E631 - World Bank Documents & Reports

E631 n- }

September 2002 Draft Report

Environmental Review

Cambodia Health SectorSupport Project

PREPARED FOR PREPARED BY

The World Bank, ]VS consultants

Washington D.C. ESnlt

\ Vancouver, BC, Canada

FiLn: E COPX92

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized

Pub

lic D

iscl

osur

e A

utho

rized

CAMBODIA HEALTH SECTOR SUPPORT PROJECT

DRAFT ENVIRONMENTALREVIEW REPORT

Prepared for

East Asia Human Development Sector UnitThe World Bank

1818 H Street N.W.Washington, D.C., USA 20433

Prepared by

EVS Environment Consultants195 Pemberton Avenue

North Vancouver, BCCanada V7P 2R4

EVS Project No.

05/1112-01

2

TABLE OF CONTENTS

TABLE OF CONTENTS ................................................... 3ABBREVIATIONS AND ACRONYMS .................. ................................. 4EXECUTIVE SUMMARY ................................................... 5

1. INTRODUCTION---------------------------------------------------------------------------------101.1 Project Description ................................................ 101.2 Project Boundaries ................................................ 11

2. LEGISLATIVE AND INSTITUTIONAL------------------------------------------------------132.1 Environmental Assessment ................................................ 142.2 Pollution Control ................................................ 152.3 Pesticide Use ................................................ 17

3. ASSESSMENT METHODOLOGY-----------------------------------------------------------183.1 Assessment Scope and Content ....................................... 183.2 Assessment Procedures ...................... .......................... 19

3.2.1 Civil Works ................................................ 193.2.2 Disease Prevention and Control Programs .......................... ............ 20

4. PROJECT-RELATED ENVIRONMENTAL ISSUES ------------------------------------ 224.1 Civil Works ................................................ 22

4.1.1 Health Care Facility Construction and Rehabilitation ........................ 224.1.2 Laboratory Construction ................. ............................... 234.1.3 Drinking Water Quality ................ ................................ 254.1.4 Health Care Waste ................................................ 284.1.5 Wastewater ................................................ 314.1.6 Tuberculosis and HIV/AIDS ...................... .......................... 32

4.2 Malaria and Dengue Vector Control ..................................... 324.2.1 Pesticide Use ................................................ 324.2.2 Human Health Risks ................................................ 334.2.3 Environmental Risks ................................................ 34

5. ENVIRONMENTAL MITIGATION MEASURES ---------------------------------------- 365.1 Environmental Management Plan ...................................... 36

5.1.1 Health Care Facility Construction and Rehabilitation ........................ 365.1.2 Laboratory Construction ................. ............................... 375.1.3 Asbestos ................................................ 375.1.4 Drinking Water Quality ................ ................................ 385.1.5 Health Care Waste Management ........................................... 39

5.2 Pesticide Management and Monitoring Plan ............................................... 415.2.1 Malaria ........................................... 415.2.2 Dengue ........................................... 42

REFERENCES ........................................... 44ANNEX I - SUMMARY OF ENVIRONMENTAL ISSUES ....................................... 46ANNEX 2 - LIST OF CONTACTS ........................................... 52

3

ABBREVIATIONS AND ACRONYMS

CENAT National Center for Tuberculosis and Leprosy ControlCNM National Center for Parasitology, Entomology and Malaria ControlEIA Environmental Impact AssessmentEA Environmental AssessmentEC European CommissionEMP Environmental Management PlanEPI Extended Program of ImmunizationsER Environmental ReviewEVS EVS Environment ConsultantsHCF Health Care FacilitiesHCW Health Care WasteHCWM Health Care Waste ManagementHSSP Health Sector Support ProjectIEE Initial Environmental EvaluationISDS Integrated Safeguards Data SheetITN Insecticide Treated NetsJICA Japan International Cooperation AgencyMAFF Ministry of Agriculture, Forestry and FisheryMIME Ministry of Industry, Mines and EnergyMoE Ministry of EnvironmentMoH Ministry of HealthNCHADS National Center for HIV/AIDS, Dermatology and STINEAP National Environmental Action PlanNGO Non Government OrganizationNLDQC National Laboratory for Drug Quality ControlOD Operational DistrictPAD Project Appraisal DocumentPEO Provincial/Urban Environmental OfficePHD Provincial Health DepartmentPMMP Pesticide Management and Monitoring PlanPOP Persistent Organic PollutantsPVC Polyvinyl chlorideSFKC Social Fund of the Kingdom of CambodiaSTD Sexually Transmitted DiseaseSTI Sexually Transmitted InfectionsUNICEF United Nations Children's FundWHO World Health OrganizationWHOPES World Health Organization Pesticide Evaluation SchemeWWTP Wastewater Treatment Plant

4

EXECUTIVE SUMMARY

1. This report documents the findings of an environmental review (ER)completed for the World Bank Cambodia Health Sector Support Project (HSSP).The ER complies with the Bank's environmental review policy and procedures andenvironmental assessment guidelines. In addition, the ER references Cambodia'senvironmental laws, regulations, policies and other relevant legislation to ensurethat applicable environmental assessment requirements are fully addressed inproject implementation.

2. The HSSP project is classified as a Category B activity where limitedenvironmental analysis is considered appropriate to address specific environmentalissues. Potential environmental and human heal6i impacts of the project examinedin completing the ER were: construction and rehabilitation of health care facilities(HCF) focusing on civil works and related HCF operational issues such as drinkingwater supply; health care waste management (HCWM) practices; and pesticide usein malaria and dengue vector control programs. Environmental issues relevant tothese HSSP activities are detailed and recommendations made as to appropriatemitigation measures and monitoring programs with a view to guiding project designand incorporating appropriate management plans during HSSP implementation.

3. Extensive consultation was sought with the Ministry of Health (MoH), Ministryof Environment, provincial health authorities, and national and internationalorganizations involved in the provision of health care in Cambodia in completing theER to ensure that potential project impacts were fully understood and appropriateconclusions and recommendations were reached. Particular attention was given toobtaining inputs from targeted provinces and technical programs expected to beinvolved in HSSP delivery.

Health Care Facility Construction and Rehabilitation

4. Review of building locations and preliminary design specifications for HCF tobe constructed and rehabilitated at the provincial and district level as part of theHSSP indicates that hospitals and health center civil works does not pose anyserious environmental concerns and as such will not trigger assessment underCambodia's environmental impact assessment (EIA) guidelines. Notwithstanding,it is recommended that best environmental and occupational health practices befollowed during construction and rehabilitation to minimize or avoid any potentialminor adverse impacts.

Laboratory Construction

5. The new National Laboratory for Drug Quality Control (NLDQC) in PhnomPenh is expected to trigger additional assessment under Cambodian EIA

5

requirements. Anticipated construction-related environmental impacts of the newlaboratory are expected to be minimal as the site selected is situated in an existingbuilt urban area of the city. Adjacent land uses are multi-storey residential andinstitutional. No environmentally sensitive areas were identified in the projectvicinity. Recommendations are made as to assessment issues to be addressedduring both construction and operational phases. Construction mitigationmeasures encompass: occupational health and safety during demolition; nuisanceto neighbors, dust and noise emissions; and proper disposal of demolition materialsto landfills. It is recognized that greater emphasis should be given to operationallaboratory practices in satisfying assessment requirements. These include: airemissions containing pollutants harmful to the environment; laboratory wastewaterdisposal practices; and disposal of hazardous laboratory wastes. Waste generatedby the new NLDQC present special disposal concerns that will need to beconsidered. It is recommended that best availab(e disposal options be explored indetermining appropriate hazardous waste handling practices.

Drinking Water Quality

6. Ensuring the safe supply of drinking water to HCF as part of the HSSP is ofparamount concern. In completing the ER, the safety of drinking water sourcesavailable to HCF was examined. Particular attention was given to potential risksassociated with naturally occurring arsenic in groundwater and microbial waterquality. Both surface and groundwater are used as sources of drinking water inCambodia. Although surface water quality in generally very high and is thepreferred source of drinking water, an estimated 50% of the country's populationcurrently uses groundwater. Available water quality monitoring data indicates thatchemical water quality, particularly for surface waters, is generally very good inCambodia but that groundwater in certain areas of the country contains levels ofchemicals that could pose problems for human health. The most important of thesechemicals is arsenic - which has been found to exceed the World HealthOrganization (WHO) recommended limit of 10 pg/l in some provinces targeted bythe HSSP. Water quality data also indicates that microbial water quality is aserious concern for untreated surface waters and shallow groundwater obtainedfrom open wells. Microbial water quality is widely recognized as representing themost serious human health threat in Cambodia with infectious diseases orparasites being the most common and widespread health risk associated withdrinking water.

7. To address any concerns relating to HCF water supply, it is recommendedthat a water quality monitoring program be undertaken as part of HSSPimplementation to confirm that existing and intended water supply to HCF meetsWHO guideline values - particularly for microbial quality and arsenic content.Recognizing that the human health threat from bacteriologically unsafe drinkingwater is by far the most important water quality issue in Cambodia at the presenttime, emphasis is given in the ER to prescribing mitigative measures to ensure themicrobial water quality of drinking water supplied to HCF. Additional, mitigation and

6

remedial measures are outlined for situations where elevated arsenic levels arefound in drinking water sources.

Health Care Waste Management

8. Activities undertaken to improve health services will inevitably create wastethat is potentially hazardous. Health care wastes are typically more hazardous that

other types of wastes and are of concern in assessing planned health careimprovement activities. Exposure to hazardous health care waste (HCW) canresult in disease or injury to: medical doctors and nurses; auxiliary andmaintenance staff; patients and visitors; and workers at waste disposal facilities.To address these concerns, it is essential to put in place safe and reliable methodsfor handling and proper disposal of medical waste.

9. Generally accepted strategies for HCWM encompass: waste minimization,recycling, and reuse; ensuring proper handling, storage and transportation; andtreatment of waste by safe and environmentally sound methods. To ensure thatbest practices are promoted as part of the HSSP, specific recommendations aremade for:

* Adoption of strict waste segregation practices by HCF to ensure that wastesare properly identified and separated and that different waste streams arehandled and correctly disposed of.

* Expanded use of incineration to ensure proper treatment of wastesgenerated by HCF that cannot be recycled, reused or safely disposed of inlandfills; emphasis is given to the importance of proper incineration practicesto ensure that any environmental concerns are addressed.

* Land filling of wastes in sanitary or engineered landfills or controlleddisposal of health care wastes that cannot be safely incinerated as anacceptable disposal option if proper precautions are taken to minimizepotential exposure to infectious wastes.

10. Wastewater from HCF represents a sub-category of HCW that should beaddressed in planning construction and rehabilitation as part of the HSSP.Although wastewater from HCF is typically of a similar quality to urban wastewaterit may also contain potentially hazardous components of concern from a humanhealth perspective. Typically sewage discharged from HCF is greatly diluted and,as such, no significant health risks should be expected if effluents are treated inmunicipal wastewater treatment plants. In more remote locations where it is notfeasible to connect to municipal systems then appropriate precautions must betaken to avoid health risks associated with discharge of untreated or inadequatelytreated sewage to the natural environment. It is recommended that, wherepossible, HCF should be connected to municipal systems. Where there are nosewage systems, technically sound on-site sanitation should be provided.

7

11. Comprehensive guidelines have already been developed by the MoH to

address both waste management and hygiene issues at HCF. The guidelinesincorporate best HCWM practices and are intended for practical application at HCFwith limited available financial and technical resources. Additional guidelines on

injection safety have also been developed by the MoH to provide specific guidance

to HCF on the distribution, use, collection and safe destruction of disposablesyringes and safety boxes. Taken together, both sets of guidelines provide an

excellent basis for HCWM in HCF targeted by the HSSP.

12. Notwithstanding the availability of HCWM guidelines, it is recommendedthat capacity building be provided to improve site-specific waste managementpractices at HCF. Training in best HCW handling and disposal practices isexpected to create more awareness of HCWM issues and foster responsibility

among HCF staff in an effort to prevent occupatiAal exposure to HCW and relatedhealth hazards. Provisions should be made in HSSP implementation to ensure that

adequate waste handling and disposal infrastructure and management systems are

put into place at HCF.

Malaria and Dengue Vector Control Programs

13. All products intended for use in vector control programs to be funded underthe HSSP have successfully passed WHO's Pesticide Evaluation Scheme

(WHOPES). Chemicals currently recommended by WHO are considered to pose a

very low risk to humans if used correctly. Of the WHO recommended insecticidesfor malaria control, Deltamethrin, the chemical selected for the HSSP, is considered

one of the least toxic and highly unlikely to cause adverse effects at concentrationsnormally used. Results of human health risk assessments indicate that normal

exposure to this insecticide poses little or no hazard. Similarly, the larvicideTemperos, to be used in dengue vector control as part of the HSSP, has a very low

toxicity to humans. The Temperos formulation to be used in the HSSP (i.e., 1%sand granules) is thought to present a negligible risk to humans.

14. The toxicity of the insecticides/larvicides intended for use in HSSP malaria

and dengue vector control programs to non-target species varies widely.Laboratory and field test results indicate that Deltamethrin is only slightly toxic tobirds but is moderately to very highly toxic to fish and other aquatic organisms.Temperos has been shown to be highly toxic to some bird species but moderatelytoxic to others. It is considered highly toxic to bees and moderately to highly toxic

to fish. Both Deltamethrin and Temperos have been shown to be very highly toxicto aquatic invertebrates. Environmental risks to non-target species, particularlyaquatic organisms, can result from the unintentional release of these chemicalsthrough improper handling or disposal. Although Deltamethrin and Temperos are

highly toxic to aquatic organisms, under normal circumstances only small amounts

of these pesticides are likely to be released into ponds, streams and rivers. Of the

two chemicals, Deltamethrine is more likely to enter the natural environment as a

result of washing of insecticide treated nets in streams and ponds. No scenarios

8

were identified where Temperos might be released unintentionally to the naturalenvironment.

15. Recognizing that all pesticides are toxic to some degree, it is paramount toensure that proper care and handling practices form an integral part of any programinvolving their use. To this end, appropriate mitigation measures and bestmanagement practices are recommended with a view to minimizing or avoiding anypotential adverse human health or environmental effects associated with the use ofinsecticides/larvicides in malaria and dengue programs to be undertaken as part ofthe HSSP. Guidelines and training materials already developed for vector controlprograms in Cambodia represent best available practices and provide adequatesafeguards. Recommended enhancements are intended to build upon existingsafeguards including: elaboration of guidelines covering safe transport and storageof chemicals; strengthening occupational health guidelines to better addresschemical-handling risks; additional training for health workers and compliancemonitoring to ensure adherence to guidelines; and extension of training to localcommunities to more explicitly address environmental risks.

9

1. INTRODUCTION

16. EVS Environment Consultants (EVS) were tasked with undertaking anenvironmental review (ER) of the planned World Bank Cambodia Health SectorSupport Project (HSSP). The ER complies with the Bank's environmental reviewpolicy, procedures and environmental assessment guidelines. In addition, the ER

documents Cambodia's environmental laws, regulations, policies and other relevant

legislation to ensure that applicable environmental assessment requirements arefully addressed in project implementation.

17. This ER assesses potential environmental and human health impacts of

the planned project, particularly with regard to: (a) construction and rehabilitation ofhealth care facilities (HCF) focusing on operational health care waste management(HCWM) practices, incinerator use, arsenic in groundwater, and extraction ofasbestos when present during civil works; and (b) pesticide use in malaria anddengue vector control programs. Environmental issues relevant to these HSSPactivities are detailed in the body of the report. Recommendations are made as toappropriate mitigation measures and monitoring programs with a view to guidingproject design and incorporating appropriate management plans during HSSPimplementation. Specific questions on environmental issues included in the Project

Appraisal Document (PAD) and Integrated Safeguards Data Sheet (ISDS) areaddressed in Annex 1.

1.1 PROJECT DESCRIPTION

18. The planned HSSP is intended to contribute to the improvement of thehealth status of the Cambodian population through: (a) supporting thegovernment's health sector reform process and the strengthening the sector'scapacity to manage resources efficiently; and (b) improving the health system'sability to provide quality services. Main components of the project are:

Component I - Improved delivery of health services aims at increasing theaccessibility, quality and affordability of primary health care and first referralservices through financing of civil works, medical equipment, support for a hospitalmaintenance system, pharmaceuticals, a quality assurance program, contracting ofhealth services to non government organizations (NGO), support for specificschemes to protect the poor, and training for program implementation.

Component 2- Support to programs addressing public health priorities aims atstrengthening infection disease control epidemics and improving the overallnutritional focus on the poor, children and mothers. Sub-components includemalaria, dengue, tuberculosis, HIV/AIDS and STD, nutrition, and safe motherhood.

10

Component 3 - Strengthening institutional capacity aims at strengthening Ministryof Health (MoH) management capacities, strengthening health administration atdecentralized levels, and developing human resources. Specific activities willinclude implementation of sector reform measures, capacity building in healthservices planning and management, provision of training, and development ofmonitoring and evaluation indicators.

1.2 PROJECT BOUNDARIES

19. Component 1 of the HSSP - involving rehabilitation of HCF will beundertaken in a total of twelve Cambodian provinces, namely: (1) Banteay MeanChey; (2) Bat Dambang; (3) Kampong Spueu; (4) Kampong Thum; (5) Kampot;(6) Kracheh; (7) Krong Kaeb; (8) Krong Pailin; (9) Otdar Mean Chey; (10) Pousat;(11) Preah Vihear; and (12) Stueng Traeng.

20. The HCF to be targeted in each province under this component will befinalized during the project preparation stage. The initial phase of the HSSP willfocus on health facilities being direly in need of rehabilitation works, and on thebasis of utilization rates, numbers of inhabitants in the catchment area, distance toa public or private facility and availability of health providers in the facility. Healthfacilities eligible for funding under this component will include provincial hospitals,district first referral hospitals, health centers and pharmacies.

21. At time of writing, HCF to be constructed and rehabilitated underComponent 1 are being prioritized based on poverty levels, available facilities andmissing facilities in operational districts (OD) of the provinces targeted by theproject. Over the five-year project implementation period, it is anticipated that civilworks will include rehabilitation and extension of sixteen existing Referral orProvincial hospitals, the construction of twenty-four Health Centers and therehabilitation/extension of forty-six existing Health Centers. The project will alsoprovide for the construction of six District Offices and ten Pharmacies. In addition,under the Accessibility and Quality of Health Services sub-component, the projectwill finance the construction of a new building for the National Drug Quality ControlLaboratory (NDQCL).

22. Implementation of activities to be undertaken under Component 2comprising infectious disease control programs (i.e., dengue, HIV/AIDS,tuberculosis and malaria), nutrition and safe motherhood will be delivered in allprovinces covered by the HSSP. Minimal activities are planned in thepredominantly urbanized provinces of Kandal, Phnom Penh, and Siem Reab. Thescope and extent of implementation strategies will vary among programs asfollows:

* Malaria vector control support for the MoH's National Malaria Control Programincluding procurement of environmentally safe chemicals for use in theirinsecticide treated bed-net and hammock-net activities in areas of hightransmission risk.

11

* Logistical and training support for dengue vector control activities to beexecuted by the World Health Organization (WHO).

* Technical assistance and management, training, procurement and minor civilworks (i.e., excluding HCF rehabilitation) support for the MoH's TuberculosisProgram at the district and provincial levels.

* Procurement support for HIV/AIDS programs at the provincial level.

* Capacity building support to improve capacity to deliver nutrition services atthe national level and at provincial, district, and health center levels.

* Supporting the MoH strategy to reduce maternal mortality throughinfrastructure improvement, procurement support, and training.

23. Capacity building for health sector refornr under Component 3 of the HSSPwill involve strengthening of MoH management and institutional capacity anddevelopment of human resources at the central, provincial and OD level.

12

2. LEGISLATIVE AND INSTITUTIONAL

24. This section provides an overview of applicable legislation, and institutionalarrangements pertaining to environmental protection and management inCambodia. Particular attention is given to legal and administrative requirementsthat must be addressed in completing in assessing potential environmental andhuman health impacts of HSSP activities.

25. The Law on Environmental Protection and Natural Resource Management(1996) provides for: (i) protection and promotion of environmental quality and publichealth through the prevention, reduction and contpol of pollution; (ii) assessment ofenvironmental impacts of all projects subject to g6vernment decision; (iii) rationaland sustainable conservation, development, management and use of naturalresources; and (iv) public participation in environmental protection and naturalresource management. Responsibility for enforcing the law is under the Ministry ofEnvironment (MoE) either by themselves or in collaboration with other concernedministries and institutions. Pursuant to this law, national and regionalenvironmental plans were to be prepared and sub-decrees promulgated to enforcespecific provisions of the law.

26. Cambodia's environmental policy and strategic framework forenvironmental management is detailed in the 1998 National Environmental ActionPlan (NEAP) (MoE, 1998). The NEAP predominantly focuses on forestry, fisheries,agriculture, biodiversity and protected areas and energy development but alsocontains policy guidance on urban waste management including disposal of solidwastes, special wastes and wastewater.

27. A key issue highlighted for the topic of solid waste concerns "disposal ofhazardous industrial waste, medical waste and other toxic waste into open landfillsor illegal vacant lots, swamps, waterways, and drainage canals, creates majorpublic health and environmental problems." The NEAP notes that Cambodia lacksthe capacity to properly dispose of special waste including medical wastescontaining pathological wastes, syringes and bandages which are commonlydisposed of in open landfills.

28. Strategies outlined in the NEAP to improve waste management includeupgrading of existing landfills and construction of new sanitary landfills to ensurethat they meet adequate environmental and public health standards. The NEAPhighlights the desirability of constructing a pilot medical waste disposal facility inPhnom Penh and provision of training to medical personnel in ensuring properhandling of hazardous medical waste. It was noted that proper disposal wouldminimize the risk of exposing the public to the adverse health and environmentalhazards associated with inappropriate disposal of medical waste.

13

29. Implementation of the strategies outlined in the NEAP was to be in twophases: Phase I (years 1-2) covering the development of an effective policy andregulatory framework on environmental and sanitation standards; and Phase II(years 3-5) covering improving the disposal of solid waste to minimize adversepublic health and environmental impacts.

30. Specific sub-decrees that were subsequently promulgated to effectprovisions of the Law on Environmental Protection and Natural ResourceManagement relating to environmental assessment and pollution control aredetailed in the follow sections. Corresponding management initiatives taken by theMoE in responding to priority issues identified in the NEAP are also described.

2.1 ENVIRONMENTAL ASSESSMENT

31. The Sub-decree on Environmental Impact Assessment Process (1999)provides for assessment of potential environmental effects associated with everyproposed and ongoing project and activity by either private, joint venture or stategovernment and ministry institutions. Responsibility for review and approval ofproposed projects is under the MoE's Department of Environmental ImpactAssessment Review. The MoE is responsible for: (i) scrutinizing and reviewing EIAreports prepared by project proponents in collaboration with other concerningministries; and (ii) follow up, monitor and taking appropriate measures to ensurethat the project proponent adheres to the environmental management plan (EMP)conditions specified on project approval. If proposed projects or activities are totake place at the provincial level, the sub-decree requires that project proponentsconsult with the relevant Provincial/Urban Environmental Office (PEO). Forpurposes of the HSSP it will be necessary to consult with the provincial MoEauthorities to discuss potential site-specific environmental concerns andassessment requirements - building renovations are not normally subject toassessment but the PEO must review construction plans and permits prior toconstruction proceeding.

32. An annex of the sub-decree lists projects that are subject to an initialenvironmental evaluation (IEE) or full EIA. In completing the ER, a clarification wassought from the MoE as to whether hospitals and hospital operations are subject toenvironmental assessment under this sub-decree. They advised that size andthreshold triggers apply to infrastructure projects - new hospital buildings > 12m inheight or with a floor space > 8,000 m2 will trigger an IEE or EIA.

33. Draft Guidelines for Conducting Environmental Impact Assessment (EIA)Report have been prepared by the MoE to provide a standardized reportingtemplate for project proponents. Specific guidance is provided on the scope andcontent of an IEE or EIA report including: (i) description of environmentalresources at risk; (ii) public participation; (iii) analysis of environmental impacts; (iv)mitigation measures; (v) environmental management plan (EMP); and(vi) institutional capacity.

14

2.2 POLLUTION CONTROL

34. The Sub-decree on Solid Waste Management (1999) is intended toregulate solid waste management in a proper technical manner and safe way toensure the protection of human health and the conservation of biodiversity. Thissub-decree applies to all activities related to disposal, storage, collection, transport,dumping of garbage and hazardous waste. 'Solid waste' refers to hard objects,hard subjects, and products or refuse which are intended or required to bedisposed of. 'Hazardous waste' is further defined as: radioactive substances,explosive substances, toxic substances, inflammable substances, pathogenicsubstances, irritating substances, corrosive substances, oxidizing substances, orother chemical substances which may pose a da(ger to human health and theenvironment. Specific articles dealing with hazardous waste management include:

* MoE shall establish guidelines for the management of hazardous waste toensure their safe management.

* MoE shall stipulate quantities of toxins or hazardous substances in hazardouswaste that can be disposed of.

* The owner of hazardous waste is responsible for safe temporary storage oftheir waste.

* The owner of hazardous waste shall submit quarterly reports to MoEspecifying type and quantity of waste, temporary storage method, andtreatment or elimination method.

* Storage, transportation and disposal of hazardous waste is to be separatefrom household wastes.

* Owners of landfills receiving hazardous waste shall report quarterly to MoEspecifying type and quantity of waste, sources, handling and processing.

35. Hospitals and health clinics are specifically required under the sub-decreeto report to the MoE on types and quantities of hazardous waste generated, andstorage, treatment and disposal methods. No specific requirements or guidance onactual treatment methods are provided in the sub-decree.

36. The MoE have advised that actual enforcement of provisions of this sub-decree has been limited to date; reflecting the lack of appropriate facilities forhandling hospital waste in Cambodia. Although the majority of hospitals arecurrently employing incineration to treat selected hospital wastes, plastic wastescontinue to be disposed to open landfills. The MoE are currently drafting guidelinesfor handling of hospital wastes. They have already completed a survey of wastestreams generated by urban hospitals in Phnom Penh and are seeking inputs fromhospitals on practical and affordable management practices. The MoE are stillexamining the issue of incinerator use by hospitals and identified environmentalconcerns - primarily air pollution and Cambodia's obligations under international

15

conventions on climate change and persistent organic pollutants (POPs) - relatingto the use of incineration as the preferred treatment method. Recognizing the

concerns of the MoE regarding incinerator use, additional consultation should be

sought with the Ministry concerning the possible expanded use of small incinerators

in rehabilitated and new HCF under the HSSP.

37. The Sub-decree on Pharmaceutical Management (1996) applies to HSSP

activities involving purchase and distribution of drugs in HCF. This sub-decree

encompasses prescription of drugs at pharmacies, private clinics and public health

units and is intended to closely track usage of drugs, particularly restrictedsubstances such as opiates. Provisions of the sub-decree apply to all aspects of

drug procurement, storage, handling and disposal. Actual disposal of expired

drugs is covered by the Sub-decree on Solid Waste Management.

38. The Sub-decree on Water Pollution Control (1999) provides for water

pollution control through prevention and reduction of water pollution in public waters

to ensure the protection of human health and conservation of biodiversity. The

sub-decree is broadly defined to include surface waters - canal systems, streams,

rivers, ponds, lakes, and the sea - and groundwater. Specific articles dealing with

pollution include:

* Defining 'pollution sources' as any premise or facility from which wastewater,solid waste, sewage, pollutants or hazardous substances are directly or

indirectly discharged into water areas or drainage systems.

* Defining 'pollution' as any substance that can cause any physical, chemical or

biological change in receiving water characteristics.

* 'Hazardous substances' are further defined as any substance that endangersliving organisms or adversely impacts or damages the environment.

* Discharge of potentially polluting substances are subject to effluent discharge

standards enforced by the MoE.

39. Of relevance to the HSSP, this sub-decree encompasses solid wastes and

garbage and provides that the storage and disposal of solid wastes or any garbage

and hazardous wastes that lead to pollution of water be prohibited. Hospitals and

clinics are specifically listed as pollution sources required to have securedpermission from the MoE before discharging.

40. In responding to specific HCWM issues of concern in Cambodia, the MoH

have developed comprehensive Waste Management Guidelines covering all

aspects of waste management and hygiene at HCF. In addition, the MoH have

promulgated a National Policy for the Safety of Injections and a corresponding

Strategic Plan of Action to address safety issues relating to an extended program of

immunizations (EPI) initiative being carried out countrywide. Detailed Injection

Safety Guidelines for Referral Hospitals have also been developed to provideguidance to health care workers on the safe distribution, use, collection, and

destruction of disposal syringes and safety boxes.

16

2.3 PESTICIDE USE

41. Although mention is given to pesticides in the fisheries section of theNEAP, no specific strategies or guidelines are outlined other than identifying theneed to strengthen existing laws by including national standards to regulate theimport or manufacture, sale or application of agro-chemicals such as fertilizers,pesticides, and herbicides. A recommendation is made to ban the import and/oruse of extremely hazardous pesticides to prevent harm to ecologically sensitive fishhabitats.

42. In completing the ER, clarification was sought from the MoE as to whetherprovisions of the Sub-decree on Standard and Mahacement of AgriculturalMaterials (1998) might apply to the HSSP. They advised that this sub-decree waspromulgated by the Ministry of Agriculture, Forestry and Fishery (MAFF) and isintended to regulate the use of agricultural materials such as agricultural pesticidesand therefore does not cover chemicals typically used as part of malaria anddengue vector control programs.

43. At present there are no specific policies or guidelines regarding safehandling and use of pesticides intended for use in public health programs inCambodia. The MoE are currently drafting a new Law on Hazardous SubstanceControl that will include provisions for the safe handling and use of pesticides usedin public health programs; this law will likely come into effect by 2004.

17

3. ASSESSMENT METHODOLOGY

3.1 ASSESSMENT SCOPE AND CONTENT

44. Bank environmental review requirements pertaining to the HSSP aresummarized in this section. The following sections provide a synopsis of theprocedures that were applied in assessing environmental issues for each of theproject components.

45. Environmental review is required for all Bank loans and credits to ensurethat environmental issues are identified early in the project cycle. The overallintention of the ER is to demonstrate that potentiab'project-related environmentalimpacts are well understood and that appropriate mitigation measures areincorporated during the design phase and throughout project implementation. Theintensiveness of ER necessary for specific projects is dependent on the nature,magnitude and sensitivity of the environmental issues identified during initial projectscreening. Environmental review may entail preparation of a full environmentalassessment (EA), a more limited environmental analysis, or no further analysis atall. Bank projects are assigned to one of four categories for ER purposes:

Category A - EA is normally required as the project may have diverse andsignificant environmental impacts.

Category B - More limited environmental analysis is appropriate, as the projectmay have specific environmental impacts.

Category C - Environmental analysis is normally unnecessary, as the project isunlikely to have significant environmental impacts.

Category D - Environmental projects for which separate EAs are not required, asenvironment is the major focus of project implementation.

46. Following screening of the project by Bank staff to determine the type ofER to be conducted; the HSSP project was classified as a Category B activitywhere limited environmental analysis was considered appropriate to addressspecific environmental issues. Particular issues identified for examination incompleting the ER were:

* Civil works planning and implementation. Particular emphasis was to begiven to: (i) ensuring the safety of drinking water supply to new andrehabilitated HCF; and (ii) safe removal of hazardous building materials ifpresent in HCF targeted for rehabilitation.

* Solid and liquid waste collection, disposal and management at HCF.Particular attention was to be given to HCWM practices.

* Potential health and environmental impacts related to the use of pesticidesin malaria and dengue vector control programs. Emphasis was to be given

18

to assessing the safety of all chemicals used and on recommendingappropriate occupational health and environmental safeguards.

3.2 ASSESSMENT PROCEDURES

47. Extensive consultation with MoH staff, provincial health departments (PHD)and MoH partners was sought in completing the ER to ensure that potential HSSPimpacts were fully understood and appropriate conclusions and recommendationswere reached. Particular attention was given to obtaining inputs from technicalprograms expected to be involved in project delivery. A list of contacts is providedas Annex 2 to this report.

3.2.1 Civil Works

48. Interviews were completed with MoE, MoH, PHD and Social Fund of theKingdom of Cambodia (SFKC) representatives to identify potential environmentalimpacts of planned new construction and rehabilitation of HCF. Field visits toreferral hospitals in Banteay Mean Chey and Bat Dambang provinces provided anopportunity to review rehabilitation plans and complete a preliminary assessment ofsite-specific environmental issues. Follow up discussions were completed with theMoH to obtain additional details of the design specifications for new health centerand referral hospital construction. Preliminary drawings for the proposed newNLDQC in Phnom Penh were also reviewed with the laboratory Director todetermine whether this construction will trigger an assessment under CambodianEIA requirements and to characterize potential environmental issues to beaddressed in completing an assessment.

49. Consultations were also completed with specialists from the NGO Partnersfor Development, the United Nations Children's Fund (UNICEF) and the WorldHealth Organization (WHO) to discuss the issue of drinking water quality at HCF inCambodia. Results of water quality monitoring programs completed to date by theJapan International Cooperation Agency (JICA), UNICEF and the WHO werereviewed to characterize human health threats related to drinking water used byHCF. Although emphasis was given to determining whether naturally occurringarsenic in groundwater presents a threat to patients, attention was also given tooverall drinking water quality (e.g., microbiology).

50. Bank environmental assessment guidelines (World Bank, 1991 a,b)provided the analytical framework for evaluating potential environmental issuesrelating to planned HSSP civil works activities. Specific aspects considered inanalyzing HCF construction and rehabilitation included:

* Destruction or degradation of environmentally sensitive areas

* Loss of existing land uses

* Air pollution19

* Surface and groundwater pollution

* Solid waste pollution (e.g., handling and disposal of hazardous constructionmaterials such as asbestos roof tiles)

* Drinking water sources and quality (e.g., arsenic).

51. Health care waste (HCW) generated by new and rehabilitated HCF wasconsidered as a discrete issue in completing the ER. During site visits to referralhospitals in Banteay Mean Chey and Bat Dambang, a Health-Care WasteManagement Rapid Assessment Tool developed by the WHO (2002) was appliedto compile information on existing HCWM practices. This tool provided a basis forgathering information at HCF visited and in questioning hospital staff. Hospitalsvisited were intended to be representative of goon and poor HCWM practices at theOD level. Information gathered at each hospital covered: geographical situationand catchment population; health care services provided; staffing levels; types ofHCW generated; HCW segregation and handling; HCW storage containers; HCWstorage areas; HCW collection and on-site transport; HCM off-site transport; HCWtreatment; HCW final disposal; HCWM regulations and guidelines; HCW policy andbudget; and sanitation and wastewater.

52. On completion of the field visits, follow up discussions were held with thePHD and MoH to discuss HCWM problems identified and simple, practical actionswhich should be taken to solve them.

3.2.2 Disease Prevention and Control Programs

53. Interviews were completed with both national and internationalorganizations to review potential environmental impacts associated with thedelivery of disease prevention and control programs. Malaria and denguespecialists from the National Center for Parasitology, Entomology and MalariaControl (CNM), the European Commission (EC), and the WHO providedcomprehensive inputs concerning the scope and content of vector control programsto be implemented under the HSSP. Particular attention was given tocharacterizing the way that insecticides are selected and handled in ITN distributionand dengue larviciding programs with a view to determining where there may bescope for improving practices to limit risk of adverse occupational andenvironmental impacts occurring as a result of using of these insecticides. Specificissues examined were:

* Insecticides used, formulation, and dosage

* Distribution strategies

* Storage, transport and disposal

20

* Information, education and communication

* Environmental and human health issues.

54. Additional consultations were completed with the National Center forHIV/AIDS, Dermatology and STI (NCHADS) and the National Center forTuberculosis and Leprosy Control (CENAT) to characterize the activities to befunded under the HSSP and identify any relevant environmental issues. A visit wascompleted to the National Tuberculosis Center to view HCWM practices. Emphasiswas given to assessing potential environmental issues relating to infectious wastesgenerated during treatment - handling and disposal of infectious wastes isaddressed as part of the HCWM topic.

21

4. PROJECT-RELATED ENVIRONMENTAL ISSUES

4.1 CIVIL WORKS

4.1.1 Health Facility Construction and Rehabilitation

55. At time of writing, building locations and design specifications for HCF tobe constructed and rehabilitated at the provincial and OD level as part of the HSSPhad not been finalized. Review of the preliminary design models for referralhospitals indicates that hospital construction will not trigger an assessment underthe MoE EIA guidelines - new full service referralpospitals (i.e., inpatients,outpatients, surgery, x-ray, laboratory, emergency, ambulance, patient wards,maternity, blood bank, pharmacy, janitorial, kitchens, administration) are expectedto have a total floor space of approximately 2,000 m2 which is well within the 8,000m size threshold for new buildings requiring assessment. Building height is notexpected to exceed 6 m; again well within the 12 m height threshold. Similarly,design models for health centers - both outpatients and combined outpatients andinpatients - provide for modest sized buildings with a maximum floor space of 110m2 and a height not exceeding 6 m. As such, health center construction is notsubject to assessment.

56. Although environmental assessment is not required for HCF constructionand rehabilitation, best practices should be followed to preempt any potentialhuman health and environmental impacts. Particular attention should be given theproper handling and disposal of hazardous building materials such as asbestos thatmay be present at facilities undergoing rehabilitation.

57. Asbestos - a fibre mined in several countries - has been widely usedworldwide as a construction material and insulator because of its strength,durability and heat resistance characteristics. In recent years, evidence on theadverse health effects of exposure to asbestos has been mounting globally leadingto urgent calls to cease production of the most-harmful asbestos types, limit the useof less-harmful asbestos (e.g., discontinued spraying of asbestos), and to imposestrict exposure standards for workers handing raw asbestos and asbestos-containing products. Occupational exposure to asbestos by inhalation can causeasbestosis (scarring of the lung tissue), lung cancer, and mesothelioma (cancer ofthe lung's lining). In developed countries, occupational asbestos exposure isthought to have peaked in the 1970's but the effects of exposure continue tomanifest themselves today with an estimated 30,000 new asbestos-related cancersbeing diagnosed every year.

58. The surge of asbestos use in developing countries as they increasinglyindustrialize has raised concerns of a second epidemic of asbestos-related cancerdeaths over the next three decades. Although the use of asbestos has fallen indeveloped countries, it has climbed dramatically in developing countries in the past

22

twenty years. For example, asbestos consumption in Thailand rose from 21,271metric tons in 1970 to 164,000 metric tons in 1994. In Thailand, asbestos is usedextensively in the manufacture of construction materials such as roofing, flat sheetsfor wall and water pipes - these fibre cement products typically contain 13%asbestos by weight. Demand for asbestos building materials is expected to remainhigh in developing countries due the their low cost compared to alternatives suchas polyvinyl chloride (PVC) plastics and galvanized metal.

59. Occupational health risks posed by asbestos in Cambodia are difficult toquantify because of limited information concerning the use of asbestos buildingmaterials. Consultations with the SFKC, who are responsible for government civilworks in Cambodia, suggest that asbestos may be a problem in existing buildingcontaining fibre cement products. While clay roofing tiles are the preferred roofingmaterial used in provincial and district HCF, fibrescontaining ceiling sheeting is acommonly used building material in Cambodia. Since 2000, the SFKC havespecified that asbestos-fibre concrete building materials are no longer permissible -construction is closely supervised to ensure that contractors do not use cheapasbestos materials manufactured in Thailand.

4.1.2 Laboratory Construction

60. Review of preliminary drawings for the planned new NLDQC in PhnomPenh indicates that the laboratory will trigger an assessment underCambodian EIA requirements. Although the total planned building floor space ofapproximately 2,000 m2 falls within the size threshold, the approximately 20 mheight of the building, necessary to fit the laboratory within the available confinedsite, exceeds the 12m height threshold. Discussions should be initiated with theMoE at the earliest possible time once final preliminary drawings have beenprepared. Review of architectural and engineering specifications by the MoE willensure that environmental considerations are properly addressed at the planningand design stage.

61. The new NLDQC laboratory is situated in an existing built urban area ofthe city and will occupy a site that currently contains two derelict concrete buildings- the existing structures on the site are a MoH warehouse and the oldEpidemiology Institute buildings. These structures will be demolished. Adjacentland uses are multi-storey residential and institutional. No environmentallysensitive areas were identified during a site visit.

62. Although minimal construction phase impacts are considered likely,attention should be given to:

* Occupational health and safety during demolition (e.g., caution should betaken when handling hazardous building materials such as friable asbestos)

* Nuisance to neighbors from increased construction vehicular traffic, dustand noise emissions

23

* Disposal of demolition materials to landfills

* Surface water run-off from the construction site.

63. It is expected that greater emphasis will need to be given to operationallaboratory practices in completing an IEE or EIA. Recommended guidelines forassessing laboratory operations (U.S. EPA, 2000) provide a useful analyticalframework for assessing the planned NLDQC laboratory. Key issues that shouldbe considered are:

Air Emissions - Steps should be taken to minimize emissions from the newlaboratory because even small amounts of pollutants can be harmful to theenvironment. Air emissions are also a potential occupational health issue. In orderto understand the risk posed by air emissions it v11 be necessary to identify airemissions sources in the laboratory (e.g., fume hoods, stacks, vents) and toquantify actual and potential emission levels. Emphasis should be given toidentifying the most air volatile and commonly used chemicals, such as organicsolvents, as well as any especially hazardous or stringently regulated chemicals.

Water Discharges - Proper disposal of wastewater is essential to ensure thatenvironmental problems do not occur as a result of laboratory operations. Carefulcontrol and disposal of chemical wastes via sewer systems is desirable because itminimizes wastes sent off-site but precautions must be taken to ensure thatchemicals are not improperly disposed of down sink drains. To completelyunderstand and effectively manage wastewater, it will be necessary: to inventorywastewater discharges; evaluate programs and practices for preventing,controlling, and minimizing wastewater; and review existing operating andmaintenance procedures for wastewater collection and treatment as part of anenvironmental assessment with a view to affecting improvements.

Hazardous Wastes - Managing the generation and disposal of hazardous wastesis one of the most difficult challenges for laboratories. Common issues to addressinclude classification, storage, labeling, emergency preparedness, and treatmentand disposal of laboratory wastes as well as identifying opportunities to minimize itsgeneration. It is common for laboratories to generate waste streams that contain acombination of chemical, biological, or radioactive substances necessitating thatappropriate treatment technologies give priority to constituents that pose thegreatest hazard. Best management practices for laboratories that generatehazardous waste depend on how much waste they generate and accumulate in acertain time period. For this reason, it will be necessary to make an initialdetermination of the quantity and composition of hazardous waste expected to begenerated by the new NLDQC laboratory. Once hazardous waste projections areavailable, the laboratory can then develop waste handling and storage practicesand procedures based on applicable requirements and regulations. Finally,laboratories must consider transportation and disposal procedures. If on-sitetreatment is not appropriate, then the laboratory must transfer its hazardous wasteto a regulated disposal or recycling facility.

24

4.1.3 Drinking Water Quality

64. Considerations relating to ensuring the supply of safe drinking water tonew and rehabilitated HCF are outlined in this section. Particular attention is givento potential risks associated with arsenic in groundwater and microbial waterquality.

Arsenic

65. The potential for naturally occurring arsenic to appear in groundwater wasidentified as a concern in connection with provision of safe water supply to HCF. Inrecent years, it has become increasingly apparent that drinking water guidelinesare quite frequently exceeded in available water sources worldwide. Arsenic is nowrecognized as one of the most serious inorganic Aontaminants in drinking water ona global basis (UN/WHO, 2001). The most serious groundwater problem identifiedto date has been in Bangladesh where very high arsenic levels in groundwateraffects drinking water wells. The heavy reliance on groundwater for public drinkingwater supply in Bangladesh has resulted in an estimated 40 million people havingbeen exposure to high arsenic levels. Consumption of elevated levels of arsenic indrinking water over long periods of time has been associated with a variety ofhuman health problems including skin disorders and respiratory, cardiovascular,immune, reproductive, gastrointestinal and nervous system ailments.

66. Both surface and groundwater are used as sources of drinking water inCambodia. Although surface water quality in generally very high and is thepreferred source of drinking water, an estimated 50% of the country's populationcurrently uses groundwater. A recently completed water quality study indicatedthat groundwater from certain areas of the country contains levels of arsenic thatcould pose problems for human health (Feldman, 2001). Arsenic levels measuredare summarized by province in Table 1. These values represent the highest or'worst case' arsenic levels measured for individual wells in each province - spatialvariability for arsenic is typically high and it is not unusual to get widely differentmeasurements even for wells located in the same village. Study results reveal thatseveral water sources, in both urban and rural locations, were found to containarsenic concentrations above WHO's recommended limit of 10 pg/I (WHO, 1993).The highest arsenic concentrations were detected in Kandal Province - wells in TaKhmau were found to contain between 30 and 90 pg/l. Elevated levels were alsodetected at sampling locations in Kracheh, Svay Rieng, Kampong Thum and BatDambang provinces.

25

Table I Overview of groundwater arsenic levels in Cambodia.

Province Arsenic Concentration (pgIl)

Banteay Mean Chey <10

Bat. Dambang > 50

Kampong Cham <10

Kampong Chhnang <10

Kampong Speue <10

Kampong Thum 10 - 50Kampot _ No DataKandal 0- -50Kaoh Kong . No Data

! Krachelh > 50Krong Kaeb No DataKrong Pailin No DataKrong Preah Sihanouk No DataMondol Kir No DataOtdar Mean Chey No DataPhnom Penh 50 -100

Pousat . . < 10

Preah Vihear: No Data

Prey Veaeng < 10

Rotanak Kiri No Data

Siem Reab <10

StuengTraeng No Data

Svay Rieng 10-50Takaev < 10

67. It is noted that monitoring of arsenic in groundwater has not yet beencompleted in all twelve provinces targeted by the HSSP (indicated by shading inTable 1). Feldman's (2001) study covered only thirteen of the twenty-fourprovinces and municipalities of Cambodia due to budget and time constraints.Follow up sampling completed by the WHO and UNICEF subsequently includedStueng Traeng Province and increased the number of wells sampled -groundwater arsenic in Stueng Traeng was found to exceed 10 pg/l. JICA havealso completed extensive sampling of villages in Central and Southern Cambodia.Although these studies augment the spatial coverage of groundwater arsenicsurveys in Cambodia some data gaps remain in the HSSP provinces. Specifically,

26

limited or no data is presently available for Kampot, Koah Kong, Krong Kaeb, KrongPailin, Otdar Mean Chey, and Preah Vihear. Of these provinces, it is likely that lowarsenic levels are prevalent in Kampot and Krong Keab (P. Feldman, PersonalCommunication). The surficial geology of Cambodia is dominated by the Mekongand Tonle Sap river systems. Study results suggest that elevated arsenic levelsare closely correlated with alluvial sediments (i.e., river deposits). Lowergroundwater arsenic levels have been measured in the southeastern,southwestern, and northeastern provinces where bedrock lies closer to the surface.Extrapolating from available geological and groundwater survey data suggests thatgroundwater arsenic may be elevated in Krong Pailin and Preah Vihear, with lowerlevels likely in Otdar Mean Chey (P. Feldman, Personal Communication).

68. There are currently no standards or regulations concerning drinking waterquality in Cambodia; although it was learned that,(he Ministry of Industry, Minesand Energy (MIME) are in the process of developing guidelines. In the absence ofnational guidelines, WHO guidelines values can be used to evaluate the potentialhuman health impacts of drinking water sources. It is important to note that theWHO guidelines are not intended as standards but instead as guidance values ininterpreting data. In reviewing survey results, it should be recognized that theWHO's provisional guideline for arsenic of 10 pg/I may not be practical for manydeveloping countries to achieve. For this reason, an action level of 50 pg/l hasbeen proposed by UNICEF in Cambodia. The provisional WHO guideline of 10 pg/lis considered appropriate for a long-term goal but may be overly stringent in thenear term given the difficulty of measuring trace arsenic and the expense oftreatment at such low levels. Instead an interim standard of 50 pg/I isrecommended - this represents the current drinking water standard in mostcountries. Further, a tiered-system of categorizing risk is suggested where: (i) no

actions are necessary when arsenic concentrations are < 10 pg/l; (ii) arsenicconcentrations of 10 - 50 pg/l are ranked as a medium priority triggering additionaltesting to assess the geographical extent of the problem and periodic monitoring to

assess temporal changes; and (iii) arsenic concentrations > 50 pg/l are a highpriority requiring treatment of affected drinking water or substitution of alternativewater sources.

Microbial Water Quality

69. Problems posed by bacteriological contamination of drinking water supplycontinues to be the most important health related concern in Cambodia's watersupply sector. Feldman (2001) emphasizes that the human health threat frombacteriologically unsafe drinking water is by far the most important water qualityissue in Cambodia at the present time and urges that national attention shouldcontinue to focus on this well-documented public health threat. Recognizing thisthreat, both the WHO and UNICEF have recommended that attention also be givento ensuring microbial water quality of drinking water supplied to HCF under theHSSP. To this end, recommendations contained in Section 5.1 - EnvironmentalManagement Plan are intended to ensure the overall quality of drinking waterutilized by hospitals and health centers.

27

4.1.4 Health Care Waste

70. Activities undertaken to improve health services will inevitably create waste

that is potentially hazardous. Health care wastes are typically more hazardous that

other types of wastes and are of concern in assessing proposed health careimprovement activities. To address these concerns, it is essential to put in place

safe and reliable methods for handling and proper disposal of HCW.

71. Health care waste includes all wastes generated in the delivery of health

care services. WHO (1999a) estimates that 75-90% of waste produced by HCForiginates from non-risk or general sources (e.g., janitorial, kitchens, administration)

and is comparable to domestic waste. The remaliing 10-25% of HCW is classifiedas hazardous and poses a variety of potential health risks. Categories of HCW, as

defined in WHO (1999a), which are considered of most concern in Cambodian HCF

are summarized in Table 2.

72. A wide number of persons are potentially at risk from HCW, both inside

and outside of HCF. Exposure to hazardous HCW can result in disease or injuryto:

* Medical doctors, nurses - Occupation health risks to health care workers

are numerous and varied with the greatest risk being infection (e.g.,HIV/AIDS and hepatitis B and C) through injuries from contaminated sharps.

* Auxiliary and maintenance staff - Hospital workers such as janitors are at

significant risk of infection or injury due to improper handling of infectiousand chemical wastes at HCF.

* Patients and visitors - Although risks of exposure to hazardous waste areconsidered lower than for hospital staff there is a potential for accidentalexposure to infectious sharps and chemical waste (e.g., childrenaccompanying families during extended stays at HCF are particularly atrisk).

* Workers at waste disposal facilities (e.g., incinerators and landfills) - Wastemanagement workers are at significant risk of infection or injury fromhazardous wastes; particularly scavengers at open landfills who are either

not aware or ignore risks and often do not wear even rudimentary protectiveclothing.

73. Generally accepted strategies for HCWM encompass: (i) wasteminimization, recycling, and reuse; (ii) proper handling, storage and transportationof HCW; and (iii) treatment of waste by safe and environmentally sound methods.These strategies are intended for tiered application - initially focusing on managingwaste generation before moving on to actual disposal. Significant reductions in

waste generated by HCF can be achieved through source reduction, use ofrecyclable products, and good management and control practices.

28

Table 2 Health care waste characteristics and hazards profile.

Classification Characteristics/Associated Hazards

Infectious Comprises waste that is suspected to contain pathogensincluding laboratory cultures, surgery and autopsy wastes frompatients with infectious diseases, bodily wastes from patients ininfectious disease wards, and miscellaneous waste such asdisposable gloves, tubing and towels generated duringtreatment of infectious patients). Pathogens from infectiouswaste may enter the human body through puncture of skincuts, mucous membranes, inhalation or ingestion.

Pathological Consists of tissue, organs, body parts, blood and body fluids.Pathological wastes are considered a sub-category ofinfectious wastes and pose the same hazards.

Sharps Describes items that could cause cuts or puncture wounds,including hypodermic needles, scalpel, and broken glass.Because sharps can not only cause cuts and punctures butalso infect these wounds if they are contaminated withpathogens, this sub-category of infectious wastes is consideredvery hazardous.

Chemical Consists of discarded solid, liquid and gaseous chemicals withtoxic, corrosive, flammable, reactive, and genotoxic properties.Chemicals most commonly used in HCF include formaldehyde,photographic chemicals, heavy metals such as mercury frombroken clinical equipment, solvents, organic and inorganicchemicals, and expired, usused or spilt pharmaceuticals.Hazards from chemical and pharmaceutical waste includeintoxication as a result of acute or chronic exposure fromdermal contact, inhalation or ingestion and contact burns fromcorrosive or reactive chemicals.

Radioactive Includes solid, liquid and gaseous materials contaminated withradio nuclides; produced as a result of procedures such as in-vitro analysis of body tissue and fluid, in-vivo organ imagingand various investigative and therapeutic practices. Becauseradioactive waste is genotoxic, health workers in handlingactive sources and contaminated surfaces must take extremecare.

29

Of these measures, waste segregation - careful sorting of waste matter intodifferent categories - is critical to minimization of health care wastes; resulting insignificant reduction of hazardous waste that needs to be handled and treated.Although safety concerns necessarily limit opportunities to reuse medicalequipment (i.e., aside from items that are intended to be reusable), segregation andsubsequent recycling of materials such as plastics, metal, paper and glass is oftenpractical and can represent an income source for HCF.

74. Segregation of HCW is intended to ensure that wastes are properlyidentified and separated and that different waste streams are handled and disposedof correctly. It typical involves sorting different wastes into color-coded plastic bagsor containers at source. Examples of WHO (1 999a) recommended HCW handlingpractices are:

* General HCW (in black bags or containerg) should join the domestic refusestream for disposal.

* Sharps should be collected together into puncture-proof yellow safety boxesand held for high-temperature incineration.

* Infectious waste should be deposited in yellow bags and containers markedwith the international infectious substance symbol and held for incineration.

* Highly infectious material should be placed in marked yellow containers forimmediate sterilization by autoclaving and then incinerated.

* Large quantities of chemical wastes should be packed in chemical-resistantcontainers and sent to specialized treatment facilities. Small quantities ofchemical waste can be held in leak proof containers and enter the infectiouswaste stream for incineration.

* Waste containing high heavy metal concentrations should be collectedseparately in brown containers and sent to specialized treatment facilities.

* Low-level radioactive waste should be collected to yellow bags or containersfor incineration. High-level radioactive waste must be sent to specializeddisposal facilities.

75. Incineration is a widely used treatment method for most hazardous wastegenerated by HCF. Incinerators can range from simply, single-chambercombustion units to sophisticated, high-temperature plants. WHO (1 999a) notesthat all types of incinerator, if operated properly, eliminate pathogens from wasteand reduce the waste to ash. Used correctly, incineration allows for a verysignificant reduction of waste volume and weight and is typically selected to treatwastes that cannot be recycled, reused or safely disposed of to landfills. The keyto environmentally-safe incineration is proper segregation of waste streams withinHCF - inappropriate waste types include large volumes of chemicals, photographicand radioactive wastes, PVC plastics, and waste with a high mercury or cadmiumcontent. Incineration of these wastes causes the release of toxic emissions to theatmosphere if insufficiently high incineration temperatures are attained or in theabsence of adequate emission controls.

30

76. Land filling of wastes that cannot be safely incinerated is regarded as anacceptable disposal option if proper precautions are taken to minimize potentialexposure to infectious wastes. Disposal of HCW to open landfills is not consideredacceptable. Open landfills are characterized by the uncontrolled and scattereddeposit of wastes at a site which can lead to groundwater and surface waterpollution and a high risk to scavengers working at the landfill. Instead, HCW shouldonly be deposited to sanitary landfills that are designed to prevent contamination ofsoil, surface water, and groundwater and limit air pollution, odors and direct contactwith the public. In the absence of sanitary landfills - which may not be feasible forcost and technical reasons - HCW can be safely disposed of to landfills thatprovide for controlled dumping; including measures to control leachate release fromthe site, confined disposal of wastes, and rapid bufial to avoid human or animalcontact.

77. Recognizing that sanitary or engineered landfills are unlikely to beavailable in remote locations, another option is safe burial of HCW on HCFpremises. On-site disposal represents an acceptable disposal option only if certainrequirements are met as follows:

* Restricted access to disposal site by authorized personnel only

* Lining of burial site with a material of low permeability such as clay toprevent groundwater pollution

* Limit use to hazardous materials which cannot safely be incinerated tomaximize the lifetime of a landfill

* Proper management of landfill (i.e., layering of HCW with layers of earth) toprevent odors.

4.1.5 Wastewater

78. Wastewater from HCF represents a sub-category of HCW that should beaddressed in planning construction and rehabilitation as part of the HSSP. WHO(1999a) notes that although wastewater from HCF is typically of a similar quality tourban wastewater, it may also contain potentially hazardous components.Microbiological pathogens introduced into the wastewater stream by patients beingtreated for enteric diseases are of most concern. Lesser hazards are posed bysmall quantities of hazardous chemicals, pharmaceuticals, and other pollutantscommonly found in HCF wastewater. Adherence to the hazardous wastesegregation practices described in the preceding section provides assurances thatchemicals and pharmaceuticals are not entering the wastewater stream.

79. Typically sewage discharged from HCF is greatly diluted and as such nosignificant health risks should be expected if effluents are treated in municipalwastewater treatment plants (WWTP). In more remote locations where it is notfeasible to connect to municipal WWTP then appropriate precautions must be taken

31

to avoid health risks associated with untreated or inadequately treated sewage tothe receiving environment (e.g., wetlands or agricultural lands immediately adjacentto a HCF). Where possible, HCF should be connected to municipal systems.Where there are no sewage systems, technically sound on-site sanitation should beprovided. Recommended mitigation measures covering wastewater from HCF areelaborated in Section 5.1 - Environmental Management Plan.

4.1.6 Tuberculosis and HIV/AIDS

80. Health care wastes generated during treatment of patients withtuberculosis and HIV/AIDS at HCF can be considered a sub-category of HCW.Tuberculosis outpatient and hospital services to be funded under the HSSP arebest addressed in the overall context of proper H6WM at HCF. Safeguardsapplicable to handling and disposal of highly infectious waste as described in theprevious section are therefore applicable.

81. No specific HCWM-related environmental concerns were identified for theHIV/AIDS activity to be funded under the HSSP. Grant funding for HIV/AIDSprevention and treatment in Cambodia will cover the cost of drugs used in sexuallytransmitted disease (STD) clinics for treatment of sexually transmitted infections(STI) in sex workers and operating costs of the NCHADS 100% condom useprogram. Drugs to be procured are Cexime, Doxycycline, Clotrimazole andCiprofloxacin. Procurement and distribution of the drugs to STD clinics is closelysupervised by NCHADS. A comprehensive manual exists for STD casemanagement at clinics that contains guidelines on how to organize services andpolicies for delivery.

4.2 MALARIA AND DENGUE VECTOR CONTROL

4.2.1 Pesticide Use

82. Insecticide and larvicides intended for use in malaria and dengue vectorcontrol programs as part of the HSSP are summarized in Table 3. It is noted thatall products have successfully passed WHO's Pesticide Evaluation Scheme(WHOPES) (see WHO, 1997 for overview). The WHOPES was set up in 1960 topromote and coordinate the testing and evaluation of pesticides for public health.Products proposed for use are subject to a rigorous four-phase evaluation andtesting program that examines the safety, efficiency and operational acceptability ofpublic health pesticides and specifications for quality control. WHOPES reviewsand recommendations are based on methodologies developed through extensiveconsultation with the international community and should be consideredauthoritative.

32

Table 3 Insecticides/larvicides to be used in vector control programs.

Insecticide/Larvicide . . Comments onIntended for Use and Quantity Required Purpose Environmental

Specifications Safety

Deltamethrin (K- 2,000 liters/year Treatment of One of theOthrine®) 1% SC in a from year 2 to year 5 bed nets productsdose of 15 mg/M2 successfully

passed byWHOPES

Deltamethrin (K- Quantities required Treatment of SuccessfullyOthrine®) specially will depend on hammock nets passed byformulated 25% water actual demand WHOPESdispersible tablets created by socialproviding a nominal marketing;treatment rate of 25 procurement will bemg/M2 undertaken by WHO

Temephos 160 metric tons x 5 Larvicide of Successfully(Abate®1 % sand years choice for passed bygranules) applied in a Aedes aegypti WHOPESdosage of 1g/10 liter control in

portable watercontainers

4.2.2 Human Health Risks

83. Chemicals currently recommended by WHOPES for use in ITN areclassified as synthetic pyrethroids - considered to pose a very low risks to humansif used correctly. Potential exposure pathways to humans from ITN insecticides arethrough oral, dermal and inhalation routes. Exposure predominantly occurs as aresult of improper handling of insecticides during regular re-impregnation ofmosquito nets (e.g., splashing on the skin, into the eyes or through ingestion),accidents caused by insufficient awareness of pesticide risks and safe handlingpractices, and poorly or miss-labeled containers (i.e., children are particularly at riskfrom accidental exposure). Exposure during actual use of ITN (i.e., sleeping underthe nets) can occur due to inhalation of insecticide that has volatilized from the net,dermal contact with the net, and oral exposure from hand-to-mouth or direct contact(e.g. an infant sucking on the net) (USAID, 2002; WHO, 2001; 1999b; 1984).

84. Risks to humans from ITN insecticides will vary depending on actualexposure. Occupational risks resulting from frequent exposure to lowconcentrations of pyrethroids are considered to be very low if proper precautionsare taken (e.g., use of protective gloves and face shields). An additional safetyfactor can be achieved by persons involved in re-impregnation of ITN through useof the lowest-toxicity products and avoiding exposure as much as possible. Of theWHOPES recommended pyrethroids, Deltamethrin is considered one of the least

33

toxic and highly unlikely to cause adverse effects in normal use. Results of humanhealth risk assessments indicate that exposure to this insecticide during actual useof ITN poses little or no hazard. Worst-care risk calculations indicate a high marginof safety for adults and children at estimated exposure via inhalation, skin contactand oral exposure while sleeping under an ITN.

85. The larvicide Temperos (commonly known by the trade name Abate® inCambodia) to be used in dengue vector control is classed as an orgnophosphate.This pesticide has a very low toxicity to humans. Potential exposure routes areingestion, inhalation of dust and to some extent dermal contact (i.e., skin contact isconsidered insignificant because absorption is inherently slow). The Temperosformulation to be used in the HSSP (i.e., 1% sand granules) is thought to presentminimal risk to humans - no adverse effects have been observed duringoccupational handling or in the general population using treated water overextended periods. Similarly, no poisoning in humans as a result of accidentalexposure have been documented (WHO, 2001; 1999b; 1975).

4.2.3 Environmental Risks

86. The toxicity of the pesticides intended for use in malaria and dengue vectorcontrol programs in Cambodia to non-target species varies widely. Laboratory andfield tests indicate that Deltamethrin is only slightly toxic to birds but is moderatelyto very highly toxic to fish. Temperos has been shown to be highly toxic to somebird species but moderately toxic to others. It is considered highly toxic to beesand moderately to highly toxic to fish. Both Deltamethrine and Temperos havebeen shown to be very highly toxic to aquatic invertebrates (WHO, 1 999b; 1984;1975).

87. Environmental risks to non-target species, particularly aquatic organisms,can result from the unintentional release of these pesticides through improperhandling or disposal. Although Deltamethrin and Temperos are highly toxic toaquatic organisms, under normal circumstances negligible quantities are likely tobe released into ponds, streams and rivers. In assessing potential toxicity to non-target organisms it is important therefore to recognize that risk is a product oftoxicity and exposure (i.e., there is little or no risk even at high concentrations if noexposure actually occurs). Exposure, if any, is likely to be short-term because: (i)these pesticides break down rapidly to products that are non toxic to aquaticorganisms; (ii) rapid dilution will occur in flowing waters; and (iii) products typicallyare rapidly adsorbed to suspended solids and bottom sediments.

88. Malaria and dengue vector control experts from the CNM and WHOinterviewed in completing this ER advised that the potential for unintentionalrelease of pesticides to the natural environment is very limited. Of the twopesticides currently being used in vector control programs, Deltamethrine is mostlikely to enter the receiving environment as a result of washing of ITN in streamsand ponds. Loss of pesticides from ITN during washing is estimated at 50% for the

34

initial wash and 2-20% for subsequent washes until ITN re-impregnation isnecessary - re-impregnation typically occurs annually in Cambodia although morefrequently impregnation is desirable to maintain the effectiveness of the nets. Atthese loss rates, risk to aquatic organisms from washing of ITN is consideredminimum if only a few nets are washed in a pond, stream or river at any one time.However, if a sufficiently large number of nets are washed at the same time, thenthere is a slightly higher potential to cause short-term acute toxicity to aquaticorganisms. Similarly, improper disposal of excess net treatment solutions couldcause rapid fish kills and other adverse impacts especially in small ponds andstreams with limited assimilative capacity. No scenarios were identified whereTemperos might be released unintentionally to the receiving environment.

35

5. ENVIRONMENTAL MITIGATIVE MEASURES

5.1 ENVIRONMENTAL MANAGEMENT PLAN

89. The intent of an EMP is to recommend feasible and cost-effectivemeasures to prevent or reduce significant adverse impacts to acceptable levels.For purposes of the HSSP for which environmental impacts are expected to belimited, particular attention is given to outlining best management practices whichshould be put in place to ensure that environmental impacts are minimized duringcivil works activity and that human health and environmental concerns are fullyaddressed on a ongoing basis during project implementation. Recommended bestmanagement practices and mitigation measures #re detailed by activity in thefollowing sections.

5.1.1 Health Care Facility Construction and Rehabilitation

90. Although HCF construction and rehabilitation to be undertaken as part ofthe HSSP does not require environmental assessment, best practices should stillbe followed to avoid potential adverse environmental impacts. Environmentalchecklists developed by the SFKC provide a comprehensive basis for identifyingany environmental impacts of civil works projects. It is recommended that theSFKC's Checklist of Likely Environmental Impacts Arising From School and HealthCare Projects be completed during the design stage for each referral hospital andhealth center planned under the HSSP. The checklist covers:

* Environmental effects related to project location and design including naturalhabitat and wildlife, land use and settlement, drainage, water quality, trafficcongestion, noise, and health and safety.

* Environmental effects related to project construction/operation includingnatural vegetation, land use and settlement, health and safety, drainagepattern, water quality, noise and dust, and traffic congestion.

91. Available mitigation measures for potential negligible and moderateimpacts include:

* Consultation with the local community regarding site selection

* Design specifications that provide for minimization of disruption of naturalvegetation and terrestrial and aquatic habitats

* Design modifications for flood prone areas

* Supervision and monitoring of construction (e.g., restricting work to daylighthours, limiting noise and dust emissions, safe traffic control, occupationalhealth and safety).

36

5.1.2 Laboratory Construction

92. Waste generated by the new NLDQC presents special disposal concernsthat should be considered in completing additional environmental assessment ofthis activity. Because laboratory waste typically includes a diverse array ofchemicals in small quantities, available disposal options should be examined indetermining the best handling strategy. Deciding on the best recycling or disposalmethod should be done in consultation with the MoH and reputable hazardouswaste management facilities to review cost-effective and environmentally friendlyoptions. Typical disposal options for chemical wastes include incineration for toxicmaterials, and land filling of non-hazardous materials.

93. In addition to waste disposal, it is imperative that laboratory staff be trainedin hazardous waste management and emergency procedures. Obviously, sincehazardous waste management responsibilities differ for various staff, so do trainingrequirements. Laboratories should fashion their training programs so that they areappropriate to their operations.

94. Recognizing that it is preferable to prevent unnecessary waste generationin the first place, the new NLDQC should develop plans to minimize hazardouswaste generation. Examples of such measures available to laboratories are:

* Maintaining a limited inventory of chemicals on hand to minimize the need todispose of expired chemicals

* Reduce of eliminate use of highly toxic chemicals in laboratory operations

* Centralize waste management to better track generation rates

* Establish waste minimization goals

* Reuse/recycle spent solvents

* Keep individual hazardous waste streams segregated (i.e., hazardous fromnon-hazardous and recyclable from non-recyclable)

* Replace cleaning solutions with more environmentally friendly substitutes.

5.1.3 Asbestos

95. Potential risks associated with fibre-concrete building materials containingasbestos must be considered in planning HCF rehabilitation. Recommendedmitigation measures to avoid or minimize occupational health risks associated withasbestos exposure are:

* Survey of all building structures (i.e., both existing HCF and buildings to bedemolished before construction of the new NLDQC) by qualified andexperienced building inspectors to determine whether asbestos is present instructures.

37

* Adherence to best practices to ensure construction worker protection duringrenovation and demolition activities. Occupational exposure can be avoidedby controlling dust emissions and through use of effective respiratoryprotective equipment.

* Workers involved in asbestos removal should be properly trained.

* Ensuring that demolition waste is disposed of at secure landfills or handledby a reputable hazardous waste management facility.

* Prohibit procurement of asbestos-containing building materials.

* Close supervision and monitoring of all demolition and constructionactivities.

5.1.4 Drinking Water Quality

96. Ensuring the safe supply of water to HCF as part of the HSSP is ofparamount concern. Mircobial water quality represents the most serious humanhealth threat in Cambodia with infectious diseases caused by pathogenic bacteria,viruses and protazoa or by parasites representing a common and widespreadhealth risk associated with drinking water. Microbial water quality is of mostconcern for untreated surface waters and shallow groundwater obtained from openwells - handpump wells commonly used to tap aquifers at depths of greater than15 m are generally considered to provide water that is safe from a biologicalperspective if the wells are properly drilled and maintained.

97. Available water quality data indicates that chemical water quality,particularly for surface waters, is generally very good in Cambodia but thatgroundwater in certain areas of the country contains levels of chemicals that couldpose problems for human health. The most important of these chemicals is arsenicwhich has been found to exceed the WHO's recommended limit of 10 pg/l in someHSSP provinces - most notably Kampong Thum and Kracheh. Although waterchemistry sampling has yet to be undertaken in all HSSP provinces, elevatedarsenic levels are predicted for Krong Pailin and Preah Vihear based on geologicalevidence.

98. Based on available information on groundwater arsenic levels in HSSPprovinces, it is recommended that a water quality monitoring program be includedas part of project implementation to confirm that water supply to HCF will meetWHO guideline values - particularly for microbial quality and arsenic content.Although data exist for some of the rural communities to be served by the HCF, thehigh spatial variability of groundwater arsenic necessitates that drinking watersupply be tested at all existing and planned HCF as the only certain way ofdetermining its potability. Routine follow up monitoring of water supply should alsobe undertaken to ensure that water continues to meets drinking water guidelines.Provision of simple testing kits and delivery of basic training to MoH and PHD staffwould enable their involvement in monitoring of water quality on an ongoing basis.

38

99. Available mitigative and remedial measures to ensure microbial quality ofsurface waters include (WHO, 1993):

* Pre-treatment of surface waters through impoundment in reservoirs.Microbial quality can be improved considerably as a result of sedimentationand the effect of ultraviolet content of sunlight.

* Use of slow sand filtration or an activated carbon system are simple andeffective methods for removing pathogenic bacteria, viruses, and parasites.

* Disinfection, typically through chlorination, provides an effective barrier totransmission of waterborne bacterial and viral diseases.

100. Available mitigative and remedial measures when high arsenic levels arefound in drinking water sources include:

* Investigate possibility of digging deeper wells to access groundwater frombelow alluvial areas. Handpump wells are typically 30m deep compared todeep aquifers at 70-120 m depths.

* Extending water supply to HCF from proven water sources such as municipalwater systems or pumping from other safe wells.

* Substitution of alternative low-arsenic sources of drinking water such asrainwater or potable surface water where available and appropriate.Alternative water supplies such as surface water should be tested to ensurecompliance with drinking water guidelines (e.g., microbial water quality).

* Segregation of water use within HCF. Water containing elevated arsenic isreserved for non-drinking purposes such laundry and sanitary uses. Waterfrom safe wells, surface water sources or bottled water purchased fromcommercial suppliers is used exclusively for consumption by patients andHCF staff.

* Treatment of water supply to remove arsenic. Considered the leastpreferable option due to installation costs and high maintenancerequirements.

5.1.5 Health Care Waste Management

101. Guidelines have been developed by the MoH to address both wastemanagement and hygiene issues at HCF. These guidelines are comprehensiveand cover all aspects of safe hospital waste management, including risksassociated with waste collection, segregation, transportation, storage, disposalmethods, containers, waste minimization techniques and protective clothing. Theguidelines incorporate best HCWM practices as elaborated in WHO (2000; 1999a)and are intended for practical application at HCF with limited available financial andtechnical resources. Additional guidelines on injection safety have also beendeveloped by the MoH to provide specific guidance to HCF on the distribution, use,collection and safe destruction of disposable syringes and safety boxes. Taken

39

together both sets of guidelines provide an excellent basis for HCWM in HCFtargeted under the HSSP.

102. Notwithstanding the availability of HCWM guidelines, it is apparent thatthere is considerable scope for adopting more rigorous HCWM practices in healthcenters and referral hospitals. Of particular concern is uneven application ofguidelines regarding proper waste handling and disposal. To address thisweakness it is recommended that capacity building be provided to improve site-specific waste management practices at HCF. Capacity building should compriseboth training and technical support. Training in best health care handling anddisposal practices is expected to create more awareness of HCWM issues andfoster responsibility among HCF staff in an effort to prevent occupational exposureto hazardous HCW. Training materials could be readily drawn from WHO's (Prussand Townsend, 1998) Teacher's Guide on Management of Wastes from HealthCare Activities and MoH's own HCWM and injection safety guidelines. Trainingshould be provided to all HCF staff - both health care personnel and auxiliary andsupport staff. Recognizing that sustaining adequate waste management practicesat HCF ultimately depends on auxiliary staff, it is highly recommended that wastemanagement responsibilities be clearly defined and linked with performance basedmonitoring and evaluation.

103. Adequate waste handling and disposal infrastructure and managementsystems should be put in place at HCF. A standard HCWM package for HCFwould encompass: (i) color-coded waste plastic bags and containers; (ii) safetyboxes for disposal of syringes; and (iii) installation of appropriate incinerators andlandfills. Selection of incinerator technology should be done in consultation withMedecins sans Frontiers and WHO incineration experts. Simple brick incineratorshave proven effective for disposal of most wastes generated by HCF while referralhospitals should additionally be provided with dedicated Sicim® incinerators whichproduce the higher temperatures required for proper destruction of disposablesyringes. To reinforce the effectiveness of ongoing efforts to promote properincineration of syringes, referral hospitals should be encouraged to collaborate fullyin used injection equipment exchange programs - involving collection of safetyboxes containing used immunization materials from health centers and mobileteams and transport to provincial or district level HCF for incineration.

104. Safe disposal practices for wastewater as specified in the MoH's WasteManagement Guidelines should be followed in handling of sanitary wastes fromHCF. Specific mitigation measures to ensure environmentally-safe disposal ofwastewater from HCF are also described in WHO (1 999a). Recommendedpractices include:

* Where possible, hospitals should be connected to municipal WWTP.

* Hospitals that are not connected to municipal WWTP should install compacton-site sewage treatment (i.e., primary and secondary treatment,disinfection) to ensure that wastewater discharges meet applicable permitrequirements.

40

* HCF in remote locations should provide for minimal treatment of wastewaterthrough affordable means such as lagooning; the system should comprisetwo successive lagoons to achieve an acceptable level of purification,followed by infiltration of the effluent to the land.

* Sewage from HCF should never be used for agricultural or aquaculturalpurposes.

* Sewage should not be discharged into or near water bodies that are usedfor drinking water supply or for irrigation purposes (i.e., infiltration to soilmust take place outside of the catchment area of aquifers).

* Convenient washing and sanitation facilities should be available for patientsand their families, and HCF staff to minimize the potential for unregulatedwastewater discharge.

5.2 PESTICIDE MANAGEMENT AND MONITORING PLAN

105. The intent of this Pesticide Management and Monitoring Plan (PMMP) is to

summarize mitigation measures and best management practices with a view to

minimizing or avoiding any potential adverse human health or environmental effects

that have been identified for malaria and dengue vector control programs to befunded under the HSSP.

106. Recognizing that all pesticides are toxic to some degree, it is paramount toensure that proper care and handling practices form an integral part of any programinvolving their use. In formulating management practices, it is necessary to takeinto account both the nature of the pesticides being used (i.e., their formulation andthe proposed methods of application) and any existing safeguards that have beenincorporated into programs to address potential occupational safety andenvironmental concerns. Guidelines and training materials have already beendeveloped for both malaria and dengue programs in Cambodia and fewimprovements are considered necessary to ensure the continued safety of theseactivities. Existing best management practices and recommended enhancementsare detailed in the following sections by activity.

5.2.1 Malaria

107. Distribution and re-impregnation of ITN in Cambodia as part of malariavector control programs was previously undertaken directly by the CNM and NGOsworking in various parts of the country. Current practice has decentralizedresponsibility for program implementation to provinces and OD with all activitiesnow being undertaken by local health workers.

108. Existing guidelines provide that pesticides used in malaria programs beprocured by CNM directly from manufacturers to ensure that they conform toWHOPES quality specifications. Guidelines do not presently cover the safe

41

transport of pesticides to the provinces and secure storage of pesticideconcentrates by PHD. Although no problems have been reported to date (e.g., lossduring transport, theft, access by children to storage facilities) it is recommendedthat provisions be added to the guidelines to strengthen health safeguards duringtransportation and storage. Guidelines do cover distribution of pesticides as aprecaution against misuse; specifying that all empty containers be returned to thePHD for inventory before being transported back to Phnom Penh for properdisposal.

109. Strict safeguards have been put in place by the CNM to minimize thepotential for accidental exposure of both villagers and health workers to pesticidesduring actual field activities. Written guidelines have been distributed to all PHDand OD to raise awareness of safe handling practices and regular training isprovided to health workers involved in the ITN pro6ram. An important safeguard isthe provision that no pesticides can be distributed directly to villagers. Instead re-impregnation of nets is undertaken by PHD and OD workers in the presence ofvillagers - previously washed nets are dipped in a prepared solution and thenreturned in individual plastic bags with instructions to allow proper drying of the netprior to use. These precautions effectively remove the risk of pesticide exposureamong villagers. Although well considered, it is recommend that the distributionsafeguards be further strengthened to address remaining concerns regardingoccupational exposure among health workers. Additional training would also bebeneficial to ensure that health workers fully understand safety guidelines and spotchecks be completed to gauge compliance. Guidelines should be revised tospecify that needed safety supplies (e.g., rubber gloves to be worn while handlingpesticides to avoid dermal contact) be issued to health workers and a provisionmade for procurement and distribution of safety supplies along with pesticides.

110. Environmental risks associated with ITN programs are addressed in partby existing CNM guidelines that provide for education of villagers in the proper useand handling of ITN. This training focuses primarily on storage procedures andwashing frequency for nets to extend their effectiveness although some mention ismade regarding environmental safeguards (e.g., ITN should not washed in streamsand ponds). It is recommended that education materials be revised to deal moreexplicitly with potential environmental concerns - they might provide additionalexplanation of environmental risks posed by ITN pesticides and safeguards to betaken by villagers to minimize or avoid environmental harm.

5.2.2 Dengue

111. Larviciding programs inherently pose fewer occupational health andenvironmental risks due to the pesticide formulations used, their controlledapplication, and the lower potential for exposure of health care workers involved inprogram implementation. Notwithstanding these factors, extensive safeguardshave been developed by the CNM and WHO to minimize or avoid potential humanhealth and environmental problems.

42

112. Dengue programs undertaken in Cambodia are scheduled to coincide withthe peak transmission period occurring during the rainy season. Two applicationsof Temperos are made each year in targeted provinces; in May-June and repeatedin July-August. In preparation for field distribution, approximately 160 metric tons ofTemperos is procured annually by the MoH for use in dengue programs.Purchased Temperos is securely stored in a government warehouse untilimmediately prior to program implementation at which time casual workers areemployed to pre-package the granular product into 20g satchels. Pre-packaging isintended to facilitate field activities (i.e., addition of a 20g satchel of Temperos to astandard 200 liter water jar or two satchels to the alternative 400 liter container sizeprovides the required dosage) and increase the efficacy of the chemical whenplaced in water containers. Although some safety precautions (e.g. children are notallowed to be involved or present) are taken in the packaging of Temperos, it isrecommended that these safeguards be strengthened to addressed potentialoccupational health concerns. Specifically, strict precautions should be taken inhandling the chemical such as: ensuring adequate building ventilation; wearingprotective gloves to avoid dermal contact; wearing protective masks to avoidinhalation of chemical dust; and washing of hands after handling.

113. Comprehensive guidelines have been developed by the CNM forTemperos larviciding programs to address potential human health andenvironmental concerns during field operations. Safeguards include:

* Tiered supervision by CNM, provincial and district health departments toclosely track all aspects of inventory and distribution of stocks.

* Daily supervision of all field activities to ensure proper handling andhousehold coverage.

* Water containers that are used frequently and those holding fish and otheraquatic life are not treated.

* Households are educated on proper procedures for care and handling ofwater containers to which Temperos has been added (e.g., removeTemperos before washing containers).

* First aid procedures are explained for use if Temperos is accidentallyingested.

114. Safeguards developed by the CNM for dengue programs in Cambodia areconsidered to represent best available practices. With the exception of the need tostrengthen occupational health practices during pre-packaging of Temperos intosatchels, available guidelines are comprehensive and inclusive. Provision shouldbe made for: (i) regular delivery of training to PHD and OD staff involved in programimplementation to ensure that each person knows precisely what theirresponsibilities are; and (ii) ongoing monitoring and evaluation to ensurecompliance with safeguards.

43

REFERENCES

Feldman, P. 2001. Drinking Water Assessment in Cambodia. Final ActivityReport. Prepared in cooperation with the Cambodian Ministry of RuralDevelopment and the Ministry of Industry, Mines and Energy. Funded by theWorld Health Organization, Western Pacific Regional Office. 144 pp.

MoE. 1998. Kingdom of Cambodia: National Environmental Action Plan 1998-2002. Ministry of Environment, Phnom Penh. 90 pp.

Pruss, A. and W.K. Townsend. 1998. Teacher's Guide: Management of Wastesfrom Health-Care Activities. World Health Organization, Geneva. 227 pp.

USAID. 2002. Programmatic Environmental Assyssment for Insecticide-TreatedMaterials in USAID Activities in Sub-Saharan Africa. United States Agencyfor International Development. 76 pp.

U.S. EPA. 2000. Environmental Management Guide for Small Laboratories. EPA233-B-00-001. U.S. Environmental Protection Agency, Washington, D.C.113 pp.

UN/WHO. 2001. United Nations Synthesis Report on Arsenic. Chapter 1: Sourceand Behavior of Arsenic in Natural Water. United Nations and World HealthOrganization. 52 pp.

WHO. 2002. Health Care Waste Management: Rapid Assessment Tool. DraftVersion 2. World Health Organization. 33 pp.

WHO. 2001. Chemistry and Specifications of Pesticides. Technical Report Series899. World Health Organization, Geneva.

WHO. 2000. Starting Health Care Waste Management in Medical Institutions: APractical Approach. Health Care Waste Practical Information Series No. 1.World Health Organization, Copenhagen. 16 pp.

WHO. 1999a. Safe Management of Wastes from Health-Care Activities. Edited byA. Pruss, E. Giroult and P. Rushbrook. World Health Organization, Geneva.230 pp.

WHO. 1999b. Safety of Pyrethroid-Treated Mosquito Nets. Fact Sheet.WHO/CDS/CPE/WHOPES/99.5. World Health Organization, Geneva. 8 pp.

WHO. 1997. Chemical Methods for the Control of Vectors and Pests of PublicHealth Importance. D.C. Chavasse and H.H. Yap (Eds.).WHO/CTD/WHOPES/97.2. WHO Pesticide Evaluation Scheme. WorldHealth Organization, Geneva. 129 pp.

WHO. 1993. Guidelines for Drinking-Water Quality. Volume 1:Recommendations. 2nd Edition. World Health Organization, Geneva.188 pp.

WHO. 1984. Deltamethrin. Data Sheets on Pesticides No. 50. VBC/DS/84.50.World Health Organization, Geneva. 12 pp.

44

WHO. 1975. Temperos. Data Sheets on Pesticides No. 8 Rev. 1. VBC/DS/75.8(Rev. 1). World Health Organization, Geneva. 10 pp.

World Bank. 1991a. Environmental Assessment Sourcebook. Volume I: Policies,Procedures, and Cross-Sectoral Issues. World Bank Technical PaperNumber 139. The International Bank for Reconstruction and Development,Washington, DC, USA. 227 pp.

World Bank. 1991b. Environmental Assessment Sourcebook. Volume ll: SectoralGuidelines. World Bank Technical Paper Number 140. The InternationalBank for Reconstruction and Development, Washington, DC, USA. 267 pp.

Law on Environmental Protection and Natural Resource Management. 1996.Royal Government, Kingdom of Cambodia.

Sub-decree on Pharmaceutical Management. 1996.

Sub-decree on Standard and Management of Agricultural Materials. 1998.Ministry of Agriculture, Forestry and Fisheries. Kingdom of Cambodia.

Sub-decree on Water Pollution Control. 1999. Royal Government, Council ofMinisters. No. 27 ANRK.BK.

Sub-decree on Solid Waste Management. 1999. Royal Government, Council ofMinisters. N. 36 ANRK.BK.

Sub-decree on Environmental Impact Assessment Process. 1999. RoyalGovernment, Council of Ministers. No. 72 ANRK.BK.

Checklist of Likely Environmental Impacts Arising From School and Health CareProjects. Social Fund of the Kingdom of Cambodia.

Guidelines for Conducting Environmental Impact Assessment (EIA) Report.Department of Environmental Impact Assessment Review and Monitoring, Ministryof Environment, Kingdom of Cambodia.

Injection Safety Guidelines for Referral Hospitals. Ministry of Health, Kingdom ofCambodia.

National Policy for the Safety of Injections. Ministry of Health, Kingdom ofCambodia.

Strategic Plan of Action for 2001-2005 to Improve Injection Safety (and Disposal)for EPI Vaccines. Ministry of Health, Kingdom of Cambodia.

Waste Management Guidelines. Ministry of Health, Kingdom of Cambodia.

45

ANNEX 1 - SUMMARY OF ENVIRONMENTAL ISSUES

Specific responses to environmental assessment issues raised in the ProjectAppraisal Document (PAD) and Integrated Safeguards Data Sheet (ISDS) areprovided in this section.

PAD 5.1 Summarize the steps undertaken for environmental assessmentand Environmental Mitigation Plan (EMP) preparation (including consultationand disclosure) and the significant issues and their treatment emerging fromthis analysis.

Potential environmental and human health impa($s examined in completing theenvironmental review (ER) were: construction and rehabilitation of health carefacilities (HCF) focusing on civil works and drinking water supply; health care wastemanagement (HCWM) practices; and pesticide use in malaria and dengue vectorcontrol programs. Findings are summarized by activity as follows.

(a) HCF Construction and Rehabilitation - Review of this activity confirmed that itdoes not pose any serious environmental concerns and as such will not triggerfurther scrutiny under Cambodia's environmental impact assessment (EIA)guidelines.

(b) Construction of a new National Laboratory for Drug Quality Control - Thisactivity is expected to trigger additional assessment under Cambodian EIArequirements. Anticipated construction-related environmental impacts areexpected to be minimal as the site selected is situated in an existing built urbanarea of Phnom Penh. No environmentally sensitive areas were identified during asite visit. Potential environmental and human health concerns that were identifiedrelating to laboratory operations include: air emissions containing harmfulpollutants; laboratory wastewater disposal; and disposal of hazardous solidlaboratory wastes. These aspects of laboratory operations are well understood andreadily addressed through adoption of industry best environmental managementpractices.

(c) Drinking Water Quality - Review of the safety of drinking water sourcesavailable to HCF identified potential risks associated with microbial water qualityand naturally occurring arsenic in groundwater. Microbial water quality representsthe most serious human health threat countrywide in Cambodia with infectiousdiseases and parasites being the most common and widespread health riskassociated with drinking water. Available data indicate that overall chemical waterquality in Cambodia is generally very high but that elevated arsenic levels areprevalent in some provinces targeted by the HSSP. Additional study of watersources typically used by HCF will be necessary to ensure that World HealthOrganization (WHO) guidelines for drinking water are consistently met.

46

(d) Health Care Waste Management - Potential human health environmentalthreats associated with wastes generated by HCF, particularly hazardous chemicaland infectious wastes, were reviewed in detail in completing the ER. It wasdetermined that risks are well defined and can be readily addressed throughadoption of best HCWM practices encompassing: waste minimization, recycling,and reuse; proper handling, storage and transportation; and treatment of waste bysafe and environmentally sound methods. The need to address wastewater, a sub-category of health care waste (HCW), in construction and rehabilitation of HCF wasalso examined and recommendations were made to provide appropriate treatmentto avoid human health risks associated with discharge of untreated or inadequatelytreated sewage to the natural environment.

(e) Pesticide Use in Vector Control - Review of,zlanned malaria and denguevector control activities confirmed that insecticide/larvicide to be used in the HSSPhave successfully passed WHO's Pesticide Evaluation Scheme (WHOPES).Chemicals currently recommended by WHOPES pose very low risks to humans ifused correctly. Of these Deltamethrine, used in insecticide treated nets (ITN), isconsidered the least toxic and highly unlikely to cause adverse effects in normalusage. Temperos, used in larviciding of drinking water containers, has a very lowtoxicity to humans. Although both chemicals are known to be highly toxic to non-target species such as aquatic organisms, environmental risks are limited undernormal circumstances where only trace quantities of these chemicals are likely tobe released to the natural environment. Review of existing occupational health andenvironmental safeguards in place for vector control programs in Cambodiaconfirmed that risks associated with possible improper handling or disposal ofthese chemicals are negligible.

PAD 5.2 What are the main features of the EMP and PMMP and are theyadequate?

Recommended mitigation measures intended for application during HSSP planningand implementation are detailed in an Environmental Management Plan (EMP) andPesticide Management and Monitoring Plan (PMMP). Recommendationscontained in the EMP and PMMP were developed in close consultation with theBorrower and will be implemented and monitored together with the other HSSPactivities and evaluated both at mid-term and at HSSP final evaluation. Mainrecommendations contained in the EMP and PMMP are summarized below.

47

Environmental Management Plan

Health Care Facility Construction and Rehabilitation - Best environmental andoccupational health practices should be followed during HCF construction andrehabilitation to minimize or avoid any potential minor adverse impacts.Environmental checklists currently used to assess government civil works projectsshould be completed for all HCF to ensure that potential site-specific environmentalimpacts are documented and that appropriate mitigation measures are taken toaddress any impacts relating to project location and design, construction, andoperation. Specific mitigation measures are outlined to avoid or minimizeoccupational health risks associated with the potential presence of asbestos inexisting HCF.

Laboratory Construction - Environmental concerns arising from construction of anew quality control laboratory in Phnom Penh should be comprehensivelyaddressed in laboratory planning, design and construction. Appropriate mitigationmeasures during the construction phase include: strict adherence to occupationalhealth and safety guidelines; controlling dust emissions and noise to minimizenuisance to neighbors; proper disposal of demolition materials to landfills; andcontrol of surface water run-off from the construction site. Emphasis should begiven during laboratory operations to the adoption of an environmentalmanagement system encompassing: air emissions controls; proper disposal ofwastewater; and best management practices for the minimization, handling anddisposal of hazardous chemical wastes.

Drinking Water Supply - The safety of drinking water used in HCF is to be assuredthrough conducting water quality monitoring to evaluate whether available drinkingwater sources meet WHO drinking water guideline values. Recommendedmitigation and remedial measures specify selection of the best available drinkingwater source and installation of treatment systems to ensure that acceptable waterquality is achieved.

Health Care Waste - Environmental issues posed by HCW are readily resolvedthrough provision of adequate management systems encompassing all aspects ofwaste generation, collection and segregation, transportation, storage and safedisposal. Recommended mitigation measures are intended to enhance existingcomprehensive guidelines that have been developed by the Ministry of Health forapplication in HCF. Mitigation measures to be applied at all HCF includeinstallation of appropriate waste handing and disposal infrastructure and systems(e.g., waste-segregation, incineration and landfills) and capacity building for HCFstaff concerning best management practices.

48

Pesticide Management and Monitoring Plan

Recommended mitigation measures are intended to ensure that safeguardsalready in place are adhered to in the delivery of HSSP malaria and dengue vectorcontrol programs. Because existing guidelines and training materials areconsidered to represent best management practices, recommendations focus onpossible enhancements to strengthen selected aspects of program implementation.Specific recommendations made to further reinforce occupational health safety andenvironmental protection include provisions for: secure transport of pesticides totarget provinces; additional occupation health safeguards during pesticide handlingand distribution; and extending training provided to local communities to creategreater awareness of environmental issues and sustainable practices.

PAD 5.4 How have stakeholders been consulted at the stage of (a)environmental screening and (b) draft EA report on the environmentalimpacts and proposed environment management plan? Describemechanisms of consultation that were used and which groups wereconsulted?

Extensive consultations were sought in undertaking the ER to delineate potentialenvironmental impacts associated with completion of HSSP activities and to solicitinputs with a view to crafting appropriate mitigation and remediation measures.Interviews were completed with government agencies including the Ministry ofHealth and the Ministry of Environment to identify potential environmental impactsof planned new construction and rehabilitation of HCF and construction of a newquality control laboratory in Phnom Penh. Field visits to provincial referral hospitalsprovided an opportunity to review rehabilitation plans and complete a preliminaryassessment of site-specific environmental issues. Follow up consultations withnational and provincial level government officials were held to review, discuss, andreach agreement on the project's environmental issues and recommendations toprevent, minimize or mitigate any adverse impacts and to improve environmentalperformance. Consultations were also completed with specialists from national andinternational institutions and non government organizations to solicit inputs onspecific issues such as drinking water quality, health waste management treatmentpractices, and infectious disease programs. A complete list of contacts is providedas Annex 2.

PAD 5.5 What mechanisms have been established to monitor and evaluatethe impact of the project on the environment? Do the indicators reflect theobjectives and results of the EMP?

Mitigation measures prescribed in the ER are expected to fully address all humanhealth and environmental impacts associated with implementation of HSSPactivities. Although no significant environmental impacts have been identified forplanned HCF construction and rehabilitation, provisions have been incorporated

49

into the EMP to document all environmental resources potentially at risk and toundertake appropriate proactive mitigative measures during project implementation.Follow up assistance to the Borrower will include review of their intendedimplementation strategy and approach to ensure that environmental safeguards areproperly applied throughout. Planned activities to be undertaken in this regard are:(i) completion of a drinking water survey at existing and future HCF to evaluateavailable drinking water sources and ensure that drinking water is of acceptablequality; (ii) site-specific assessment of representative HCF to further validaterecommendations contained in the EMP; and (iii) revision of existing trainingmaterials to incorporate best HCWM practices as recommended in the EMP.Technical assistance will also be financed under the project to ensure thatapplicable environmental assessment requirements relating to the planned newquality control laboratory in Phnom Penh are met - all environmental aspects of theplanned laboratory will be assessed to the satisfaction of the Ministry ofEnvironment before commencing construction. Recommendations outlined in theEMP and to be elaborated in the follow up activity-specific assessment will includeadoption of a comprehensive environmental management system, and linkedmonitoring and evaluation procedures to enable the laboratory to demonstratecompliance with best management practices on a continuous basis. Minorrevisions to existing comprehensive guidelines and training materials for themalaria and dengue vector control programs as recommended in the PMMP will becompleted during the initial phase of project implementation. Adoption ofrecommended revisions will provide assurances that human health andenvironmental concerns relating to these programs are fully addressed.Satisfactory implementation of all recommended safeguards will be evaluated bothat mid-term and at HSSP final evaluation.

PAD 7.2 Describe provisions made by the project to ensure compliance withapplicable safeguard policies.

The HSSP is subject to the Bank provision for Environment Assessment OP 4.01.To fully satisfy this requirement, an ER was completed for the project to ensure thatall environmental issues are properly characterized and that appropriate mitigationand remedial measures are detailed in an EMP and PMMP. No significant adversehuman health or environmental impacts were identified relating to any activity to beundertaken as part of the HSSP. Minor impacts, although unlikely but which couldconceivable occur during implementation of HSSP activities, are readily addressedby incorporating best available practices in project planning and implementation assummarized in the answer to question PAD 5.2. As such, recommended mitigationmeasures represent proactive responses to ensure that potential impacts areminimized or avoided entirely. The Ministry of Health, and provincial andoperational district counterparts are expected to play an important role in theapplication and overseeing of recommended environmental safeguards, monitoringtheir results, and ensuring their sustainability. In this respect, extensive technicalsupport and training will be provided to build the necessary capacity to fulfill theseresponsibilities.

50

ISDS II.D.1 Describe any environmental safeguard issues and impactsassociated with the proposed project. Identify and describe any potentiallarge scale, significant and/or irreversible impacts.

The reader is referred to the answer provided previously to question PAD 5.1 for adiscussion of potential minor environmental impacts associated with specific projectactivities and corresponding recommended mitigation and remediation measures.No large scale, significant or irreversible impacts were identified for the HSSP.

ISDS II.D.3 Describe arrangements for the Borrower to address safeguardissues.

Minor environmental concerns that were identified for the HSSP will be fullymitigated in project planning and implementation. The ER prepared for the projectdescribes existing environmental regulations and guidelines relevant to individualHSSP activities to be undertaken and details corresponding environmentalscreening, appraisal and monitoring requirements. Each HSSP activity has beenexamined separately for any negative impacts and recommendations made toaddress all potential human health and environmental concerns. The EMP andPMMP included in the ER detail appropriate safeguards in accordance with theBank environmental assessment guidelines. Additional technical assistance andcapacity building will be provided to the Borrower to complete additionalassessment tasks and to ensure proper evaluation and monitoring of HSSPactivities to agreed environmental standards on an ongoing basis.

ISDS II.D.4 Identify the key stakeholders and describe the mechanisms forconsultation and disclosure on safeguard policies, with an emphasis onpotentially affected people.

Extensive consultation has been undertaken in identifying project-relatedenvironmental concerns and in reaching consensus on appropriate mitigation andremediation measures to ensure that all human health and environmental issuesare fully addressed. Additional consultation is planned with key stakeholdersduring project planning and implementation. Stakeholders include: localcommunities; provincial and operational district government health officials; Ministryof Environment officials at the national and provincial levels; and laboratory andHCF professional staff and administrators. Stakeholder inputs gathered duringfollow up on-site visits will guide completion of any additional assessmentrequirements, and refinement of recommended mitigation and remediationmeasures contained in the EMP and PMMP. Particular emphasis will be given toensuring that recommendations are practical and sustainable.

51

ANNEX 2 - LIST OF CONTACTS

Person Position Organization

Dr. Seshu BABU Malaria Program National Malaria Center, MinistryAdvisor of Health

Mom Sareth CHOTANA Medical Staff National Tuberculosis Center

Char Meng Chuor Director Department of Health PlanningIand Information, Ministry of Health

Chan DARARITH Appraisal Director Social Fund of the Kingdom ofCambodia

Dr. Mao Tan EANG Director National Center for Tuberculosisand Leprosy Control, Ministry ofHealth

Peter FELDMAN Water Resources Partners for DevelopmentProgram Manager

Keith FELDON Technical Officer, World Health OrganizationExtended Program forImmunizations

Peter Godwin Regional Advisor, Asian Development BankHIV/AI DS

Dr. Cristian-Adrian Public Health Asian Development Bank & TheHAVRILIUC Management Specialist World Bank

Dr. Sean HEWITT Malaria Adviser European Commission MalariaControl Programme

Dr. Stephan HOYER Infectious Disease World Health OrganizationControl Coordinator

Steve IDDINGS Environmental World Health OrganizationEngineer

Dr. Pratap JAYAVANTH Tuberculosis National Center for Tuberculosis &Programme Leprosy Control, Ministry of HealthCoordinator

Dr. Lo Veasna KIRY Deputy Director Department of Planning & HealthInformation

Ngoun KONG Deputy Director Department of EnvironmentalImpact Assessment, Ministry ofEnvironment

52

Person Position Organization

Yin Veng KY Assistant to Malaria Battambang Provincial HealthSection Chief Department

Dr. Sergiu LUCULESCU Public Health Specialist The World Bank

Dr. Nam NIVANNA Director National Laboratory for DrugQuality Control, Ministry of Health

Chum Bun RONG General Director Social Fund of the Kingdom ofCambodia

Dr. Chang Moh SENG Vector Control Scientist World Health Organization

Chea SINA Deputy Director ! Pollution Control Department,Cambodia Ministry of Environment

Dr. Ngo SITTHY Director Battambang Referral Hospital

Dr. Duong SOCHEAT Director National Center for Parasitology,Entomology and Malaria Control,Ministry of Health

Dr. Kuy SOK Deputy Director Battambang Provincial HealthDepartment

Dr. Chhum VANNARITH Director Banteay Mean Chey ProvincialHealth Department

Dr. Hou Serei VITHOUK Director Mongkul Bory Referral Hospital

Dr. Tan VUTHA Tuberculosis Section Battambang Provincial HealthHead Department

53

ANNEX 3 - RECOMMENDED FOLLOW-UP ACTIVITIES

Numerous action items are identified throughout the ER report with a view to: (i)addressing outstanding human health and environmental issues relating toindividual HSSP activities; (ii) validating conclusions reached andrecommendations made; and (iii) strengthening overall HSSP planning andimplementation by providing focused capacity building. Suggested follow-upactivities to be completed in support of the MoH in responding to these action itemsare itemized in this annex.

Conduct EIA for National Laboratory for Drug Quality Control - It is expectedthat either an IEE or full EIA will be required for tile planned new laboratory inPhnom Penh - the trigger for additional assessment is the building height thatexceeds the size threshold stipulated in the MoE's EIA guidelines. Bothconstruction and operational aspects of the laboratory should be examined in detailas part of any assessment to ensure that human health and environmentalconcerns are adequately dealt with. Proposed steps in responding to thisrequirement are as follows:

1. Review current NLDQC laboratory operations and draft building plans with theMoH, NLDQC administration and their architects/engineers. Someconsideration may be given to 'alternatives to' the proposed site for the newlaboratory and 'alternative means of utilizing the intended site to minimize anyadditional environmental assessment requirements.

2. Complete a preliminary screening of the existing NLDQC laboratory and futurelaboratory operations to characterize potential human health and environmentalissues.

3. Meet with MoE EIA officials to review building plans, clarify assessmentrequirements, and confirm an assessment timeframe (i.e., it will be desirable tocommit the MoE to an agreed timetable for review and approval).

4. Conduct a detailed assessment of all human health and environmental issuesrelating to laboratory construction and operations.

5. Prepare a short-form IEE report for submission to the MoE.

6. Undertake additional assessment of specific issues as necessary in response towritten feedback received from the MoE.

7. Advise the MoH, NLDQC administration, and their architects and engineers onselection of appropriate and cost-effective mitigation and remediation measuresfor incorporation into the new laboratory design specifications.

8. Prepare final short-form EIA report for submission to MoE.

9. Prepare guidelines on demolition and construction practices for use by thebuilding contractor (e.g., worker safety precautions when handling asbestos).

1

10. Advise NLDQC on adopting an environmental management system (EMS)encompassing all aspects of future laboratory operations.

The estimated level of effort needed to respond to anticipated assessmentrequirements and advise the MoH and NLDQC on implementation of mitigation andremediation measures is 25 days for an EIA specialist. Well-defined inputs will alsorequired from: (i) a building inspector to determine whether asbestos is present inexisting structures to be demolished; and (ii) the MoH's architects and engineers toadvise on design alternatives and best means of incorporating environmentally-sound technologies into building design and construction (e.g., treatment of airemissions, wastewater treatment, hazardous chemical storage).

Site Review of Health Care Facilities - Complet(on of visits to HCF to be fundedunder the HSSP will be invaluable to validate conclusions and recommendationscontained in the ER report. Brief visits to two referral hospitals in Banteay MeanChey and Bat Dambang allowed only a cursory review of site-specificenvironmental issues. Additional field visits will provide an opportunity to more fullycharacterize human health and environmental concerns relating to both civil worksand HCF operations. Recognizing that it will be time consuming for an EIAspecialist to visit all HCF in the 12 HSSP provinces (i.e., rehabilitation of 16 referralhospitals, construction of 24 health centers and rehabilitation of 46 health centers),a suggested strategy is to visit only HCF selected for the 1 st phase of projectimplementation. Completing site assessments for this sub-set of 5 referralhospitals, 4 new health centers and 11 rehabilitated health centers in 5 provinces isexpected to provide sufficient information to achieve desired outputs. Proposedtasks and expected outputs are as follows:

1. Complete the SFKC's Checklist of Likely Environmental Impacts Arising fromSchool and Health Centre Projects for each HCF visited. Information gatheredwill be incorporated into: (i) a revised environmental assessment checklistsuitable for use by less experienced assessors in evaluating 2nd phase HCF civilworks; and (ii) recommended guidelines on environmental safeguards forinclusion in the technical specifications of tendered civil works.

2. Complete WHO's Health Care Waste Management Rapid Assessment for eachHCF visited. Assessing existing operations at referral hospitals and healthcenters will highlight deficiencies in HCWM, sanitary wastewater systems, andincineration and land filling practices. Results will be presented asrecommendations to improve HCW handling, and incineration, landfill andwastewater treatment practices.

3. Consult with incineration experts from WHO and Medecins sans Frontiers toidentify small-scale incineration technology and landfill practices appropriate forHCF. It would be useful for a Bank representative to attend a Safe Injectionworkshop to be hosted by the WHO in Phnom Penh from October 25-26. Ofparticular interest is a 1-day session on small-scale incinerator technologiesappropriate for use in health centers. Attending the workshop will provide anopportunity to examine and cost incinerator options and obtain additional

2

insights from government agencies, NGOs and other parties on environmentalconcerns relating to incinerator use.

The estimated level of effort to undertake field visits to planned 15' phase HCF andto complete specified outputs is approximately 20-25 days assuming that travel tothe five provinces will consume roughly 60% of the allocated time.

Water Quality Survey - Completion of a drinking water survey is considerednecessary to provide assurances that drinking water available to existing andplanned new HCF meets WHO guideline values. Although monitoring programscompleted to date by the WHO and others provide a good overview of water qualityin many parts of the country, insufficient data exist on actual water sources forHCF. To address this important data gap, a phased approach is suggested to testwater supply at existing and planned new HCF as follows:

1. A quantitative survey of actual and intended drinking water sources (e.g.,municipal supply, surface water, rain water or groundwater) should becompleted for all existing and planned new HCF, respectively. Possiblestrategies for gathering information are to either send a questionnaire to HCFdirectly or instruct the MoH's architects and engineers to collect this informationduring their initial survey of HCF.

2. Sampling and analysis of water quality at existing and new HCF to be targetedduring the 1 st phase. Actual water sources would be tested at existing facilitieswhile intended water sources would be sampled at new HCF - it will not bepossible to sample groundwater at new HCF sites but nearby wells might besampled if considered representative. This survey might best be included aspart of the previously recommended field visits to be completed by an EIAspecialist. In situ analysis of drinking water samples for arsenic andmicrobiology is feasible using field test kits; which provide acceptable accuracyand precision. For sampling stations where high arsenic concentrations aremeasured, additional samples would need to be collected by the HCF or MoHfor submission to a predetermined laboratory for analysis.

3. Sampling of remaining HCF to be targeted during the 2nd phase of the projectcan realistically be undertaken by MoH staff involved in the initial samplingprogram; samples collected would be submitted to a predetermined laboratoryfor actual analysis. Field test kits could be provided to HCF at a minimum cost(i.e., US$200 each) to allow regular follow up analysis of drinking water beingused by HCF to ensure that it continues to meet WHO guideline values.

4. Advise the MoH's architects and engineers on available options for providingpotable water to HCF (e.g., opportunities to connect to municipal systems,installation of water treatment systems, incorporating rainwater holding tanks,drilling deep wells).

3

The preceding phase strategy is considered a measured response to concernsregarding chemical and microbial quality of water utilized by HCF. Theapproximate level of effort needed to complete field sampling and analysis is 15days if the sampling is combined with field visits to complete site-specificenvironmental review of HCF. Additional time and analytical costs would beincurred for any follow up sampling and laboratory analysis (e.g., trace arsenicanalysis costs US$20/sample) if WHO guidelines are exceeded. It isrecommended that an additional budget (i.e., estimated 5 days labour) be allocatedto the NGO Partners for Development (PFD) to allow their involvement in anadvisory and training capacity - they possess the necessary sampling bottles,arsenic test kits and microbiology portable incubator and could make theseavailable on a cost recovery basis and also provide initial training to MoH staff onproper sampling techniques.

A more conservative approach than that recommended above would involveimmediate water quality testing at all existing and new HCF to ensure that WHOguideline values are being met or are likely to be met. This approach wouldescalate the level of effort considerably - the estimated cost to complete acomprehensive survey in all 12 provinces targeted by the HSSP is approximatelyUS$60,000 to 100,000. Such a comprehensive sampling program would best beaccomplished in collaboration with PFD and WHO and or UNICEF. This alternativeis presented for discussion purposes only and is not recommended unless majorconcerns are raised regarding the quality of water utilized by HCF.

Capacity Building - Capacity building and institutional strengtheningrecommendations contained in the ER report are intended to address recognizedgaps in human resources relating to occupational health and environmentalprotection. Specific training recommendations are as follows:

1. Delivery of training in EMS and quality assurance to NLDQC staff to ensure thatnew laboratory operations meet best industry standards. This training willintroduce laboratory staff to EMS concepts and practices to provide therequisite knowledge and tools to allow the laboratory to demonstrate goodenvironmental performance on a continuous basis. The expected level of effortto deliver EMS training is 5 days.

2. It will be desirable for MoH staff to work closely with the EIA specialist to gainexperience in conducting site-specific environmental assessments so that theMoH has an in-house capacity to oversee 1st phase civil works and to undertakeadditional screening-level assessments of planned 2nd phase HCF. Provision ofon-the-job training to selected MoH staff is expected to provide sufficientcompetence in recognizing and ranking the magnitude of likely impacts of HCFconstruction and operations. Although no additional consulting time will berequired to provide on-the-job training to selected MoH staff, a formal 5-daytraining course on EIA could be delivered to MoH staff to provide a broaderunderstanding of environmental assessment concepts and techniques.

4

3. Advise the MoH on revisions to existing HCF guidelines including theincorporation of new technical content (i.e., encompassing best availableHCWM, incineration and landfill practices) and strengthened HCF staff trainingmaterials. Delivery of corresponding training to HCF staff is critical to heightenawareness of human health and environmental issues and to expandknowledge of best working practices. To address this need, additional trainingmaterials should be developed - the training package would include visualpresentation materials for use in introductory and refresher training courses,instructional posters intended for distribution in HCF, and checklists for use bystaff to demonstrate compliance with all applicable safeguards. The majority oftraining materials can be drawn from WHO's HCWM Teachers Guide and therevised MoH guidelines but some additional sppplementary materials wouldneed to be developed. The estimated level of effort required to advise MoH onrevisions to their guidelines and to develop a corresponding training package isapproximately 10-15 days.

4. It is desirable for MoH staff to develop a basic capability in water qualitymonitoring to enable them to undertake future monitoring activities with minimalexternal assistance. For this reason, it is recommended that MoH staff assist inthe HCF drinking water sampling program described previously. No additionallevel of effort will be necessary to involve selected MoH staff in sampling andanalysis.

5. Existing guidelines developed by the CNM for dengue and vector controlprograms represent current best practices. Adoption of recommendedadditional human health and environmental safeguards will further strengthenthe guidelines and address remaining weaknesses identified in the ER report.A minimum level of effort is appropriate (i.e., technical inputs could be providedon an as-needed basis) to assist CNM and the MoH as needed in revising theirguidelines, and to develop additional training materials for delivery to healthstaff involved in program delivery and environmental educational materialssuitable for delivery to local communities.

5