1
TABLE OF CONTENTS
TABLE OF CONTENTS 2
LIST OF TABLES 3
ABBREVIATIONS AND ACRONYMS 4
EXECUTIVE SUMMARY 5
1. Introduction 8
1.1 Project Description 8
1.2 Project Boundaries 8
2. assessment methodology 11
2.1 Assessment Scope and Content 11
2.2 Assessment Procedures 12
3. legislative and institutional Context 14
4. Project-related environmental issues 19
4.1 Health Care Facility Civil Works 19
4.1.1 Construction Phase Aspects 19
4.1.2 Asbestos 19
4.1.3 Drinking Water Quality 21
4.2 Health Care Facility Operations 23
4.2.1 Solid Health Care Waste Management 23
4.2.2 Liquid Waste Management 27
5. Environmental management plan 29
5.1 Health Care Facility Civil Works 29
5.1.1 Construction and Renovation 29
5.1.2 Asbestos 30
5.1.3 Drinking Water Quality 32
5.2 Health Care Facility Operations 34
5.2.1 Solid Waste Management 34
5.2.2 Liquid Waste Management 38
5.2.3 Capacity Buildiing 40
5.2.4 Regulatory Compliance 40
ANNEX 1 - LIST OF PERSONS MET 42
LIST OF TABLES
Table 1 Proposed HCF for WB-HSIP civil works funding 9
Table 2 National drinking water criteria for rural water supply 17
Table 3 Groundwater arsenic levels in WB-HSIP provinces 22
Table 4 Health care waste characteristics and hazards profile 24
Table 5 Recommended colour-coded HCW container system for larger HCF 25
Table 6 Interim WB-HSIP water quality guidelines 32
Table 7 Liquid effluent concentrations for HCF 39
Table 8 Anticipated capacity building needs 40
abbreviations and acronyms
ADB / Asian Development Bank
BOD / Biochemical Oxygen Demand
COD / Chemical Oxygen Demand
EA / Environmental Assessment
EIA / Environmental Impact Assessment
EMP / Environmental Management Plan
EMS / Environmental Management System
EPI / Extended Program of Immunizations
EPL / Environmental Protection Law
GOL / Government of Lao PDR
HCF / Health Care Facility
HCW / Health Care Waste
HCWM / Health Care Waste Management
HRD / Human Resources Development
WB-HSIP / World Bank Health Services Improvement Project
ICU / Intensive Care Unit
IEE / Initial Environmental Examination
IFC / International Finance Corporation
IFI / International Funding Institution
MCTPC / Ministry of Communication, Transport, Post and Construction
MIH / Ministry of Industry and Handicrafts
MOH / Ministry of Health
MPH / Ministry of Public Health
NCEW / National Center for Environmental Health and Water Supply
NGO / Non-Government Organization
NOHSC / National Occupational Health & Safety Commission
NTU / Nephelometric Unit
PCU / Project Coordination Unit
PIP / Project Implementation Plan
PMU / Project Management Unit
PVC / Polyvinyl Chloride
QA/QC / Quality Assurance/Quality Control
SOP / Standard Operating Procedures
STEA / Science, Technology & Environment Agency
TSS / Total Suspended Solids
UNICEF / United Nations Children's Fund
US EPA / United States Environmental Protection Agency
WASA / Water Supply Authority
WHO / World Health Organization
WWTP / Wastewater Treatment Plant
executive summary
1. This report documents the findings of an environmental assessment (EA) completed for the World Bank Lao People's Democratic Republic (PDR) Health Services Improvement Project (WB-HSIP). The EA complies with the Bank’s environmental review policies, procedures and assessment guidelines (OP/BP/GP 4.01). In addition, the EA references Lao PDR environmental laws, regulations, policies and guidelines to ensure that applicable environmental assessment and pollution control requirements are fully addressed in project implementation.
2. The WB-HSIP is being classified as a Category B activity where limited environmental analysis is considered appropriate to address specific environmental issues. Potential environmental and human health impacts of the WB-HSIP examined in completing the EA corresponded to: planned construction and renovation of national, provincial and district health care facilities (HCF); and health care waste management (HCWM) practices at HCF. Environmental issues relevant to the forgoing aspects are detailed and recommendations made as to appropriate mitigation measures and monitoring programs with a view to guiding project design and incorporating appropriate management actions during project implementation. Mitigation measures corresponding to the abovementioned aspects of the WB-HSIP are detailed in an Environmental Management Plan (EMP).
3. Extensive consultation was sought with the Ministry of Health (MOH), provincial and district authorities, and representative HCF in completing the EA to ensure that potential project impacts were fully understood and appropriate conclusions and recommendations were reached. The Science, Technology & Environment Agency (STEA) was also consulted with respect to existing environmental regulations pertaining to HCF, and corresponding monitoring and reporting responsibilities. Technical support was provided throughout by the Project Coordination Unit (PCU) of the current World Bank Health System Reform and Malaria Control Project, which facilitated successful completion of the EA.
Health Care Facility Civil Works
4. New construction and renovation of existing structures at HCF proposed for funding as part of the WB-HSIP does not pose any serious environmental or human health concerns. Notwithstanding, planned civil works have the potential to damage local ecosystems and disturb neighbouring communities if best practices are not adhered to and appropriate safeguards are not taken. To ensure that potential construction-related issues are properly addressed, comprehensive environmental and human health safeguards will be adopted to avoid or minimize adverse impacts. Safeguards will encompass:
· Protection of ecosystems to prevent damage to sensitive species and habitats;
· Avoiding pollution of watercourses and tainting of drinking water aquifers;
· Addressing safety hazards posed by construction-related vehicular traffic;
· Minimizing nuisance to neighbors from visual impacts and increased dust and noise emissions;
· Conducting surveys of construction sites to identify potential human health and environmental concerns (e.g., the presence of hazardous materials such as asbestos);
· Strict adherence to occupational health and safety guidelines applicable to construction work (e.g., safe removal and handling of asbestos); and
· Ensuring the proper disposal of construction wastes, with particular attention given to safe disposal of asbestos and other potentially hazardous materials.
5. Attention will also be given to ensuring the safe supply of drinking water to HCF as part of the WB-HSIP. Although drinking water quality in central and southern Lao PDR is generally acceptable, some concerns remain regarding inorganic and organic pollutants, and microbiological quality of available water sources. Specifically, groundwater arsenic concentrations have been found to exceed applicable guidelines in some provinces. In addition, bacteriologically unsafe drinking water poses a recognized general threat to human health if adequate precautions are not taken. Recognizing the importance of assuring the supply of safe drinking water to HCF, mitigation measures to be adopted include: (i) use of proven water sources; (ii) routine testing of water supply; (iii) water treatment to remove harmful constituents; and (iv) proper design and installation of water distribution systems in HCF to ensure consistent delivery of good quality water.
Health Care Facility Operations
6. Activities undertaken to improve health services will inevitably create waste that is potentially hazardous. Health care wastes (HCW) are typically more hazardous than other types of wastes and should be considered in planning HCF operations. Exposure to hazardous HCW can result in disease or injury to: medical doctors and nurses; auxiliary and maintenance staff; patients and visitors; and workers at waste disposal facilities. To address these concerns, it is essential to put in place safe and reliable methods for handling and disposal of medical waste.
7. Generally accepted HCWM strategies encompass: waste minimization, recycling, and reuse; proper handling, storage and transportation; and treatment of potentially hazardous waste by safe and environmentally sound methods. To ensure that best practices are promoted as part of the WB-HSIP, specific recommendations are made to:
· Adopt strict waste segregation practices at HCF to ensure that potentially hazardous wastes are identified and separated, and that different waste streams are correctly disposed of.
· Develop detailed guidelines to individual HCF concerning appropriate HCWM practices.
· Deliver capacity building on HCWM and compliance monitoring to HCF and regulatory agencies.
8. Wastewater from HCF represents a sub-category of HCW that should be addressed in planning construction and renovation activities as part of the WB-HSIP. Although liquid waste from HCF is typically of a similar quality to urban wastewater, it may also contain potentially hazardous components of concern from a human health perspective. Typically, effluents discharged by HCF are greatly diluted and, as such, no significant health risks should be expected if discharged to municipal sewer systems which provide for proper treatment. Where connection to municipal systems is not feasible, then appropriate precautions must be taken to avoid health risks associated with discharge of untreated or inadequately treated effluents to the receiving environment. It is recommended that, where possible, HCF should be connected to municipal systems and that pre-treatment of potentially hazardous waste streams (e.g., infectious wastes) be provided. Where there are no sewage systems, appropriate on-site wastewater treatment systems are required.
9. A new regulation, scheduled for promulgation in June 2004, has been developed by the MOH concerning the handling and disposal of solid HCW. Review of the draft version of the regulation and discussion with the responsible department within MOH provided assurances with respect to the regulation's comprehensiveness and the appropriateness of technical recommendations contained therein. Concerning liquid waste management which is not covered under the aforementioned regulation, the MOH advised that a separate regulation is to be drafted with a view to providing guidance on best practices for HCF. It is recommended that every effort be made to expedite completion of the aforementioned liquid waste management regulation. Further, it is recommended that corresponding guidelines be developed by the MOH with a view to providing specific guidance to each HCF category (i.e., national, provincial and district hospitals, and health centers) in adopting practical and affordable HCW handling and disposal options. Priority should also be given to developing standard operating procedures (SOP) and training materials in support of human resources development (HRD) for use by HCF administration, medical staff and janitorial workers.
10. Monitoring of HCF operations will be undertaken under the WB-HSIP to ensure that regulatory reporting requirements are fully met and to demonstrate good environmental performance on an ongoing basis. Responsibility for monitoring will rest with individual HCF with oversight under the guidance of the WB-HSIP Project Management Unit (PMU) to ensure compliance with reporting requirements and timely submission of reports to the Science, Technology & Environment Agency (STEA). Monitoring parameters, quality assurance and quality control requirements, and desired reporting format will be determined in consultation with STEA at both the national and provincial levels. Funding will be allocated under the project to procure necessary equipment and consumable supplies, and to deliver appropriate training in support of monitoring activities.
1. Introduction
11. This report details the findings of an environmental assessment (EA) completed for the planned World Bank Lao People's Democratic Republic (PDR) Health Services Improvement Project (WB-HSIP). The EA complies with the Bank’s environmental review policies, procedures and assessment guidelines (OP/BP/GP 4.01). In addition, the EA references Lao environmental laws, regulations, policies and guidelines to ensure that applicable environmental requirements are fully addressed in project implementation.
12. This EA assesses potential environmental and human health impacts of the WB-HSIP, particularly with regard to: (i) health care facility (HCF) civil works; and (ii) HCF health care waste management (HCWM) practices. Environmental issues relevant to these WB-HSIP activities are detailed Section 4 of this report. Mitigation measures and compliance monitoring requirements corresponding to the aforementioned environmental issues are detailed in an Environmental Management Plan (EMP) included as Section 5 of this report. These mitigation measures are intended to guide project design and planning with a view to incorporating appropriate management actions during project planning and implementation.
1.1 Project Description
13. The WB-HSIP's overall objective is to contribute to the improvement of the health status of the Lao population towards meeting the Government of Lao PDR's (GOL) health targets for the year 2020 through: (i) improving the quality of integrated basic health care services and their access by the poor; (ii) strengthening sector capacity through human resources and institutional development; and (iii) improving equity and sustainability of health care financing. Poor quality of basic health care in Lao PDR is due largely to inadequate technical skills and remuneration of health personnel, poor infrastructure and equipment, and limited responsiveness to the health needs of the population. Utilization of HCF is low because of poor accessibility, cost of care, especially for the poor, and health-seeking behavior dominated by self-medication. The WB-HSIP will help address these issues by enhancing teaching at the national level, and strengthening health systems at the provincial and district levels.
1.2 Project Boundaries
14. Civil works priorities identified under the WB-HSIP component dealing with improving quality and accessibility of health care services encompass both new construction and renovation of existing HCF. The WB-HSIP will have a geographical focus on eight central and southern provinces, encompassing: two National teaching hospitals in Vientiane; the Faculty of Medical Sciences (FMS) in Vientiane; three Provincial hospitals; eight District hospitals; and four Health Centers. Civil works proposed for the WB-HSIP at the national, provincial and district levels are summarized in Table 1. It is anticipated that rehabilitation and construction works and equipment procurement will be completed in a phased manner beginning in Khammouane Province and Vientiane.
Table 1 Proposed HCF for WB-HSIP civil works funding.
Location / Province / LevelMahosot / Vientiane / National
Mittaphab (Friendship) / Vientiane / National
Faculty of Medical Sciences / Vientiane / National
Paksanh / Bolikhamsay / Provincial
Thakhek / Khammouane / Provincial
Saravane / Saravane / Provincial
Songkhone / Savannakhet / District A
Thapangthong / Savannakhet / District B
Knongxedone / Saravane / District B
Champasack / Champasack / District B
Soukhumma / Champasack / District B
Batieng / Champasack / District B
Mahaxay / Khammouane / District B
Phouvong / Attapeu / District B
2 Health Centers / Sekong / A/B
2 Health Centers / Attapeu / A/B
15. New construction and rehabilitation works at the above listed HCF proposed for funding under the WB-HSIP are summarized as follows: