels to ensure that health plan implementation takes place seamlessly. Figure 1: PHAP Organization Organization Flow Chart Project Management 3 Provincial Hospitals Board District CWHP PHMT Hospitals DHCs Facilitators Clinic Commune Health Centers Safety Preventive Impacted Villages/Communes CWHP Construction Worker's Health Program PHMT Project Health Management Team DHCs District Health Centers The PHAP is a comprehensive approach to the process of mitigation in an impacted population. The experience from similar programs elsewhere suggests that a separate team is required to achieve the objectives of the program. A team with public health skills and knowledge of the national health care delivery system is essential to implement the PHAP in the project area. The team will also require an expert in public health with experience in Health Impact Assessment and implementation of the Public Health Action Plan, to support and advise the PHMT in implementation of the health plan. The scope of work and the mandate of the PHMT are detailed in Annex 2. 2.4.3 PHAP Steering Committee A PHAP steering committee will be established to monitor the progress of the PHAP. The Committee will be responsible for overseeing the project progress together with TSHPMB. Membership of the steering committee will be as follows: 57 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 Directors of three Provincial Departments of Health (one chairs the committee) TSHPMB senior representative possibly Health & Safety Officer TSHPMB coordinator/PHMT leader Representatives of four District People's Committees Four District Health Officers. The health facilitators from the project area 2.4.4 Trung Son Hydropower Project Management Board Planning, coordination, management and supervision of the PHAP will be assured by PHMT within the TSHPMB. The PHMT office will be based in the main construction site offices where it can effectively operate between impacted populations and districts providing health services. The PHMT will regularly report to the Project Steering Committee. The TSHPMB, through PHMT, will provide technical assistance to public health institutions for both overall coordination and for implementation of specific activities of the PHAP. At each of the District Health Offices one health worker will be selected to serve as a facilitator to the PMB health coordinator. Together they are responsible for coordinating and reporting on PHAP activities implemented at various levels. The TSPMB will be responsible for setting up and financing the PHMT to assist the government health infrastructure in the implementation of the PHAP. The scope of work, the health team and the budget is detailed in Annex 2. Most health promotion, preventive and curative services are provided by the CHCs supported by District Health Centers (DHCs) and District Mobile Teams. Support, supervision and inspection activities will be the responsibility of DHCs, the Provincial Health Office (PHO) and for specific aspects (including technical assistance) the Ministry of Health through its central support departments. The planned training activities will be conducted by several institutions at provincial and district hospitals. 2.4.5 District Health Centers/Offices The district health services are responsible for the provision of primary and secondary health care to the population. The district health office is responsible for equipping the CHCs, providing training, support and supervision to the CHCs. PHMT will provide the required support to the district health offices. 2.4.6 Commune Health Centers The resettled communities will be moving in their own original groups and CHCs will move with them where applicable. It is expected that most CHCs and staff will remain functional and will continue to provide health services to their assigned populations. However, where the new CHC will have to be built, it will be an opportunity to provide all essential components and have a purpose built facility for the resettled population. The CHCs must provide the following functions: 58 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 Develop active community participation through Commune People's Committee Provide capable and motivated personnel speaking the local language Provide technical, administrative, management and monitoring systems Conduct family census and introduce family files Provide required infrastructure and functioning (buildings, water, sanitation electricity) Provide a steady supply of medical and non-medical consumables Provide required medical and non-medical equipment Provide transport for outreach activities and transfer of patients Provide operational funds Assure adequate support and supervision by DHC The CHCs in areas of relocation and other impacted areas will require essential refurbishment. Staffing of the CHCs The staffing of the CHCs in the impacted area is variable. On average each CHC has four staff, with numbers ranging from 1-6. Uniform distribution of health staff in CHCs will be a priority. Most of the CHCs have medical assistants or nurses. Midwives are few and not well distributed. Each CHC in the impacted areas must have at least three health workers and must include at least one midwife. 2.4.7 International Support to National Programs Most national health programs implemented in the project area are already receiving support from different international organizations. Health programs such as the Tuberculosis Program, the Expanded Program for Immunization and the Family Planning Program will be implemented with assistance from existing support organizations including UNICEF, UNFPA and the Global Fund. Table 2 sets out the supporting organizations and their role. Table 28: Support to National Health Programs by International Organization Vertical Program Supported Organization Major Support Extended Program of WHO, UNICEF, GAVI Financial and technical Immunization Malaria Control Program Global Fund Financial and technical Tuberculosis Control Program Global Fund Financial and technical Reproductive Health UNFPA Financial and technical STI & HIV/AIDS control World Bank, DFID, Financial and technical Program Global Fund Maternal and Child Health UNICEF, UNFPA Financial and technical The PHAP will depend on some of these inputs. For reasons of standardization, continuity, feasibility and economies of scale, it is essential that supports like anti- 59 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 tuberculosis drugs, condoms and family planning medicine continue to come from these organizations through district health administration. 2.4.8 National Mass Organizations Mass movement organizations such as the Vietnam Women's Union and the Vietnam Youth Union will be involved under DHC coordination, in promotional and preventive activities. 2.5 BUDGETS AND FINANCING Under the national health insurance, all villagers are covered irrespective of being in the project or non-project area. CHC staff will be expected to assist those who lack health insurance in obtaining it. Some additional services will be provided as detailed later in the Public Health Action Plan. This issue is detailed in RLDP and EIA/EMP reports of the project as required by the Bank and consists, but not limit, to the following: Organization and implementation of services to the impacted populations in the project area; A program of capacity building for health staff in village, commune and district levels Assistance with the essential equipment in impacted districts and the commune health centers to improve primary health care. Investment in Infrastructure Improvement Plan This plan will concentrate on building the new CHC at Trung Ly including provision of equipment and human resources for the health center and strengthening the capacity of local health staff through short training courses. Rebuilding Of Trung Ly CHC Under TSPMB funding, building of a new CHC in Trung Ly commune will be the first health infrastructure project. The location of the CHC will be decided by investor and the commune people's committee. Existing health staff and equipment from the old health center will be transferred to the new CHC. Any items missing for a functional health centre will be procured. 60 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 TABLE 29: PUBLIC HEALTH ACTION PLAN ­ BUDGET IN USD Construction Phase (2010-2014) Operation Phase (2015-2018) Total Health Functions Resettlement Regional Total Resettlement Regional Total $US % Health Health Health Health Program Program Program Program Upgrading Commune Public Health Health Infrastructure Center 30,000 21,000 51,000 8,000 14,000 22,000 73,000 10 Medical and other Equipment 15,000 30,000 45,000 2,000 15,000 17,000 62,000 9 Health Awareness Education & Programs Awareness Programs 50,000 80,000 130,000 50,000 80,000 130,000 260,000 37 Strengthening Human Human Resource Resources in Development Public Health (Training) 20,000 35,000 55,000 20,000 35,000 55,000 110,000 16 Public Health Supervision Monitoring and and Monitoring Surveillance (Per diems and allowances) 10,000 15,000 25,000 10,000 15,000 25,000 50,000 7 Equity Fund 2,000 4,500 6,500 2,000 4,500 6,500 13,000 2 Contingency 35000 65,000 100,000 12,000 20,000 32,000 132,000 19 Total 162,000 250,500 412,500 104,000 183,500 287,500 700,000 100 61 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 2.6 MONITORING AND SURVEILLANCE Surveillance and monitoring (S&M) is an integral and essential part of the PHAP. The importance of a well established and functioning S&M system cannot be overemphasized in providing crucial information on emerging health problems and indicates when, how and where to intervene. In the broader sense, it is a tool for health authorities to guide the investment of the resources available and allows measuring of efforts undertaken by government to mitigate adverse health outcomes - a most important PHAP activity. Information collection can be very complicated if too much is collected but only a little used. Moreover, it is the grassroots workers who face the burden of data collection so, where possible, it should be limited to routine data collection in an institution. If properly used, this data can provide high quality of information. 2.6.1 OBJECTIVES The objective of S&M is to provide health information on people affected by the TSH project and to assess and quantify progress of public health actions. Therefore, regular and systematic collection, analysis, interpretation and dissemination of information on health, disease risk factors and public health actions are mandatory. The information collected must be available in a timely manner to health authorities and PHMT to facilitate adequate responses to emerging diseases and health risks. 2.6.2 STRATEGIES The following strategies will be implemented: 1. Capture all routinely collected data in a systematic manner at regular intervals 2. Help grassroots workers understand the need for data collection and periodically provide feedback 3. Appropriate support for those who collect and collate the data to improve the quality of data collected 4. Initiate and implement appropriate response interventions. 5. A well defined list of indicators helps in accumulating good data 2.6.3 Data Requirements Each of the seven major health areas to be implemented as described in Annex 1 includes a table of indicators. These indicators provide the type of information required to monitor the activities of the PHAP. Regular review of this information will bring home the positive and negative impacts of the project. Data collection will be based on routine reporting and collected and monitored by the DHCs. They will share data with PHMT at TSHPMB for PHAP monitoring purposes. 2.7 CAPACITY BUILDING AND TRAINING Capacity building is another important aspect of the PHAP. The strengthening of existing health workers under the national health program will require regular updating and refresher programs to ensure the PHAP is implemented in its entirety. The training areas set out in Table 3 will be implemented. Training of trainers will be essential before the training programs for the Health workers. Financial support, as required for consultants to provide the training, will be provided by TSPMB. Table 30: Training Needs of Health Workers No. Training Area Trainee Trainer Expert Technical Support Subject area to be covered 1. Maternal and CHC staff District To be able to implement the Mother ­ ANC, PNC, supervised Child Health and health PHAP effectively, the PHMT skilled delivery, management of services VHWs office will require technical support complications of pregnancy, family in a number of areas: planning and prevention of STIs Child ­ Growth monitoring, nutrition 1. Initial training of trainers advice to mothers and immunizations 2. Respiratory CHC staff District for one week for all staff Integrated Management of Childhood Diseases and health involved in the PHAP Diseases including acute respiratory VHWs office infections of young children 2. Regular remote support for DOTS for Tuberculosis control 3. Sexually CHC staff District any queries and advice Awareness of sexual transmission of Transmitted and health STIs including HIV/AIDS and Infections (STIs) VHWs office 3. Base Line Survey: intravenous drug abusers. including Planning, sampling, Understanding of preventive HIV/AIDS questionnaire, training, measures data analysis and report Syndromic approach for treatment of writing. STIs 4. Vector-borne All health District Prevention strategies and appropriate diseases and workers and 4. Monitoring & Evaluation: diagnostic and treatment protocols vector control provincial Monthly review of reports for malaria, dengue (DF, DHF, DSS) staff (remote) and one annual and other diseases with fever as review on site for one presenting argument. Dengue vector week. control, including use of insecticide and spray equipments in case of 5. Advice on addressing and outbreak. responding health issues raised by monitoring missions. 6. Any other technical support. NB: Initially, during the first year, this support is required as listed above. In subsequent years the support will depend upon the progress of the project. It is anticipated that the support will gradually decline to minimal by the end of the construction phase. 5. Soil and water CHC staff District Prevention strategies, appropriate borne diseases and and diagnostic and treatment protocols VHWs provincial for water and soil borne diseases. staff Prevention strategies for water borne diseases including preschool and 63 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 primary school program of biannual worm treatment. 6. Accidents/injuries/ CHC staff District Prevention strategies and appropriate exposure to and and diagnostic and treatment protocols hazardous VHWs provincial for emergency/small surgery, materials staff infection control and nursing practices. Appropriate referral system for major injuries and accidents 7. Psychosocial CHC staff Provincial Awareness and support for impacts and staff psychosocial problems in the VHWs impacted populations due to relocation. Psychosocial issues related to HIV infection 8. Health information Health Provincial Training on importance of data systems workers at staff collection and its effective use. commune and district level 9. Health CHC staff Health General management of Drug management and workers at Revolving Fund, including cost district district recovery system. Management of HC level and (DRF management, planning e.g. provincial EPI. Village drug kits management. level Training willfroma part of the continuous program of PHAP and will be divided into three parts, initial and ongoing training programs and monitoring the implementation of the PHAP. 2.7.1 Initial Training Program Initially there will be a need for training to all CHC and DH staff. This will be carried out through a comprehensive training to explain the health impact on the impacted population and the implementation of the PHAP. The role of the government health workers at CHCs and the DHs in the PHAP and the relation with the PHMT of TSHPMB will be discussed and explained. Input in this training program from the public health expert will be essential. Various programs with in the PHAP will be discussed and explained. This will be in accordance to the existing national health priorities. 2.7.2 Training Program During the implementation of the PHAP, a continuous program of in-service training will be continued so that health workers are guided in the effective implementation of the program. This will also include participation in the monitoring system and sharing of results and improvements. Wherever possible, the training programs will be merged with the district and provincial training programs to avoid duplication. 2.7.3 Surveillance and Monitoring 64 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 The surveillance and monitoring program will be an important part of training program for health workers and encourages ownership of the program. All findings of the surveillance and monitoring programs will be shared with the health service providers so that they can see the results of their efforts and change strategies where further actions are required. 2.8 SERVICE PROVIDERS 2.8.1 Commune Health Centers Essentially the implementation of the PHAP to the impacted populations will start at the CHCs. The planned activities are listed in eight groups, seven for each Environment Health Assessment (EHA) and one for support to the public health institutions and programs. They are described in detail in Annex 1. The grouping by health impacts results in some repetition of activities. It does however allow for cross-reference with the EHAs of the HIA and simplifies verification that all possible adverse effects are covered by prevention and/or mitigation activities. Each EHA is discussed under following headings: 1. Prevention and Promotion 2. Diagnosis and detection 3. Treatment 4. Capacity Building 5. Monitoring and Surveillance 6. Specific Inputs 7. Disease Indicators 2.8.2 District and Provincial Hospitals The district and provincial hospitals will play an important role as referral hospitals. The CHCs will refer patients to the district hospital and district hospital will send complicated cases to the provincial hospital for treatment. District hospital will also supervise the activities of the CHCs and provide support in the implementation of the PHAP. 65 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 3 Construction Worker's Health Program The Workers' Health Program (WHP) should include provision of primary health care and standard safety measures in construction projects. In addition to the international safety requirements, the WHP will also include preventive measures to contain and control public health problems such as alcohol and drug abuse and sexually transmitted infections. WHP will be the responsibility of the contractors managing the project. The program will have a close working relation with the PHMT and the local government health infrastructure for referral to hospitals for any emergencies, including accidental injuries, and for consistency in the national health programs. Under health and safety regulations, the contractor shall at all times take all reasonable precautions to maintain the health and safety of personnel. In collaboration with local health authorities, the contractor shall ensure that medical staff, first aid facilities, sick bay and ambulance services are available at all times at the site and at any accommodation. Suitable arrangements are also necessary for welfare and hygiene requirements and for the prevention of epidemics. 3.1 The Management of WHP The overall management of the WHP is by the Health and Safety Officer reporting to the site manager. A medical doctor, preferably an occupational health specialist, will report to the Health and Safety Officer to manage day to day health service provision for the workers in the project. He will be assisted by an occupational nurse and other medical assistance that may be required according to the number of major sites of construction in the project. 3.2 First aid facilities A fully functional health centre needs to be established in a central location where project personnel receive primary health services for day to day medical needs and minor injuries. This centre also provides a location for all administrative responsibilities of the WHP. The centre should be open during working hours as well as provide 24 hour service through out-of-hour rota for emergency health needs. 3.3 Medical Staff The contractor is also responsible for the medical staffing of the health facility. A qualified medical officer, with knowledge of occupational health and common health problems associated with workers should be hired to coordinate all health services. The doctor should be supported by an adequate number of staff for major construction locations within the project area and work under overall guidance of the Health and Safety Officer. 3.4 Ambulance service A well maintained ambulance should be available at all times for emergencies and evacuation from the site to the hospital where treatment is provided. This could also be 66 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 arranged with the local ambulance services with special arrangements for emergency service provision to the TSPMB. 3.5 Preventive Health Services A number of preventive health services will be required under the workers health program. Hygiene and Sanitation: Suitable arrangements for workers' welfare and hygiene are made in both the work site as well as their residential quarters for the prevention of communicable diseases and outbreak of epidemics. STI Prevention: The Contractor shall conduct an STI and HIV/AIDS awareness programme via an approved service provider, and should take all specified measures in the contract to reduce the risk of the transfer of infections. Early diagnosis and assistance of affected individuals should be prompt. Contact tracing should be an important aspect of STI prevention. Accident Prevention: The Contractor must also take all measures to prevent accidents both at construction sites and on roads where vehicles are plying in the project area. This would include, in addition to education and awareness of misuse, strict rules and regulations to be in place about the use of alcohol and other recreational drugs which enhance the likelihood of accidents. Incident Management Plan Any major accident at the construction site or on the access roads involving life threatening injuries to workers will be required to be addressed through an Incident Management Plan. The contractor will have clear procedures in coordination with the health and safety officer in the event of such a disaster. The Contractor shall throughout the contract (i) Conduct Information, Education and Communication (IEC) campaigns, at least every other month, addressed to all site staff and labor (including truck drivers and delivery crews) and the immediate local communities concerning the risks, dangers and impact, and appropriate avoidance behavior with respect to STI in general and HIV/AIDS in particular. (ii) Have an orientation program for new employees before they start working for the company. (iii) Health education and awareness periodically at events such as the World AIDS Day. (iv) Provide male / female condoms for all site staff and labor as appropriate (v) Provide for STI and HIV/AIDS screening, diagnosis, counseling and referral to a dedicated national STI and HIV/AIDS services for all site staff and labor. 67 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 Reporting health, safety and welfare Reports of accidents and general reports on illnesses workers suffered during a defined period of time as well as fatal accident reporting and trends over the construction period will be an essential part of record keeping. The Construction Workforce It is estimated that a maximum of 4000 workers will be required for the construction work. The numbers will fluctuate as the intensity of the work picks up rising to a maximum around the second and third year of construction. During the later part of the third year and fourth year the number of workers will start declining as the project construction approaches completion. Objectives of the Project Staff Health Program Include: Ensure preventive and curative measures to safeguard health and safety of workers and their families To prevent and mitigate negative health effects due to construction works and the influx of project staff on the local population Project Staff Health Program Covers: - The essential medical services provided as well as the service organization - The medical facilities which provide these services - How project workers are declared fit to work - Safety measures taken to prevent diseases and accidents and the medical treatment required - Monitoring of health services through a well defined reporting system. Health Center for Construction workers A 5 bed health facility fully equipped to provide emergency medical care to stabilize emergency patients before they can be referred to district or provincial hospital Essential medical equipment for the centre to provide emergency care A plan for medical evacuation of life threatening illness or injury Short term care of patients requiring hospitalization Isolation room (one bed) for any infectious disease patient (in epidemic situations, district and provincial facilities will have to be used) MOU with local district and provincial hospitals for treatment of construction related admissions to the hospitals and emergency evacuation. If workers are living at more than one site, a make shift clinic will be required for each site to attend to an emergency before transfer to a secondary or tertiary health facility. There will also be need to have a first aid post at major sites where sizable number of people are working at a point in time, such as dam site and the powerhouse. 68 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 The Strategy The Strategy is expected to provide a level of protection that enables the project to be executed in a safe medical environment. It must consider: - Screening of all workers on recruitment and annually - Recruitment of trained health personnel to support the project - Preventive measures taken against health hazards - Regular training and awareness information for all workers about common health problems - Training of some workers in first aid rescue, emergency medical evacuation and in occupational health - Monitoring of health indicators to follow the trends Disease Prevention and Health Promotion In view of the environment and some of the health problems in the project area, specific preventive measures must be in place to educate and make workers aware of measures required for self protection: 1. Respiratory diseases ­ dust and chemical exposures, 2. STIs, including HIV/AIDS ­ treatment of STIs and supply of free condoms for prevention of infection 3. Vector borne diseases, especially malaria and dengue ­ mosquito proofing of sleeping quarters or universal use of impregnated bed nets; camp sites to be free of vector breeding sites. 4. Water and food borne diseases ­ through safe drinking water and hygienic eating places. 5. Proper waste disposal ­ toilets and general waste disposal system. 6. For the worker's safety o Procedures in case of emergencies o Safety regulations and adequate supply of safety equipment o Occupational health recommendations o Rules and regulations for prohibitions including drugs and alcohol o Company road traffic rules for speeding and driving under intoxication. 4 CONCLUSION The Trung Son Hydroelectric Project will be an environmentally friendly and sensitive program. The health needs of the impacted people will be addressed through the Public Health Action Plan, which has been developed from a comprehensive Health Impact Assessment exercise as described in this document. The health service provision will exclusively be provided by the existing government health infrastructure in collaboration with the TSPMB. The role of TSPMB will be to strengthen the government health infrastructure by supporting the national health programs in the project impacted area, both in technical and financial aspects of the identified needs of the impacted population. The program will also lead in monitoring the health of the people continuously, using 69 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 identified indicators of health, the so that improvements in health are ensured and reported. The TSPMB will also provide fully financed and functional CWHP for the project workforce, with the backup from the government infrastructure for referral for secondary health care. The CWHP will have both curative and preventives aspects and all necessary safety measures incorporated into the program. 70 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 References 1. V K hoch, B Y t, Báo cáo nghiên cu hot ng ca TYT xă; 2002. (Department of Planning, Ministry of Health, Report on health care at commune health center, 2002) 2. V K hoch B Y tê, Báo cáo ánh giá thc hin các chng tŕnh mc tiêu quc gia 2000-2005 và k hoch 2006-2010 (Department of Planning, Ministry of Health, Report on the implementation of national health programs 2000-2005 and plan for 2006-2010) 3. Báo cáo iu tra Y t Quc gia 2002 (National health servey report, 2002) 4. B Y t. Niên Giám thng kê y t 2006 (Minsitry of Health, Health statistics year book, 2006) 5. Báo cáo nm 2007 và k hoch nm 2008 ca Trung tâm Y t d pḥng huyn Mai Châu (Annual report 2007 and plan for 2008 of Mai Chau preventive medicine center) 6. Báo cáo t́nh h́nh thc hin công tác y t 12 tháng nm 2007 và phng hng nhim v nm 2008 huyn Quan Hóa (Annual health report 2007 and directions for 2008 of Quan Hoa district) 7. Báo cáo kt qu công tác y t d pḥng nm 2007 ca Trung tâm y t d pḥng huyn Mc Châu (Report on preventive medicine 2007 of Moc Chau preventive medicine center) 8. Báo cáo kt qu công tác y t d pḥng nm 2007 ca Trung tâm y t d pḥng huyn Mng Lát (Annual preventive medicine report 2007 of Muong Lat preventive medicine center) 9. Báo cáo ánh giá tác ng Môi trng (Assessment report on environment impact) 10. Báo cáo Quy hoch tng th di dân, tái nh c (Report of comprehensive resettlement master plan) 11. Báo cáo tng kt công tác y t xă Xuân Nha nm 2007 (Annualy health report 2007 of Xuan Nha commune) 12. Báo cáo tng kt công tác nm 2006, phng hng nhim v nm 2007 ca xă Trung Lư (Annual healt report 2006 and directions for 2007 of Trung Ly commune) 13. Báo cáo tng kt công tác nm 2007, phng hng nhim v nm 2008 ca xă Thành Sn (Annual healt report 2007 and directions for 2008 of Thanh Son commune) 14. Báo cáo tng kt t́nh h́nh kinh t-xă hi, an ninh, quc pḥng nm 2007 phng hng nhim v nm 2008 ca xă Phú Thanh (Report on socio-economics, security and defense 2008 of Phu Thanh commune) 71 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 15. Báo cáo tng kt t́nh h́nh kinh t-xă hi, an ninh quc pḥng nm 2007, phng hng nhim v nm 2008 ca xă Vn Mai (Report on socio-economics, security and defense 2008 of Van Mai commune) 16. Báo cáo tng kt t́nh h́nh kinh t-xă hi, an ninh quc pḥng nm 2007, phng hng nhim v nm 2008 ca xă Tân Xuân (Report on socio-economics, security and defense 2008 of Tan Xuan commune) 17. Quy nh v bi thng, di dân, tái nh c (Regulations on conpensation and resettlement) 18. Song Bung 4 Hydropower Project Social Mitigation Plan 19. Human health and dams: The World Health Organization's submission to the World Commission on Dams 20. Quyt nh s 3653/Q-BYT ca B trng B Y t ngày 29/9/2004 (Decision No 3653/QD-BYT dated September 29, 2004 of Minister of Health). 21. Ngh nh 171/2004/N-CP và 172/2004/N-CP, ngày 12/4/2005 (Decrees No 171/2004/ND-CP and 172/CD-CP dated April 12 2005 of Prime Minister) 22. Thông t 11/2005/TTLT-BYT-BNV xác nh mô h́nh t chc y t mi tuyn huyn bao gm Bnh vin a khoa huyn (Circular N0 11/2005/TTLT-BYT-BNV of Ministries of Health and internal affair on organizational structure of district level. 23. Ngh nh 01/1998/N-CP v H thng t chc y t a phng và Thông t liên B 02/1998/TTLT-BYT-BT CCBCP hng dn Ngh nh 01/1998/N-CP (Decree No 01/1998/ND-CP on local health organization and Circular No 01/1998/TTLB-BYT-BTCCBCP on the implementation of the Decree) 24. Quyt nh s 71/2001/Q-TTg ngày 4/5/2001 ca Th tng Chính ph v các chng tŕnh mc tiêu y t quc gia (MTQG) giai on 2001 ­ 2005 (Decision No 71/2001/QD-TTg dated May 4, 2001 of the Prime Minister on national health programs for 2001-2005 period) 25. Chng tŕnh quc gia pḥng chng HIV/AIDS (National HIV/AIDS prevention and control program) 26. Chng tŕnh quc gia pḥng chng Lao (National Tuberculosis prevention and control program) 27. Chng tŕnh quc gia pḥng chng st rét (National Malaria prevention and control program) 28. Chng tŕnh quc gia pḥng chng ri lon do thiu iod (National Goitre prevention program) 29. Chng tŕnh quc gia pḥng chng tai nn thng tích (National traffic accident and injury prevention program) 30. Chng tŕnh chm sóc sc kho sinh sn (National reproductive health program) 72 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 31. Chng tŕnh quc gia pḥng chng suy dinh dng tr em (National malnutrition prevention program) 32. Chng tŕnh v sinh an toàn thc phNm (N ational food safety and hygiene program) 33. Chng tŕnh tiêm chng m rng (N ational expand program of immunization) 34. Chng tŕnh quc gia bo v sc kho tâm thn cng ng (N ational community mental health care program) 35. S Y t Sn La. Báo cáo tng kt ngành y t Sn La, 2007 (Son La provincial health service, Annual health report 2007) 36. S Y t Sn La. Phng án y t im di dân tái inh c(Son La provincial health service, Plan for resettlement) 37. UN ODC. Báo cáo Hin trng Vit N am: ti www.unodc.org/pdf/vietnam/country_profile_vietnam.pdf; 2005. (UN OCD, [Vietnam Country Profile], 2005) 38. UN ODC. Báo cáo ma tuư th gii 2006, Tp 2: S liu thng kê [2006 World Drug Report, Volume 2: Statistics]. Vienna: UN ODC; 2006. 39. Household Living Standards Survey 2006. General Statistics Office. Published in 2007. 40. WHO website on HIA 41. N TPC Health Checks and Survey. www.namtheun2.com 42. N TPC Health Impact Assessemnt and Public Health Action Plan www.namtheun2.com 73 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 ANNEX 1: PUBLIC HEALTH ACTION PLAN 1. RESPIRATORY DISEASES Promotion and Prevention -Behavior Change Communication (BCC) on prevention and management of ARI and Tuberculosis requires development. So does providing of adapted materials and implementation of the national EPI program at the institutions and through outreach. -Ensure that design of new housing constructed in resettlement areas has a separate ventilated kitchen area. Diagnosis and Detection The CHC staff is familiar with the Integrated Management of Childhood Infections (IMCI) to treat acute respiratory infections in children. They must: -Ensure a proper sputum sample is collected from a suspected case and sent to the district TB lab for examination and reporting. -Ensure the district hospital laboratory handles this work in keeping with national standards. -Conduct contact tracing of all patients diagnosed with active TB through visits to the patient's village to interview and examine family members and close relatives Treatment -Follow the DOTS treatment at CHC level with support from the DHCs -Assure treatment of ARIs in children under the IMCI schedule through the CHCs and the DHCs Capacity building Capacity building of health care providers of all the communes in the project area is required: N ational DOTS program (promotion, prevention, treatment, monitoring, program management) Required laboratory skills Behavioral Change Communication Provide training for VHWs regarding appropriate diagnostic and treatment protocols for respiratory diseases (IMCI) in children Monitoring and Surveillance -Supervise compliance with diagnostic and treatment protocols for respiratory diseases (tuberculosis, respiratory infections) -Ensure that Quality Control of laboratory examinations at the District Hospital takes place periodically -Conduct a KAP survey at the beginning of the operation including issues on ARI and Tuberculosis. -Assure monitoring and surveillance of respiratory health covering ARIs and TBC Specific Inputs Anti-Tuberculosis Drugs (N ational TB Program under Global Fund) Microscope and laboratory consumables for examination in District Laboratories Operational cost for training and outreach activities related to the TB Control Program. Vaccines and consumables for EPI Respiratory Disease Indicators Indicators Sources N umber of new Lower Respiratory Tract Infection (ARI) cases N umber of deaths due to ARI N umber of newly diagnosed cases of TB N umber of deaths due to TB Routine data N umber of measles cases collection N umber of diphtheria cases N umber of whooping cough cases Activity Indicators Proportion of persons trained in relation to number planned: N umber of BCC activities by target group N umber of pharmacists trained in correct ARI treatment Routine data N umber of active contact tracings done for TB patients collection N umber of positive contacts treated N umber of CHC in target areas offering DOTS N umber of patients having sputum collected at CHC level N umber of resettlement houses with good ventilated kitchen 2 VECTOR-BOURNE DISEASES Promotion and Prevention -Conduct education programs regarding the prevention and treatment of malaria and dengue -Conduct village campaigns supporting the elimination of dengue larvae breeding grounds -Conduct education campaigns annually on prevention and treatment of malaria, more specifically on the use of Long-Lasting Impregnated Bed N ets (LLIBN ) -Assure 100% coverage to all impacted villages through provision and replacement of LLIBN -Develop and implement waste management plans for all resettlement villages Diagnosis and Detection Assure malaria testing at CHC and DHC level (rapid test and/or microscopy) Treatment -Assure adequate malaria treatment at CHC and DHC level -Assure adequate referral to district hospital of suspected dengue patients for treatment Capacity Building Training for health care providers regarding prevention strategies and appropriate diagnostic and treatment protocols for malaria, dengue and other diseases with fever should be done on a needs basis. Capacity building for health care providers should include the following 75 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 N ational malaria and dengue control programs (promotion, prevention, treatment, monitoring, program management) Required laboratory skills Behavioral change communication Monitoring and Surveillance -Conduct quality controls for laboratory examinations -Supervise compliance with established medical diagnostic and treatment protocols for malaria, dengue and other diseases accompanied by fever Specific Inputs Rapid test for malaria detection Operational costs for malaria blood slide examination quality control Long Lasting Impregnated Bed N ets Operational cost for distribution of LLIBN Some inputs for malaria control activities are provided by other funds such as the Global Fund. There should be detailed planning during implementation to avoid possible duplication. These inputs are conditional to renewal of the Global Fund country program. Vector-borne Disease Indicators Malaria disease indicators Sources N umber of malaria cases by type N umber of deaths due to malaria Routine Data N umber of blood smears or rapid tests done Collection N umber of malaria negative fever cases N umber of pregnant women with malaria N umber of malaria outbreaks Dengue disease indicators N umber of suspected dengue cases N umber of hemorrhagic dengue fever (DHF) cases N umber of deaths due to dengue N umber of dengue outbreaks Other disease indicators N umber of cases of leptospirosis and typhus Prevalence of schistosomiasis, and opistorchiasis Activity indicators Proportion of staff trained per subject in relation to training plan Routine Data Village cover with BCC sessions on malaria and dengue Collection prevention Village cover with BCC sessions on typhus and leptospirosis prevention Household coverage of LLIBN Coverage of dengue outbreak villages by spraying Village cover for treatment of Aedes breeding sites 76 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 N umber of blood transfusions for dengue or malaria 3 SEXUALLY TRANSMITTED AND BLOOD BORNE INFECTIONS Promotion and Prevention -Provide and implement BCC programs regarding STI/HIV-AIDS and prevention strategies (including provision of IEC materials) -Implement comprehensive school-based drug abuse, HIV/AIDS and sex education program -Implement the national guidelines/policy for the control of blood-borne pathogens (proper disposal of sharps, autoclave equipment, in-house medical waste collection, storage and destruction) -Implement Hepatitis B vaccination of children through the national EPI program (DTP + Hep B) -Provide condoms free of charge and educate regarding proper use and disposal, targeting high risk groups. Diagnosis and Detection Campaign on HIV voluntary counseling and testing (VCT) program especially for high risk individuals such as intravenous drug users Treatment -Provide syndromic approach treatment for STIs through the DHCs -Advice to suspected cases and high risk groups to go to DHCs for testing and therapy Capacity building -Educate concerned workers regarding hazards of medical waste handling and use of appropriate personal protective equipment. -Provide training for public health service providers (and private pharmacies) regarding prevention strategies, and appropriate diagnostic and treatment protocols for STI and HIV/AIDS -Capacity building for health care providers after needs assessment in the following domains: N ational HIV/AIDS and STI program (promotion, prevention, treatment, monitoring, program management) required laboratory skills HIV counseling - Behavioral Change Communication Monitoring -Supervise compliance with blood borne pathogens/infection control program -Supervise compliance with established medical diagnostic and treatment protocols for curable STI's -Monitor blood borne pathogen exposure accidents Specific Inputs DPT-Hepatitis B vaccines Condoms, VCT, ARVs 77 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 Financing for school-based education programs Financing education programs for high risk groups Some inputs required for the HIV/AIDS and STI control program are funded by special national programs (Global Fund and WB projects). During implementation detailed planning should avoid possible overlapping or gaps and coordinate activities. Sexually Transmitted and Blood Borne Infections Disease Indicators Sources N o. of different STI syndromes diagnosed N o. of new HIV infections N o. of mother-to-child HIV transfers Routine Data N o. of HIV/AIDS cases (total) Collection N o. of HIV/AIDS patients on treatment N o of patient deaths from AIDS Activity indicators Proportion of persons trained in relation to planned trainings STI correctly treated STI treatments in health facilities N umber of BCC activities by target group (sex workers, drivers, workers, Routine Data schoolchildren) Collection Condom use by target group (sex workers, drivers, workers, secondary schoolchildren) Proportion of health institutions with correct waste management 4 FOOD, SOIL AND WATER BORNE DISEASES Promotion and Prevention -BCC on drinking water systems, treatment of water and family latrines based on the MOH water and environmental sanitation program (including the provision of health education materials) -BCC programs regarding fecal/oral transmission of diseases, and transmission of helminthic diseases (opisthorchis, trichinosis, cysticercosis, ascaris, pinworm, etc.) ---- Ensure people are using latrines for defecation and in a hygienic way -Provide safe domestic water sources to all resettled villages -Provide safe domestic water sources for all impacted populations in the project area -Include deworming for children aged 2-6 during the integrated PHC activities -Introduce and implement the school deworming program Diagnosis and Detection Ensure laboratory diagnostic capabilities required for diagnosing food, water, and soil borne infections at district hospital level Treatment Ensure HCs and DHs have correct treatment available for food, water and soil borne diseases Capacity Building 78 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 Capacity building of health care providers should be considered in the following domains based on needs: N ational water supply, sanitation, food hygiene and Control of Diarrheal Diseases Programs (promotion, prevention, treatment, monitoring, program Management) Required laboratory skills -Behavioral Change Communication Training should include prevention strategies, appropriate diagnostic and treatment protocols. Monitoring and Surveillance -Supervise compliance with established medical diagnostic and treatment protocols for food, water and soil related diseases -Monitor prevalence of water, food and soil borne infections through routinely collected data -Test water quality in villages receiving new wells for domestic water at time of handover and later, annually. -Monitor water quality of surface and ground water in the impacted area Specific Inputs Construction of latrines Construction of domestic water-sources Landfills BCC for food handlers School deworming program Operational costs for water quality inspections Food, Soil and Water borne diseases s: Disease Indicators Sources N umber of cases of acute diarrhoea N umber of cases of dysentery N umber of deaths due to acute diarrhoea Routine Data N umber of outbreaks of food or waterborne borne diseases Collection N umber of cases of opisthorchis (not treatable by conventional deworming with mebendazole or albendazole ­ required prazaquintal treatment) N umber of Hepatitis (A) cases Activity indicators Proportion of persons trained in relation to planned trainings Village cover with BCC sessions on water and sanitation Village cover with BCC sessions on prevention and management of diarrheal diseases Village cover with BCC sessions for food handlers Routine Data Village cover with hygiene standard inspections of food Collection handlers Proportion of schools covered under deworming campaign Proportion of children covered by school deworming campaigns N umber of integrated PHC activities with deworming included N umber of children dewormed through integrated PHC 79 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 activities Coverage of households with access to domestic water Proportion of water sources by types of contamination Coverage of households with toilets Proportion of camp followers having access to domestic water Proportion of camp followers having toilets Proportion of villages implementing waste management policy Proportion of health institutions implementing waste management Proportion of restaurants and food handlers/vendors complying with hygiene regulations 5 NUTRITION AND MICRONUTRIENTS RELATED ISSUES Promotion and Prevention -Conduct BCC regarding adequate nutrition choices to avoid malnutrition and micronutrient deficiencies (including the provision of IEC materials) -Conduct BCC on correct child weaning and child feeding practices adapted to changed types of food (including the provision of IEC materials) -Implement vitamin distribution programs (vitamin A, folic acid and iron) for children and pregnant women -Collaborate with local villagers to develop alternate sources of sustainable protein to replace potential losses of fish as a staple in the local diet Diagnosis and Detection -Regular monthly growth monitoring of children less than five years of age through height, weight and general examination -Detection of anemia and other nutritional deficiencies Therapeutic Activities -Assure correct treatment of malnutrition and micronutrient deficiencies at HCs and DH -Provide supplementary feeding for malnourished children Capacity Building -Capacity building of health care providers, after need assessment, for prevention, diagnosis and treatment protocols in the following domains: N ational nutrition and micronutrient programs (promotion, prevention, treatment, monitoring, program Management) -Behavioral Change Communication Monitoring and Surveillance Activities -Supervise compliance with established medical diagnostic and treatment protocols for malnutrition and micronutrient deficiencies during growth monitoring -Detection and monitoring of nutrition status of children under five through integrated Primary Health Care Services (Growth monitoring) 80 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 -Conduct nutritional status surveys Specific Inputs: Fund for nutritional supplements for malnourished cases Vitamin A Iron and Folic Acid N utritional Surveys Vitamin A for children (6-59 months) and for postpartum women Nutrition and micronutrients related issues Indicators Disease indicators Sources Proportion of cases of nutritional deficiency by type N umber of deaths presumed related to malnutrition Proportion of cases of current night blindness N umber of beriberi cases N umber of anemia cases Routine Data Thyroid deficiency affected children Collection Activity Indicators Proportion of persons trained in relation to planned trainings Village cover by BCC sessions on nutrition and weaning Proportion of children having received vitamin A supplement Proportion of postpartum mothers having received vitamin A supplement Routine Data Proportion of pregnant mothers receiving iron and folic acid Collection supplements Proportion of health institutions including growth monitoring in their PHC outreach activities Proportion of malnourished children receiving supplementary feeding 6 ACCIDENTS/INJURIES, CHEMICAL EXPOSURES AND POISONING Promotion and Prevention -Provide education programs regarding road safety -Provide education programs for electrical safety in the home -Provide education programs for safety from power supply constructions (Pylons etc) -Provide education programs for prevention of drowning accidents Treatment -Provide first aid treatment for mechanical and chemical traumas and poisoning at the CHCs and DHs -Develop and maintain a referral system for cases requiring transfer Capacity building -Provide training for health care providers regarding prevention strategies, and appropriate diagnostic and treatment protocols for accidents, injuries, chemical exposures and poisoning 81 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 Monitoring and Surveillance -Monitor number of cases of mechanical and chemical injuries and exposures -Road Traffic Accidents (RTAs) and type (pedestrian, motor bike, cars, buses/trucks) -RTAs related to construction company vehicles -Supervise compliance with established medical diagnostic and treatment protocols for accidents, injuries, chemical exposures and poisoning Specific inputs -Intersectoral BCC session -Secondary school BCC sessions (to combine HIV/AIDS and RTAs) Accidents/injuries Indicators Indicators Sources N umber of traumas N umber of RTA cases N umber or poisoning cases Routine Data N umber of deaths due to RTA Collection N umber of deaths due to other injuries N umber of deaths due to poisoning N umber of deaths due to drowning Activity indicators Proportion of persons trained in relation to planned trainings N umber of small surgery/dressing for injuries N umber of intermediate surgery for injuries Routine Data Proportion of cases transferred Collection N umber of coordination meetings with traffic police Village coverage with BCC sessions on road and electrical safety Village coverage with BCC sessions on safe use of pesticides and fertilizers 7 PSYCHOSOCIAL DISORDERS Promotion and Prevention -IEC in schools on substance abuses -BCC on aspects of resettlement for villages Coordinate with the Community Development components of the Project Respect existing indigenous and ethnic institutions, culture and practices in all aspects of resettlement (village allocation, housing, labor, etc.) Organize community events (sporting, cultural, handicraft) in order to strengthen the social tissue in the new villages Prevent uncertainties and stress through adequate information on future plans through regular communication and consultation -Support the development and functioning of the district and commune level committees for drug control and prostitution 82 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 Treatment -Ensure recognition of psychosocial problems at village level by VHW and CHC. -Ensure recognition of psychosocial problems and limited treatment capacities at DH level and referral if required. Capacity building -Provide training for health care providers (VHWs, CHC staff) regarding preventive strategies and appropriate diagnostic and treatment protocols for psychosocial problems -Provide training for resource persons of the provincial drug control unit of the MOE (drug abuse education in schools) Monitoring and Surveillance Monitor the psychosocial situation through surveys Specific Inputs -Development of a psychosocial training curriculum for CHC and DH staff and for VHWs -Psychotropic drugs -Support BCC in schools -Support district committee for drug control Psychosocial Disorders Indicators Disease Indicators Source N umber of cases of psychosocial problems Routine Data N umber of substance abuse cases Collection N umber of injuries due to violence N umber of self -inflicted injuries and suicide cases Activity indicators Proportion of persons trained in relation to planned trainings Village cover with BCC sessions on psychosocial issues School cover with BCC on substance abuse for school Routine Data children Collection N umber of psychosocial cases correctly treated or referred Turnover of psychotropic drugs at DH level 83 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 ANNEX 2: PROJECT HEALTH MANAGEMENT TEAM MANDATE OF THE PROJECT HEALTH MANAGEMENT TEAM (PHMT) Scope of work Under the supervision of the director of the Trung Son project, the public health team will be responsible for implementing the PHAP through the Government Health Infrastructure, coordinating all activities in collaboration with the CHC and District Health services. The scope of work covers the following: (i) To prepare a detailed budget for the implementation of the program (ii) Finalize specifications for the equipment and other items for procurement after surveying the health facilities (iii) Detailed training program among different levels of staff (iv) Organize the annual review meeting with three provincial health departments (v) Monthly supervision and monitoring of operation of the CHCs (vi) Collaborate with DHC and CHC to implement all activities supporting affected people in the project area (vii) Coordinate the linkage between Construction Health Clinic and DHC and CHC (viii) Prepare a quarterly report for Trung Son project director and three provincial health departments (ix) Create and manage the M&E system of the PHAP (x) Support evaluation team to review PHAP annually. (xi) Any other tasks deemed necessary by director of Trung Son project Health Team for Implementing PHAP The composition of the Project Health Management Team should consist of: ­ one national (local) medical doctor, with public health background ­ one nurse with maternal and child health experience ­ Public health officer ­ Public Health Technical Adviser (Part time ­ 60 days a year) Qualifications of the Health Manager: QUALIFICATIONS - University degree in public health or related fields PROFESSIONAL EXPERIENCE - At least two years experience in public health, especially in HIV/AIDS field and management (familiar with the full continuum of HIV/AIDS prevention, care and treatment components) - Experience in program implementation, monitoring and evaluation - Experience of working with governmental organizations - Persuasive, open-minded and creative 84 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 REQUIRED SKILLS - Microsoft office suite literate - Committed and enthusiastic - Ability to communicate effectively with people from different backgrounds - Ability to work both independently and as a member of a small team - Strong team skills focusing on participation and consensus-building Public Health Nurse and Public Health officer will provide support to the team leader, in implementing the resettlement and the regional health programs in the impacted areas. Both should have some work experience in public health programs. Public Health Technical Adviser (Part time) A technical adviser will be required to provide additional support to the PHMT on a number of issues as listed below: 1. Initial training of trainers for one week for all staff involved in the PHAP 2. Regular remote support for any queries and advice 3. Base Line Survey: Planning, sampling, questionnaire, training, data analysis and report writing. 4. Monitoring & Evaluation: Monthly review of reports (remote) and one annual review on site for one week. 5. Addressing and responding health issues raised by monitoring missions. 6. Any other technical support. A one week of training program will be required at the start of the project for both PHMT and the Government staff (District and CHC staff). In addition the technical adviser will visit the project for a week twice annually to review and advise the PHMT and provide online support as required (anticipated 20 days a year ­ including report writing). During the first year, this support is required as listed above. Funding for longer support will have to be negociated, if required, in the second year. In subsequent years the support will depend upon the PHMT performance and progress of the project. It is anticipated that the support will gradually decline to minimal by the end of the construction phase. PHMT Budget The budget for PHMT staff and the technical adviser will be additional to the health program budget described in the main document and will be the responsibility of the TSPMB. Table below describes estimated costs of running the PHMT: 85 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 Project Health Management Team Budget (TSHPMB) No. Category Annual Years 1-3 Years 4-6 7-9 Total cost Years Years 1 Staff: 1. Project Coordinator 9 6,000.00 18,615.00 19,600.00 20,570.00 58,785.00 2. Public Health N urse 9 3,600.00 11,350.00 11,920.00 12,516.00 35,786.00 3. Public Health Officer 9 3,600.00 11,350.00 11,920.00 12,516.00 35,786.00 4. Technical Adviser 1 36,000.00 - - 36,000.00 (part-time) 5. Driver 2,400.00 9 7,600.00 7,980.00 8,379.00 23,959.00 2 Operational Costs including office space, 6,000.00 9 18,000.00 18,000.00 18,000.00 54,000.00 travel expenses etc. 3 Equipment ­ vehicle and other office equipment 30,000.00 1 30,000.00 - - 30,000.00 4 Equity Fund 5% 9 4,583.00 4,583.00 4,583.00 13,749.00 Total 137,498.00 74,003.00 76,564.00 288,065.00 86 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 ANNEX 3: PUBLIC HEALTH PROGRAMS The following section provides a matrix detailing the activities of the PHAP under the various health programs: REGIONAL HEALTH PROGRAM INCLUDING CAMP FOLLOWERS Health Time and Implementing Intervention and description Activity issue Frequency Agency Information, Education, and Behavior Change Communication on STDs and HIV/AIDS infection and N ational HIV/AIDS Program through prevention methods CHC of Trung Son, district preventive medicine centers of Twice a year Trung Thanh and Quan Hoa and Muong Lat, local radios Thanh Son of Trung Son, Trung Thanh, and Thanh Son communes Harm reduction: Distribute condoms freely at CHC Routine activity STDs and HIV/AIDS Routine activity Regional population including camp followers HIV voluntary counseling, testing and referral to health services at the higher levels Awareness and information program in Routine activity all communes on World AIDS Day HIV prevention education via health service Routine activity Implementation of HIV control and prevention activities in the community Information, Education, and BCC on risks of malaria Twice a year N ational Malaria Program implemented infection and prevention methods Malaria through District Preventive Medicine and Centers of Quan Hoa and Muong Lat, Dengue Maintaining adequate medicine stocks for malaria CHC of Trung Son, local radios of Trung Son, Trung Thanh, treatment Trung Thanh and and Thanh Son. Source reduction and planned insecticide spray Twice a year Thanh Son Respiratory diseases Information, Education, and BCC on risks of respiratory DOTS program for TB patients and Routine activity including diseases and TB contact tracing TB Food Information, Education and Communities on food hygiene Twice a year poisoning and safety Local radios of Trung Son, Trung Thanh, and Thanh Son communes Diarrhea Information, Education, and Communities on diarrhea Twice a year Traffic Information, Education, and Communities on the risks of accident Twice a year traffic accident and health services Communal Information, Education and Communities on local culture, violence Twice a year customs, social norms, and lifestyle through brochures Alcoholism Information, Education and Communities on harmful CHC of Trung Son, Awareness program in schools and drug Twice a year consequences of alcohol and drug use on health Trung Thanh and Local radios of Trung Son, Trung abuse Thanh Son Thanh, and Thanh Son communes Stress and Information, Education, and Communication on mental metal disorder through local radio and free distribution of Twice a year disorder leaflets which include information of symptoms of metal disorder Maternal and Child Education of mothers with regards to appropriate Routine activity Health supplementary feeding after six months of breast feeding Program 88 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 RESETTLERS HEALTH PROGRAM Time and Implementing Health issue Intervention and description Activity Frequency Agency Information, Education, and Bcc on STDs and CHC of Tan HIV/AIDS infection and prevention methods Xuan, Trung Son, N ational HIV/AIDS program Trung Ly, Phu through district preventive Twice a year Thanh, and medicine centers of Quan Hoa and Muong Ly Muong Lat, local radios of Trung communes and Son, Trung Thanh, and Thanh Son village health communes workers. STDs and Harm reduction: Distribute condoms freely at CHC Routine activity HIV/AIDS HIV voluntary counseling, testing and referral to Routine activity health services at the higher levels Awareness and information program in all communes on Routine activity Resettlers Health Program HIV prevention education via health service World AIDS Day Implementation of HIV control and prevention Routine activity activities in the community Information, Education, and BCC on risks of CHC of Tan N ational Malaria Program Twice a year implemented through District malaria infection and prevention methods Xuan, Trung Son, Malaria and Trung Ly, Phu Preventive Medicine Centers of Dengue Maintaining adequate medicine stocks for malaria Thanh, and Quan Hoa and Muong Lat, local treatment Muong Ly radios of Trung Son, Trung communes and Thanh, and Thanh Son Source reduction and planned insecticide spray Twice a year village health workers. Local radios of Trung Son, Trung Information, Education and Communities on food Food poisoning Twice a year Thanh and Thanh Son communes hygiene and safety 89 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 Respiratory Information, Education and BCC on risks of diseases Routine activity DOTS and IMCI Respiratory diseases and TB including TB Diarrhea Information, Education and Communities on Twice a year diarrhea Traffic accidents Information, Education and Communities on the Twice a year risks of traffic accident and health services. CHC of Tan Xuan, Trung Son, Trung Ly, Phu Communal Information, Education and Communities on local Awareness program in schools Thanh, and violation culture, customs, social norms, and lifestyle through Twice a year Local radios of Trung Son, Trung Muong Ly brochures Thanh, and Thanh Son communes communes and village health Information, Education, and Communities on workers. Alcoholism and harmful consequences of alcohol and drug use on Twice a year drug abuse health Communal Information, Education and Communities on local One time before violence culture, customs, social norms and lifestyle through resettlement local radio Twice a year Information, Education, and Communication on mental health through local radio and free CHCs of Tan Stress and metal distribution of leaflets which include initial Xuan, Trung Son, disorder symptoms of mental disorder. Trung Ly, Phu Provision of counseling on health related concerns Routine activity Local radios of Tan Xuan, Trung Thanh, and Son, Trung Ly, Phu Thanh, and Muong Ly Muong Ly communes communes and Maternal and Education of mothers with regards to appropriate village health Child Health supplementary feeding after six months of breast Routine activity workers Program feeding 90 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 CONSTRUCTION WORKERS PROGRAM Time and Implementing Health issue Intervention and description Cooperating unit Frequency unit Information, Education, and BCC: 1) Develop communication materials including leaflets and posters which can be stuck on camps/barracks; 2) Twice a year Broadcast STDs and information of risks of HIV N ational HIV/AIDS Program, infection and its prevention methods, and Construction workers & their families Construction Hospital; CHC of counseling and testing services on local radio Trong Son, Trung Thanh, and STDs and CHC Thanh Son, Local radio of Trung HIV/AIDS Son, Trung Thanh, and Thanh Harm reduction: Distribute free condoms at Routine activity Son. construction health center HIV voluntary counseling, testing and Routine activity recommendation for referral HIV prevention and control in health facilities. Routine activity Information, Education and BCC on risks of malaria Twice a year infection and its prevention methods N ational Malaria Program Provision of insecticide impregnated bed nets for implemented through District Malaria and Once CHC construction workers Preventive Medicine Centers of dengue Prophylaxis for malaria prevention Routine activity Quan Hoa and Muong Lat, and Mai Chau general hospital; Adequate supply of medicines for malaria and dengue treatment Do quarterly Treatment and reference to health facilities at higher workers & their ction levels CHC Source reduction and insecticide spray Twice a year 91 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 Information, Education and Communication on risks of TB infection and TB prevention methods: Broadcast TB related information in mass media (local TV and radio). In addition distribute other Twice a year educational materials including brochures and N ational TB Program leaflets which provide information of TB symptoms implemented through District Tuberculosis and counseling and treatment services CHC Preventive Medicine Centers of Quan Hoa, Muong Lat, and Mai Chau general hospital. Collecting and testing sputum of individuals who Routine activity are at high risk and suspected of TB infection Routine activity Monitoring DOTS Maintaining antibiotic stocks Routine activity Respiratory Routine activity Performing timely diagnosis, treatment and referral CHC Mai Chau general hospital infections to health facilities at higher levels if needed N ational Food Hygiene and Safety IEC food hygiene and safety Twice a year Program through district Food poisoning CHC preventive medicine centers of Periodic hygiene inspection of public kitchen in Quan Hoa, Muong Lat, and Mai Do quarterly construction camps Chau general hospital. Routine activity workers & their Maintaining drugs and transfusion fluid to treat N ational Food Hygiene and Safety Construction patients Program through district families Food poisoning CHC Preventive medicine centers of Quan Hoa, Muong Lat, and Mai Develop mass outbreak plan of food poisoning Do one time Chau general hospital 92 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 Information, Education and Communication on Twice a year diarrhea for construction workers Storing medicine and transfusion fluid Twice a year Routine activity Diarrhea CHC Mai Chau general hospital. Referral to health facilities at the higher level if required Refer to health facilities at the higher level if Routine activity required. Maintenance of Standard Safety program Monthly Construction workers & their families First aid training program for construction workers Twice a year Occupational Mai Chau general hospital CHC accidents Monitoring adherence to safety regulations Do quarterly Maintaining adequate medicine stocks and first aid equipment Routine checks Patient treatment and referral to health facilities at Routine activity the higher level Information, Education and Communication on risks of traffic accidents at the construction sites Twice a year First Aid training of construction workers Mai Chau general hospital Traffic accident Twice a year CHC Maintaining adequate medicine stocks and first aid Twice a year equipments. 93 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 Patient treatment and referral to the health facilities at the higher level Information, Education and Communication on harmful consequences of alcohol and drug abuse on Twice a year Alcoholism and health Investor(s) and PMU of Trung CHC Son drug abuse Development of regulations of alcohol and drug use at the construction sites Information, Education, and Communication on Occupational Twice a year occupational disease for construction workers CHC Investor(s) and PMU of Trung Health Son and specialized hospital Annual health check for construction workers. Annual 94 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 ANNEX 4: DETAILS OF THE TEN HEALTH PRIORITIES 1. Malaria prevention program General objective: To reduce malaria morbidity and mortality, prevent malaria epidemics and aim at malaria being of no concern by 2010. Specific objectives: To focus on malaria endemic areas and high risk groups such as migrants; prevent reoccurrence of malaria and reduce malaria morbidity and mortality rates nationwide: o Mortality rate less than 3/1000 populations o Morbidity rate less than 1.5/1000 populations. o N o malaria epidemic. To develop, reinforce and maintain sustainability of malaria prevention achievements including vector control. Interventions Appropriate measures to provide services for migrating work force, forest workers, and ethnic minorities Controlling malaria along borders, key socioeconomic constructions in endemic areas (hydropower plant, forest, transportation routes) Strengthening and maintaining grassroots health system, especially health services in villages, disadvantaged and mountainous areas Specific interventions in project impacted areas of Mai Chau, Moc Chau, Quan Hoa, Muong Lat are: Indoor Residual Spraying (IRS) with insecticides Other vector control measures such as eliminating mosquito breeding sites Use of impregnated bed nets Delivery of prophylaxis to communes Provision of anti-resistant malarial drugs Training for health workers on microscopic examination / rapid test Training for health workers on spraying skills Training for health workers on the application of treatment guidelines. Malaria is rapidly declining in the country as well as in the project areas. Continuous monitoring and surveillance is required to keep the area malaria free. 2. Tuberculosis prevention and control program General objective: To achieve the global target set by World Health Organization of reducing tuberculosis morbidity and mortality by 50% in 2015 compared to 2000. Specific objectives: To maintain and promote availability and access to early diagnostic and treatment services, especially for those living in disadvantaged, remote and mountainous areas. To improve capacity for health workers and quality of health services, focusing on detection, diagnosis and treatment of tuberculosis, especially for patients with multi- drug resistant TB, HIV positive and AFB negative, and among children. To strengthen education, information and communication and socialize society into tuberculosis prevention and control Contact tracing for immediate contacts of sputum positive cases Interventions Promotion of training and re-training for health workers at district and commune levels, focusing on onsite training. Specific interventions in the project impacted areas of Mai Chau, Moc Chau, Quan Hoa, Muong Lat are: Strengthening education, information and communication through parades on the Global Day of tuberculosis prevention in Mai Chau. Provision of pictures and leaflets for CHC and other health facilities. Examination and treatment for tuberculosis patients. 3. Under fives malnutrition prevention General objective: To improve child nutrition status including height and weight, to reduce malnutrition rates below average level classified by WHO. Specific objectives To reduce underweight rate by 20% nationwide by 2010 To reduce prevalence of malnutrition (height by age) by 25% nationwide To control overweigh and obesity rates by more than 5% nationwide Intervention Care for health and nutrition of women in reproductive health age, pregnant women and breastfeeding women. Implementation of breastfeeding within 30 minutes after delivery, exclusive breastfeeding up to six months of age continuing up to 24 ,months. Guide mothers regarding appropriate complementary foods with local foods. Food fortification with vitamin A for children and iron for pregnant women. Care and practice of hygiene at home and kindergarten for the prevention of parasitic infestations. Measurement of weight for children under 2 years old monthly to monitor growth chart and implementation of education, information and communication program. Specific interventions in the project impacted areas Mai Chau, Moc Chau, Quan Hoa, Muong Lat Organization of communication about malnutrition prevention on local media. Direct communication with mothers having children under five years old. Supervision and encouragement at CHCs to measure weight regularly. 4. Leprosy prevention program General objective: 96 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 To eliminate leprosy following four criteria of Vietnam Specific objectives To eliminate leprosy at district level by 2010 To ensure 100% disabled leprosy patients are cared for and treated. Intervention Implementation of the special action project for elimination of Leprosy (SAPEL) in ethnic minorities, remote areas where leprosy morbidity rate is high, health system is weak and in difficult to access where normal health services can not provided. Specific interventions in the project impacted areas in Mai Chau, Moc Chau, Quan Hoa, Muong Lat are: Communication, management, care and supervision of leprosy patients. Integration with examination and treatment activity within districts to detect new patients. 5. HIV/AIDS Prevention and STIs General objective: To control HIV/AIDS prevalence rate in the general population below 0.3% by 2010 and with no further increase thereafter; to reduce the adverse impacts of HIV/AIDS on socioeconomic development Specific objectives To raise people's knowledge about prevention of HIV/AIDS transmission; 100% of people living in urban areas and 80% of people living in rural and mountainous areas should be able to correctly understand and identify ways of preventing HIV/AIDS transmission. To control HIV/AIDS transmission from high-risk groups to the community through implementing comprehensive harm reduction intervention measures: all people with high risk behaviors for HIV/AIDS infection must be covered by intervention measures. To ensure appropriate care and treatment for HIV/AIDS-infected people: 90% of HIV/AIDS-infected adults, 100% of HIV/AIDS-infected pregnant mothers, 100% of HIV/AIDS-infected, or affected children, shall be managed and provided with appropriate treatment, care and counseling, and 70% of AIDS patients shall be treated with specific drugs. To perfect the management, monitoring, surveillance and evaluation systems for the HIV/AIDS prevention and control program Intervention Increase of quality and quantity of IEC messages and materials Development of individual skills on prevention and care for HIV/AIDS Rigorous and synchronous implementation IEC activities and behavior change Improvement of treatment system in HIV/AIDS patients Improvement of availability and accessibility to Anti-retroviral drugs Prevention of mother to child transmission Development of communicator network attaching with village collaborator network and local officers. 97 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 Determining district level is the center of HIV/AIDS care and treatment. Each district should have a unit to care for and support HIV/AIDS people under the umbrella of district health center. Specific interventions in the project impacted areas Mai Chau, Moc Chau, Quan Hoa, and Muong Lat Implementation of IEC to increase knowledge and awareness of the community about HIV/AIDS and STIs 6. Expanded Program of Immunization General objective: To reduce morbidity and mortality rates of vaccine preventable diseases Specific objectives To vaccinate 90% of all children under 1 year old for 7 diseases (tuberculosis, diphtheria, tetanus, polio, hepatitis-B, measles, pertussis) by 2010. To maintain achievements of tetanus elimination. To ensure 100% of total children under 5 years olds are vaccinated with encephalitis vaccine by 2010 To ensure 80% of children at risk are vaccinated with typhoid and cholera vaccines by 2010. To pilot some new vaccines including Hib, MR (Mumps, rubella) Intervention Improvement of professional capacity for health workers at grassroots level Use of safe injection equipment and procedure Provision of adequate vaccines and materials which should be funded by government budget and donors (GAVI, UN ICEF, JICA...) Enhancement of guidance and support for the implementation of EPI program in remote, mountainous areas Specific interventions in the project impacted areas Mai Chau, Moc Chau, Quan Hoa, Muong Lat Cooperating with other stakeholders in IEC activities on immunization campaigns Practice of right dose, right schedule and right technique when immunizing 7. Community mental health care General objective: To improve quality of mental health services for people by integrating them into commune health centers Specific objectives To detect and manage treatment at commune level for 50% schizophrenia patients (equivalent to 200.000 patients). To treat 70% of total diagnosed patients to help them reintegrate to their home and community (equivalent to 140.000 patients) To reduce dangerous behaviors and disability among treated and diagnosed patients Intervention 98 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 Health service at provincial level plays a key role in implementing the program, steering district health centers to cooperate with CHCs to detect and treat mental health patients Multiplying pilots from commune/district to the whole province Step by step improving qualifications for collaborators and patient's family making them recognize and carry out rehabilitation, manage treatment scheme. Training health workers at commune level on emergency service and provision of primary drugs. Interventions taken by Mai Chau, Moc Chau, Quan Hoa, Muong Lat Examination and detection of mental disorder patients Management of patients at commune level 8. Cancer prevention program General objective: Gradually reduce incident and mortality rate due to cancer To improve the quality of a cancer patients' life 9. Reproductive health program General objective: To improve the health of women and children Specific objectives: Reducing the maternal mortality rate by 70/1000 live births Reducing the children under 1 year old below 25 live births 10. Integrated medicine military-public program To protect and care for the health of people, military, and contribute to reinforcing defense security in mountainous, remote, boundary regions and archipelagoes 99 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 ANNEX 5: SURVEY INSTRUMENT - 1 Province: ................................................................................................................. District: Commune: .................................................................................................................... N ame of subject: Code number: Content Answer Circle on the appropriate number I. PERSONAL INFORMATION Q1 Gender Male 1 Female 2 Q2 Date of birth ........../ ............/........... Day Month Year Q3 How old are you? .........................year old Q4 What is your highest level of Primary 1 education? Secondary 2 High school 3 College/University 4 Other 5 (specify)....................... Q5 Ethnic Kinh 1 Muong 2 Thai 3 Dao 4 H'Mong 5 Other (specify)............... 6 Q6 What is your marital status? Single 1 Married/Partner 2 Divorce/Separate 3 Widower 4 Other (specify)..................... 5 Q7 Religion No 1 Buddhism 2 Christian 3 Other (specify)..................... 4 Q8 What is your occupation? Farmer 1 Worker 2 Seller 3 Student/Pupil 4 Household 5 Craftsman 6 Retired 7 100 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 Other (specify)............... 8 Q9 Do you have health Yes 1 insurance? No 2 Q 10 If yes, what kind of health Voluntary 1 insurance? Compulsory 2 Issued by policy 3 II. DISEASE HISTORY Q 11 Do you have any health Yes 1 problem which has made you No 2 sick at least for 1 year? Q 12 What is the problem? ....................................... Q 13 For how long? ...........................months III. CURRENT HEALTH Q 14 DURING LAST 2 WEEKS, Yes 1 DID YOU HAVE ANY No 2 HEALTH PROBLEMS? Q 15 If yes, what are the main 1..................................... symptoms? 2..................................... 3..................................... Q 16 If yes, did you visit any of Private 1 following health care Health commune station 2 services? (can select more District hospital 3 than one option) Other (specify)........ 4 Q 17 If yes, what is diagnosis? ....................................... IV. SANITARY ENVIRONMENT Q 18 What source of water does Lake 1 your family uses? N atural dwell 2 Fountain of UN ICEF 3 Other (specify)........ 4 Q 19 What kind of latrine does Self-destroy 1 your families use? 1 compartment latrine 2 2 compartment latrine 3 Other 4 (specify)......................... V. ATTITUDE TO HYDROELECTRIC CONSTRUCTION ON HEALTH Q 20 Have you heard that a Yes 1 hydroelectric plant will be No 2 built in your local area? Q 21 In your opinion, what will be N oise 1 the impact on your life when Dust 2 101 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 the hydroelectric plant is Many strange people 3 built? Other 4 (specify)......................... ............................................. ................................ Q 22 What are the health impacts? Chronic diseases 1 Communicable diseases 2 Accident 3 Intoxication 4 Occupational health 5 Don't know 6 Other 7 (specify)......................... ....................................... Q 23 If communicable diseases, ....................................... what specific disease? ....................................... Q 24 If non-communicable ....................................... diseases, what specific ....................................... diseases? Q 25 What are the social issues to Drug abuse 1 observe when building a Prostitution 2 hydroelectric station? Other 3 (specify)......................... Q 26 Suggest solutions for reducing ....................................... above problems ....................................... ........................... Q 27 Any other problems? ........................... ........................... ........................... ........................... ........................... VI. KNOWLEDGE ON HEALTH CARE PROGRAM AND ACCESS TO HEALTH CARE SERVICES Q 28 Do you know any health Yes 1 program which is being No 2 implemented in your community? Q 29 If yes, list 3 health programs ........................... you know ........................... ........................... ........................... ........................... Q 30 If you have any health Commune health station 1 problem, where do you intend District health centre 2 102 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 to go for diagnosis and Provincial hospital 3 treatment? Private health service 4 Healer 5 Other (specify)............... 6 103 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 ANNEX 6: SURVEY INSTRUMENT 2 Province: ........................................................................................................... District: ............................................................................................................. Commune: ........................................................................................................ N ame of subject: Code number: Content Answer Circle on the appropriate number I. PERSONAL INFORMATION Q 1 Gender Male 1 Female 2 Q 2 Date of birth ........../ ............/........... Day Month Year Q 3 How old are you? .........................year old Q 4 What is your highest Primary 1 level of education? Secondary 2 High school 3 College/University 4 Other (specify)....................... 5 Q 5 Ethnic group Kinh 1 Muong 2 Thai 3 H'Mong 4 Other (specify)................... 5 Q 6 What is your marital Single 1 status? Married/Partner 2 Divorce/Separate 3 Widower 4 Other (specify)..................... 5 Q 7 Religion No 1 Buddhism 2 Christian 3 Other (specify)..................... 4 Q 8 What is your Farmer 1 occupation? Worker 2 Seller 3 Student/Pupil 4 Household 5 Hand maker (Artisan) 6 Retired 7 Other (specify).......................... 8 Q 9 Do you have health Yes 1 104 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 insurance? No 2 Q If yes, what kind of Voluntary 1 10 health insurance? Compulsory 2 Issued by policy 3 II. DISEASE HISTORY Q Do you have a health Yes 1 11 problem which has No 2 made you sick at least for 1 year? Q What is the problem? ............................................... 12 Q For how long? ............................ months 13 III. CURRENT HEALTH Q Have you had any Yes 1 14 health problems in the No 2 last 2 weeks? Q If yes, what are the 1.............................................. 15 main symptoms? 2............................................. 3............................................. Q If yes, did you visit any Private 1 16 of the following health Health commune station 2 care services? (can District hospital 3 select more than one Other (specify)........ 4 option) Q If yes, what is the ................................................ 17 diagnosis? ............................................... ............................................... IV. SANITARY ENVIRONMENT Q What is the source of Lake 1 18 water your family N atural dwell 2 uses? Fountain of UN ICEF 3 Other (specify)........ 4 Q What kind of latrine Self-destroy 1 19 does your families use? 1 compartment latrine 2 2 compartment latrine 3 Other (specify)......................... 4 V. ATTITUDE ON THE IMPACT OF HYDROELECTRIC CONSTRUCTION TO HEALTH Q Have you heard a Yes 1 20 hydroelectric project No 2 will be built in your 105 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 area? Q Are you have Yes 1 21 satisfied with your No 2 resettlement plan? Q If not satisfied, what ........................................... 22 are the reasons? ........................................... ........................................... .......................................... Q Do you have any Yes 1 23 worries regarding No 2 health when you move? Q If yes, what are they? ........................................... 24 ............................................ ............................................. .............................................. .............................................. Q Have you received Yes 1 25 any suggestions from No 2 health care services regarding the moving? Q If yes, what support ............................................ 28 are you getting? ............................................. 106 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 ANNEX 7: HEALTH CHECKS AND SURVEY Health Needs Assessment among Impacted Populations The term Health Check is defined as a thorough physical examination by a doctor or health worker which includes a variety of tests (depending on age, sex and health of the person) to diagnose the presence of any illness. Instead of a minimalist approach, a comprehensive additional interview with the family is proposed, where as many factors affecting health as possible could be investigated so that optimal information is available for a comprehensive health care program. The data obtained from such an activity will provide robust information for future assessment and monitoring of health of impacted people. The Health Checks and Survey According to the Trung Son Hydro Project the reservoir will impact 11 communes with 1644 households and approximately 6000 people. Four communes with 544 households and a population of 2500, the resettlement population, will require relocation because their houses will be submerged under the reservoir. Another 3500 people will be indirectly impacted by the project. The relocation process will start immediately after project approval and will continue until all houses are relocated and settled. The remaining seven communes, the regional population, will not require relocation but will be impacted by various project activities and inundation of their land. A sample of the resettled and the regional populations will be the subject of the HC&S. Sample Size The resettled population being small, a larger sample will be required for comparison with the regional population. It is proposed that the sampling is conducted at household level rather than at individual level and 25% of households in the resettled population and 5% of the households in the regional population, will be surveyed to obtain comprehensive information, including information on low prevalence health conditions. Table 1 outlines the detailed time table of the HC&S. Figure 1 details the flow of the HC&S activity. Table 1: Activity and the Time Table No Activity Time required Date Started Date Completed 1. Preparation of the survey work ­ 2 weeks To be completed To be completed instrument, planning, training etc 2. Preparation of the community for 1 week To be completed To be completed the survey 3. Actual Survey 4 weeks To be completed To be completed 4. Data checks and data entry 2 weeks To be completed To be completed 5. Data analysis 2 weeks To be completed To be completed 6. Report writing 2 weeks To be completed To be completed To be completed ­ When dates are available after the approval of the project by the World Bank 107 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 Interviewers District health managements of the four impacted districts have agreed to provide the manpower to conduct the survey. PMB will provide the resources for the survey and PMB health team will overall coordinate and supervise the HC&S. Community preparedness A preparatory phase consisting of a series of meetings with the village and district authorities will be required. Village communities need to be informed and their cooperation sought. A time table for health checks in each village will be publicized well before the event. It will be important to hold discussions with village heads and other important members of the community, initially to explain the advantages of the program and seek their cooperation for full involvement in the HC&S, followed by public meeting, the day before the actual survey. The process of interviews, measurements of weights, heights, peak flow rate and blood pressure, medical examination, immunizations will be explained. The importance of testing urine, stool and blood will also have to be explained and instructions for sample collection given and any fears and misconceptions cleared. A general acceptance by show of hands from the community, a sign of general approval needs to be obtained and the village head should be asked to provide consent on behalf of the village. The community will need to be consulted for the best site for health checks in the village. Preparation of the survey work ­ instrument, planning, training Logistics The four district health managements have agreed to carry out the HC&S. Discussions will be held at all levels to ensure participation and availability of health workers at the planned time. Medical officers, laboratory technicians, medical assistants, nursing staff and their auxiliaries will have to be identified. The Instrument A questionnaire, the instrument, will be prepared beforehand and interviewers trained to use it. The proposed content of the questionnaire is shown in the Table 2. Each family will be interviewed and all members of the family will be included in the survey. The Health Checks and Survey The main objectives of the health checks are: 1. Health profile of the population and its use in health service delivery 2. Identification of any conditions requiring further study 3. Maternal and child health ­ strengthening of all aspects on MCH 4. Continuous monitoring ­ to follow trends over time 5. Community participation ­ a process which will educate the community of their own health needs and how to take responsibility of their own health. The actual process of HC&S Social and family history 108 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 The process can be best described as a set of stations where different activities could be organized. At the first station, experienced health workers will interview the head of the family or his wife, wherever possible together. The interview will provide an opportunity to ask the head of the family to verify all members of the family on the survey form. Additional information on full names of the family members, their relation to the head, date of birth and/or age and its verification, ability to read and/or write, educational attainment, occupation, marital status, reproductive health information from women, any death in the family in the last one year and the known cause, any illness in the last two weeks, sanitary information and water supply and the type of drinking water used and bed net use to sleep at night will be collected. Height, weight and blood pressure The second station will be set up to measure weight, height and blood pressure (BP), following standardized procedures. All adults will be weighed with locally available scales but children under five years of age will be weighed on hanging spring balance in a panty sling (alternative could be a balance with digital scale). Height will be obtained by measuring against a measuring tape fixed to the wall and small children on locally prepared wooden height meter. Recumbent length for children below 24 months of age will be measured using locally designed length meter. Blood pressure for adults over 15 years of age will be measured using standard sphygmanometer in sitting down position on a chair, with arm resting on the table roughly at the same height as of the heart of the person to be examined. Both diastolic and systolic readings will be recorded. Medical Examination At the third station, two to three doctors will examine each individual for any general debility through a systemic medical examination. The examination will record any findings on the questionnaire on cardiovascular system; respiratory system; ear, nose and throat; palpable or visible enlarged thyroid gland; eye conditions; skin conditions; and general dental health. Any other abnormalities found will be recorded in the remarks column. Individuals with acute health problems will be sent to the CHC or the district hospital. N o active treatment will be provided at the site and those requesting any treatment will be referred to the local health facility. Laboratory Tests The fourth station will collect the urine and stool samples from the participants and test the urine on the spot with dip stick for eight parameters. Blood sample from each individual will be collected by a technician through a venipuncture. Samples will then be labeled under each family and individual numbers. The samples will be packed and dispatched in batches to the District hospital laboratory for analysis on the same day. Small children will only provide blood by a lancet puncture for malaria slide and hematocrit. 109 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 Figure 1: Flow Chart ­ Health Checks & Survey Population data collection and checks Village Committee Meeting Community Preparation Community Meeting Survey team training Preparation Logistics and General Planning Family Family Medical Maternal & Lab Registration Interviews Examination Child Health Services Family General Information Cardio-Vascular System Blood Records Checked Fertility/RH History Respiratory System Immunization checks Stool Age/DOB Literacy/Education Peak Flow Measurement ANC/PNC services Urine Height Illness Ear, Nose and Throat Family Planning Service Sputum Weight BP Deaths Eye Conditions Nutrition advise ­ Family Planning Goiter Child rearing practices Dental health Water Supply and Sanitation Skin Conditions Smoking Other Health Problem Operation Salt test for Iodine Individual Referrals for Community Continuous Health Problems Tertiary Care Feedback Monitoring Special treatment and/or Public Meetings Data Collection Follow-up assistance for health problems 110 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 Table: Variable Profile No. Variable Remarks 1 Personal Information ­ ID, HH N o., Village, Any existing IDs could be used. Pet names and date N ame, Age ­ DOB, sex. of births are a problem and special care is needed 2. Head of the family and relation with the head For understanding family structure 3. Literacy check and level of education Ability to read and write and level of education as an influence 4. Occupation Type of occupation and assessment of financial status 5. Marital Status Divorced, separated and widows as vulnerable groups 6. Reproductive health information: For provision of comprehensive maternal and child Age at menarche, age at first pregnancy, health information to assist in reduction of number of times pregnant, total number of morbidity and mortality in women and children. children born 7. Outcome of pregnancy: Still birth, total alive, Those children who died: age, sex, cause of death. 8. Death in the family during last 12 months: For identification of preventable deaths and health Age, sex, cause of death. education programs 9. Last infant feeding: Breast feeding and N utrition and supplementation of food after six duration, age at weaning months of exclusive breast feeding 10. Current pregnancy and gestation For antenatal care and family planning advice 11. Family planning and use of contraceptives. Spacing and prevention of unwanted pregnancies Reasons for not using contraceptives, method ever used 12. Slept under mosquito net Prevention of malaria 13. Illness during last two weeks and treatment Planning of health care delivery, to seek early provider advice on illness and to strengthen referral system 14. Hospitalization in last 12 months, reason for admission, hospital name, 15. Iodinized salt use ­ salt tested Prevention of iodine deficiency conditions 16. Type of toilet used Sanitation and clean potable water supply 17. Type of water used for drinking, boiling practice, type of non-drinking water used. Satisfaction with type of water supply. 18. Measurements: Height, weight, blood Growth monitoring, nutritional needs of children pressure, peak flow rate, smoking habits and adults, to complement medical checks and 19. Medical Examination: Cardiovascular, prevention of disease respiratory systems; palpation of liver and spleen; Ear, nose and throat; eye; goiter; skin conditions; teeth; physical or mental disability. 20. Specimens collected: Urine, stool and blood Urine ­ dipstick for 10 parameters; stool for samples for all. Sputum from suspected TB. intestinal parasites through thick smear microscopy, blood for 18 parameters with hemoanalyser and malarial parasite with microscopy/or rapid check for falciparum malaria. 111 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 Data checks and data entry After the survey activity, each day's data collected and records will have to be checked by the health team under supervision from the PMB teams for its completion and correctness. After checks, the data will be entered into selected software for data entry in batches. Data analysis Data analysis will be carried out using a standard statistical package for detailed analysis (e.g. SPSS). Report writing A detailed report on the finding will be produced by a public health expert in the form of a report along with conclusions and recommendations to be incorporated into the Public Health Action Plan. The findings will be used for evaluation of the health status of the impacted populations over time. Community participation The findings of the survey will also be discussed with the impacted communes at a public meeting. Because of the distances and numbers involved, several meetings may be required. The purpose of these meetings is to share information with people for education and awareness. Costing of the HC&S The main expenditure will be for the payment of district health workers daily allowance and other expenses. Laboratory testing will be another major expense. Per head expenditure of US$5 will be required for the survey of around 625 from relocated and 175 from regional population. It is estimated that US$ 4000 will be required to complete the survey. The data entry, data analysis and report writing will be additional and expected to be another US$11.000. 112 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 ANNEX 8: DEMOGRAPHIC CHARACTERISTICS OF RESETTLERS Tan Xuan Trung Son Trung Ly Phu Thanh Muong Ly Total n (%) n (%) n (%) n (%) n (%) Gender Male 50 (43,1) 45 (38,8) 8 (16,9) 9 (7,8) 4 (3,4) 116 (100,0) Female 19 (25,7) 43 (58,1) 4 (5,4) 2 (2,7) 6 (8,1) 74 (100,0) Educational attainment Illiterate 7 (19,4) 26 (72,2) 2 (5,6) 0 (0,0) 1 (2,8) 36 (100,0) Primary school 35 (52,2) 22 (32,8) 3 (4,5) 4 (6,6) 3 (4,5) 67 (100,0) Secondary school 19 (42,2) 22 (48,9) 3 (6,7) 1 (2,2) 0 (0,0) 45 (100,0) High school 1 (20,0) 3 (60,0) 0 (0,0) 0 (0,0) 1 (20,0) 5 (100,0) College/university 7 (18,9) 15 (40,5) 4 (10,8) 6 (16,2) 5 (13,5) 37 (100,0) Ethnicity Kinh 0 (0,0) 3 (100,0) 0 (0,0) 0 (0,0) 0 (0,0) 3 (100,0) Tay 1 (50,0) 0 (0,0) 1 (50,0) 0 (0,0) 0 (0,0) 2 (100,0) Thai 42 (30,7) 64 (46,7) 11 (8,0) 11 (8,0) 9 (6,6) 137 (100,0) Muong 23 (51,1) 21 (46,7) 0 (0,0) 0 (0,0) 1 (2,2) 45 (100,0) N ung 3 (100,0) 0 (0,0) 0 (0,0) 0 (0,0) 0 (0,0) 3 (100,0) 113 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010 ANNEX 9: NATIONAL INFRASTRUCTURE STANDARDS NATIONAL STANDARDS OF INFRASTRUCTURE AND EQUIPMENT FOR COMMUNE HEALTH CENTERS (According to National standards for commune health period 2001-2010 promulgated under the Decision No 370/2002/Q-BYT of Minister of MOH) A. Infrastructure A CHC is designed according to the "standard structure" defined by the MOH and should meet the following basic requirements: 1. Location: in the center of the commune and close to inter-communal roads. 2. Width: - 500 m2 or larger in communes in rural areas. - 150 m2 or larger in the communes in urban areas 3. Physical structure of CHC: - Main part with rooms for working and other services - Sample garden of traditional herbs - Area of green plants: 30 % or more of the whole area. - Boundary fence and signpost with name of CHC 4. Main part: - Construction level should reach level III at least. - Width: 90 m2 or larger - There are 8-9 technical service rooms for: + Consultation + Administration and drugs storage + Examination and first-aid treatment + Family planning + Delivery + Post-delivery + Inpatients + Sterilization + Traditional medicine (for the CHCs having specialized traditional health staff) 5. Supporting part; Including kitchen, warehouse, water tank, toilet and space for vehicle keeping (depends on actual needs at the commune) 6. Public services infrastructure: - Having electricity from national power grid; or electricity from generators if the commune is in region III. - Having a telephone at CHC - Having safe water from a sustainable resource 7. Maintenance of facilities and equipment 8. Maintenance work is done annually B. Medical equipment 1. Having basic equipment for primary technical level: Stethoscope, sphygmomanometer, thermometer and basic emergence instrument. Instrument sets for basic specialties: Gynecology, EN T etc 2. Aerosol, microscope, simple lab-test machines (In CHCs staffed with a doctor) 3. Obstetrical instrument sets for examination, treatment, delivery, family planning, and infant care and emergency care 4. Instrument for primary preparation and storage of herbal medicine: Oven for drying herbals, scales, herbal cabinets, acupuncture needles etc 5. Instrument for health target programs, dental care, school dental care and others. 6. Instrument for health education at commune 7. Instrument for sterilization: autoclaves, steam pots 8. Furniture: Table, patient beds 9. Instrument sets for hamlet health worker's use such as injection, first aid, health education 10. Safe delivery kits for communes in mountainous and remote areas 11. Other equipment: Water pump, flashlight 115 ______________________________________ Health Impact Assessment and Public Health Action Plan Trung Son Hydropower Project ­ July 2010