Environmental Monitoring Report

# 3 Semi-Annual Report For the period covered January to June 2020 Project Number: 51141-002 Semi-Annual Report October 2020

BHU: Health Sector Development Program (Main Report)

Prepared by Construction Development Corporation Limited for the Government of Bhutan and the Asian Development Bank.

This environmental monitoring report is a document of the borrower. The views expressed herein do not necessarily represent those of ADB's Board of Directors, Management, or staff, and may be preliminary in nature.

In preparing any country program or strategy, financing any project, or by making any designation of or reference to a particular territory or geographic area in this document, the Asian Development Bank does not intend to make any judgments as to the legal or other status of any territory or area.

BHUTAN: HEALTH SECTOR DEVELOPMENT PROGRAM (BHSDP)

3rd Environmental Safeguard Monitoring Report

(Reporting Period: January 2020 – June 2020)

Project Management and Policy Support Unit, Ministry of Health August, 2020

ABBREVIATIONS

ADB: Asian Development Bank AIDS: Acquired Immunodeficiency syndrome BCC: Behavior Change Communication BHRM: Bhutan Resident Mission BHSDP: Bhutan Health Sector Development Program BHSQA: Bhutan Health Standards and Quality Assurance BHTF: Bhutan Health Trust Fund BHU: Basic Health Unit Covid-19: Novel Coronavirus DHO: District Health Officer DMS: Department of Medical Supplies EA: Executing Agency EARF: Environmental Assessment Review Framework HIV: Human Immunodeficiency Virus EMP: Environment Management Plan GAP: Gender Action Plan HCF: Healthcare Facility HIS: Health Information System HIDD: Health Infrastructure Development Division HPD: Health Promotion Division HSDP: Health Sector Development Program IEE: Initial Environmental Examination IPC: Interpersonal Counseling LPG: Liquid Petroleum Gas M& E: Monitoring and Evaluation MOH: Ministry of Health MOIC: Ministry of Information and Communication MOU: Memorandum of Understanding NCWC: National Commission for Women and Children OHS: Occupational Health and Safety OPD: Outpatient Department PAVA: Property Assessment and Valuation Agency PHC: Primary Health Care PMPSU: Project Management and Policy Support Unit PMU: Project Management Unit PPD: Policy and Planning Division PPE: Personal Protective Equipment PSC: Project Steering Committee QASD: Quality Assurance and Standardization Division RGOB: Royal Government of Bhutan RRP: Report and Recommendation of the President SDP: Sector Development Program SPS: Safeguard Policy Statement STD: Sexually Transmitted Diseases TB: Tuberculosis

Executive Summary

The third environmental monitoring covers the period from January-June 2020 for Bhutan Health Sector Development Program (BHSDP), for which the grant was signed between Royal Government of Bhutan and ADB on 29 November 2018.

The report is based on information compiled from various BHUs under the three construction packages, Dagana, Mongar, Trashigang and Trashi Yangtse districts. Three civil works package were awarded so far under this project, covering 64 HCFs in 4 districts.

Despite the small nature of the infrastructure and renovation works, actual works are widespread and physically spread around remote gewogs. The work overall seems quite challenging and proper monitoring and supervision seems important from contractors side, Dzongkhag administration and Project Management Unit.

The actual footprint of the infrastructure works at each site is very small. There are no major environmental or social issues during implementation. There are a few minor issues at a few sites, which can be verified and mitigated accordingly.

Due to the pandemic, the Ministry of Finance issued a notification No.MoF/DNP-14/2019- 2020/1219 dated 8 April, 2020, declaring a force majeure with effect from 24 March, 2020 and all constructions are granted a hindrance period, provided the contractors can justify that works are affected due to lack of materials and workers. However, no contractor so far has sought for time extension and wherever workers and material are available, work is still ongoing.

The primary concern should be to ensure that rural workers who need the income and are willing to work are able to work in a COVID 19, free environment and well aware of the symptoms, risks, norms or reporting procedures, especially if there are incoming workers from other regions.

1. Project background

1.1 Background

The impact of HSDP is aligned with the Bhutan’s National Health Policy 2011, to achieve national health goals, self-reliance and sustainability in health service delivery. The overall sustainability of health service delivery will be supported by the outcome of improved equitable access, efficiency, and financial sustainability of the health system.

1.2 Project Outputs

The HSDP has three outputs. The project grant will support output 1 for PHC service delivery improvements in selected areas and the policy based grant will support outputs 2 and output 3 for enhanced health sector financing and improved disease surveillance and health information system, respectively.

Output 1: Primary health services especially in underserved areas improved.

This project-based output will support improvements in PHC service delivery, especially in the underserved areas. The enhanced focus on PHC will help bridge regional health disparities and improve cost-effectiveness of the health delivery system. Investments include (i) construction of five PHC satellite clinics in urban peripheries; (ii) upgrading primary health facilities with improved infrastructure provisions for infection control and waste management;(iii) medical equipment support for enhanced PHC service delivery, including immunization, and transportation of laboratory samples;(iv) support for capacity development to roll-out the Bhutan Health Standards and Quality Assurance mechanism at PHC facilities; and (v) support for health advocacy, awareness and behavior change communication through civil society organizations.

Output 2: Support for health sector financing enhanced.

This policy-based output will support enhanced health financing equity and sustainability of the Bhutan Health Trust Fund (BHTF), which core mandate is to support PHC primarily through financing of vaccines and essential medicines. The policy actions include measures to (i) enhance the BHTF operations through strengthened capital, capacity, and governance; (ii) improve equitable distribution of public health financing benefits through a benefit-incidence analysis; and (iii) develop a legal basis to support provisions for health financing equity, efficiency, and sustainability in the form of a health bill. Asian Development Bank (ADB)’s budget support under this output will contribute to BHTF capital enhancement and diversification of its investment offshore.

Output 3: Disease surveillance and health information system enhanced.

This policy-based output will improve the management and governance of Bhutan’s health information system (HIS) to support PHC and patient management, disease surveillance, and overall sector management efficiency. The program will facilitate Bhutan’s incremental move to

3 an interoperable national HIS, from the current stage of fragmented individual systems. Policy actions include (i) development and adoption of a national e-health strategy, (ii) creation of HIS governing body, (iii) development and adoption of HIS enterprise architecture for interoperability, and (iv) development and adoption of technical standards for health data exchange. The implementation of the e-health strategy and interoperable HIS is reflected in the draft 12th Five Year Plan. ADB’s budget support under this output is expected to contribute to government spending in areas such as strategy and governance, information technology infrastructure, services and applications, data standards for interoperability, and workforce capacity development.

1.3 Program cost and financing

The SDP is estimated to cost $41.22 million, of which ADB will finance a total of $20 million, comprising a project grant of $6 million equivalent, and a policy-based grant of $14 million. The government will provide counterpart funds totaling $21.22 million equivalent, comprising $0.52 million for output 1 (PHC), $7.71 million for output 2 (BHTF), and $13 million for output 3.

The project grant for Output 1 is estimated to cost $6 million. ADB will finance the expenditures for civil works, goods, consulting services, and capacity development. The government will provide counterpart support in the form of additional staff, office accommodation, meeting venues, and other in-kind contributions including local taxes and duties through exemption

1.4 Project Duration

The project was approved by the board on 5 October 2018 and is expected to be completed by 31 August 2023.

1.5 Project Implementation Framework

Project implementation is the responsibility of Ministry of Heath through its project management and policy support unit. For output 1, the implementing units of MOH includes (i) Health Infrastructure Development Division (HIDD) for procurement and supervision of civil works, (ii) Medical Supplies Procurement Division for procurement and supervision of goods, (iii) Quality Assurance and Standardization Division (QASD) responsible for training of health workers on BHSQA, (iv) Health promotion Division (HPD) responsible for training of health workers on interpersonal counseling and (v) Department of Medical Supplies (DMS) responsible for operation of urban satellite clinics. Civil works at Districts will be monitored by District Administration.

Under output 2, Planning and Policy Division (PPD) will be responsible for tranche release of policy actions related to BHTF and under output 3, PPD and information, communication and technology Division of the MOH will be responsible for tranche release policy actions related to e-health services.

1.6 Approach and methodology adopted for environmental monitoring

As required by the Initial Environmental Examination (IEE), environmental monitoring is a requisite for the project components relating to infrastructure development and operation of the Satellite Clinics. Environmental Monitoring is carried out by the Civil Engineer and Monitoring and Evaluation (M&E) Officer stationed at the PMU, who is in touch with the District Health Officers, the Officer in charge of the Basic Health Unit and who is responsible for monitoring work progress (both quality, timeliness and ensuring environmental and social safeguards). The reports are compiled by the M&E officer, with the assistance of the Environmental safeguards consultant.

Results of the monitoring are to be submitted to ADB twice a year during construction and annually post-construction.

1.7 Scope of the Monitoring Report

This monitoring report covers the project period from January- June 2020

2. Compliance with ADB and National Requirements

2.1 Environment safeguard category for the Project

Under the project, the interventions with environmental implications are the physical infrastructures under Output 1: Primary health services especially in underserved areas improved, which involves the following activities

A. Construction of PHC satellite clinics in urban peripheries in Thimphu and Phuentsholing; B. Upgrading primary health facilities in BHU-Is and BHU-IIs in eight districts (Dagana, Mongar, Pemagatshel, SamdrupJongkhar, Trashigang, TrashiYangtse, Trongsa, and Zhemgang). The infrastructure provisions for infection control and waste management involve the following works: 1. Construction of 101 deep burial pits for all BHU-IIs; 2. Construction of 25 waste storage rooms for Hospitals and BHU-Is; 3. Construction of 30 new toilets for men and women, at BHU-IIs where they do not exist; and 4. Construction of 85 water reservoirs at BHU-IIs to ensure 24-hour running water and water source protection (through construction of a simple fence)

The Safeguard Policy Statement (SPS) 2009 sets out the requirements for environmental safeguard that applies to all ADB-financed projects and grants. BHSDP is categorized as a Category C for Involuntary Resettlement safeguard and C for Indigenous people resettlement safeguard. The project is categorized as a Category B for Environment and accordingly an Initial

Environmental Examination (IEE) was prepared following the procedures described in the Environmental Assessment Review Framework (EARF) established for the project. The initial environmental examination was disclosed on the ADB website in July 2018.

Since the project was approved, there have been changes to the location of the Satellite Clinics and the MOH is currently reviewing the location of the approved sites and accordingly IEE will be updated.

2.2 Compliance with Safeguard Requirements under grant agreement

Table 1. Compliance with ADB grant requirements

Environmental Covenants concerning Grant Responsibil Period Status Agreement ity Schedule 3. Environment EA/MOH Before RGOB and ADB have The recipient shall ensure or cause MOH to ensure constructi approved the IEE that the preparation, design, construction, on starts reports of the project implementation, operation, and decommissioning of including EMPs, the project and all Project facilities comply with (a) all which have been applicable laws and regulations of the recipient prepared in line with relating to environment, health and safety; (b) the all applicable laws Environmental Safeguards; (c) all measures and and regulations. requirements set forth in the IEE, the EMP and any corrective or preventative actions set forth in a Safeguards Monitoring Report

Involuntary Resettlement and Indigenous People. EA/MOH Before The project as The recipient shall ensure or cause MOH to ensure constructi specified in initial that the project does not have any involuntary on starts safeguards resettlement or Indigenous people’s impact, and documents does not within the meaning of the SPS. In the event that the have any involuntary project does have any such impacts, the recipient resettlement or shall take all steps required to ensure that the project Indigenous people’s complies with the applicable laws and regulations of impact the recipient and with the SPS.

Human and Financial resources to implement EA/MOH During The PMU has safeguards Requirements. project designated an M & E The recipient shall make available or cause MOH to implemen officer to ensure make available necessary budgetary and human tation implementation of the resources to fully implement the EMP. EMP. Safeguards- related provisions in bidding EA/MOH During Complied. documents and works contracts. project All bidding documents The recipient shall ensure or cause MOH to ensure implemen included the EMP and that all bidding documents and contracts for works tation budget for contain provisions that require contractors to: environmental a) Comply with measures relevant to the mitigation measures contractor set forth in the IEE and EMP (to are to be covered by the extent they concern impacts or affected the contractor. people during construction), and any

corrective or preventive actions set forth in the Safeguards Monitoring Report b) Make available a budget for all such environmental measures and c) Provide the recipient with a written notice of any unanticipated environmental risks or impacts that arise during construction in IEE, or the EMP or any resettlement or indigenous people risks or impact that arise during construction, implementation or operation of the project. Safeguard Monitoring and Reporting EA/MOH During Semi-annual The Recipient will do or cause MOH to do the Project safeguard monitoring following: Implemen report is submitted to (a) submit semi-annual Safeguards Monitoring tation ADB. Reports to ADB and disclose relevant information from such reports to affected persons promptly upon submission; No unanticipated (b) if any unanticipated environmental and/or environmental and social risks and impacts arise during construction, social risks and implementation or operation of the Project that were impacts. not considered in the IEE and the EMP, promptly inform ADB of the occurrence of such risks or impacts, with detailed description of the event and proposed corrective action plan; and No breach of (c) report any actual or potential breach of compliance with EMP compliance with the measures and requirements requirements set forth in the EMP promptly after becoming aware of the breach Labour standards, Health and Safety EA/MOH During Complied. The Recipient shall ensure or cause MOH to ensure project that the core labour standards and the Recipients implemen applicable laws and regulations are complied with tation Recipient’s labour law during project implementation. The recipient shall is complied include provisions in the bidding documents and contracts financed by ADB under the project requiring No use of child labour that the contractors among other things: (a) comply with Recipient’s applicable labour laws No discrimination at and regulations and incorporate applicable workplace work occupational safety norms; (b) do not use child labour No forced labour used (c) do not discriminate workers in respect to employment and occupation, Freedom of (d) do not use forced labour, association is allowed (e) allow freedom of association and effectively recognize the right to collective bargaining, and Information of health (f) disseminate or engage appropriate service risk and STD are providers to disseminate information on the risk of disseminated sexually transmitted disease, including HIV/AIDS, to the employees of contractors engaged under the project and to members of the local communities surrounding the project area, particularly women.

2.3 Compliance with National Requirements

Table 2. Compliance with national requirements

Regulation/Policy Requirement Remarks for Project Environmental Assessment Act Clearance for Complied, 2000; Construction Clearance granted by Dzongkhag for National Environment Protection works from works at Dzongkhags. Act 2007; Competent Regulation for the Environmental Authorities Clearance of Projects 2016; Labour and Employment Act During worker Complied, 2007, recruitment There were no minors at any site. Regulations on Working (Construction Conditions 2009, Regulations on phase) It is mandatory for all contractors to Occupational Health and Safety seek approval from MOLHR for for Construction Industry 2012. recruitment of foreign workers, so approval from MOHLR were sought where necessary.

It is mandatory for all contractors to follow Occupational health and safety regulations to ensure worker health and safety, all minimum necessary OHS measures were followed at sites. Water Act of Bhutan 2011. During None of the sites are near rivers or Water Regulation of Bhutan construction. streams 2014. Bhutan Environmental Standards During There are no environmental discharges 2010, construction. into rivers and streams from Drinking Water Quality Standards construction sites. 2016. Drinking water at all project sites were sourced from BHU and Hospital water line. Forest and Nature Conservation During Not specifically relevant for the project Act 1995. Construction as sites are located within BHU and Forest and Nature Conservation Hospital area. Rules 2000 (revised 2006, 2017) Biodiversity Act 2003. No tree cutting was required for the site till date

There are no impacts on protected areas, habitats or species

2.4 Compliance with EMP

As the approved IEE, under “Mechanisms for Implementation of the Environmental Management Plan and Environmental Monitoring”, given that the small infrastructure works in the various BHU –Is and IIs are spread over various locations in 8 districts, it was determined that there is no need to conduct environmental monitoring during pre-construction apart from ensuring that the required permits and building clearances are obtained where necessary.

Table 3. Compliance with EMP relevant requirements

Potential Negative Mitigation Activities and Method Remarks Impacts Design and Pre-Construction phase

Non-integration of • Design of new healthcare facility Design of healthcare facility is as environmental as well as Burial pits must be as per MoH standard for Satellite requirements into per in line with Bhutan Services Clinics and BHUs. the project “life- Standards for Satellite Clinics cycle” and Limited and BHUs Management informed Contractor delivery of health • Training of Project staff and and concerned District officials services Health officials on (DHOs, PHC in charges and Environmental safeguards and Engineers) on the importance of ADB requirements, EMP maintaining EMP and safeguards. implementation and environmental monitoring Two PMU staff (Project Manager & • Review and integration of Civil Engineer) were trained on ECOPS in Contract document Environmental Safeguard, at and clear delineation of Thimphu, Bhutan in October 2019 responsibilities between project by ADB. supervision and contractor Construction phase

Increase in air • Emissions from on-road and off- Complied emissions from road vehicles should comply The number of trucks dropping vehicular, with national or RSTA material at each site is very low due movement during regulations to nature of the work drop off of materials at construction sites and increased in vehicular traffic. Pollution from fires • Contractor shall supply Worker camps provided electricity lit in worker camps kerosene or LPG at camps and from the BHU’s. Camps in the or from burning restrict use of firewood for districts are using gas as well

Potential Negative Mitigation Activities and Method Remarks Impacts debris cooking and heating, Complied, waste is disposed into • Prohibit Open burning of solid municipal trucks in district center wastes within municipality and and into the BHU waste pits enforce strictly1 In some sites, small amounts of waste is burnt where there are no waste pits and no collection facilities Increase in dust • Stockpile and reuse excavated Excavation works is manually done from excavation material, by workers, and pit sizes are so work or dust may small that there are no issues of blow from • Remove all excess excavated large quantities of excavated soil, construction work or soil within 2 weeks of which is mostly reused for leveling from open piles of excavation at pre-approved site and filling works materials stored • Use dust control methods, such such as sand as sprinkling water on newly Water is being used in some sites excavated area* during dusty days • Use of water suppression for control of loose materials on Materials stocked at sites are small paved or unpaved road in quantity so no issues of dust is surfaces*. observed • Cordon off work area, especially excavated area to reduce dust from being carried by wind, • Cover stockpiles of sand or other loose material* to prevent it being carried off on windy days Disturbance due to • Ensure that Noise impacts do No issues with noise due to manual use of installation not exceed the levels 55dB nature of the work. equipment/electrical during daytime and 45 dB at and construction night* through the following; Other measures are not relevant for works • Carrying out excavation work BHU sites (these are for Satellite only during daytime*, Clinics) • Select equipment with lower sound power levels* • Notify the school, early daycare center and community of work scheduling Disturbance due to • Prohibit workers from playing No issues as most workers are from workers playing loud music early morning and the village and only one site has

1 In line with IFC, EHS guidelines. 10

Potential Negative Mitigation Activities and Method Remarks Impacts loud music evenings foreign workers Pollution of water • Prohibit disposal of solid and None of the BHU sites are close to sources, streams or liquid waste into nearby streams any streams or rivers other surface and or water bodies underground water Store all chemicals, fuel, paint The selection of the burial pit sites and corrosives in a designated was carried out by the BHU in- area in leak proof containers charge and conveyed to the with lids or under roof away contractor from rainwater, • Construct and connect site Some areas are prone to erosion drains to the nearest public during summer months, but not due storm water drain, prevent to the project activities. surface runoff and contamination from worksites • The deep burial pits should be Infrastructure designs are being at least 50 meters away from complied as per bidding document habitation, residential areas and and contract requirement water sources. • The area should not be prone to flooding or erosion. • The bottom of the pit should be at least 1.5 meters above ground water level to prevent pollution of ground water. Soil contamination • The entire pit should be lined Infrastructure designs are being with a 30cm layer of compacted complied as per bidding document clay or any other suitable low and contract requirement permeability material

Generation of odor • Provide waste bins and a There is not much waste as there from accumulation designated area to segregate are not many worker camps and the of organic waste or and store organic waste existing BHU toilets are being sewage • Provide sewage facilities utilized in most areas. Waste bins are provided wherever necessary.

There may be • Ensure that storage rooms have Storage room designs are being localized odor adequate ventilation complied as per bidding document and contract requirement Generation of odor • Maintain cleanliness of the Complied and monitored by BHU/ from accumulation premises and surrounding Hospital in-charge of waste Soil may be • Store all chemicals, fuel, paint There are no chemicals, fuel or

Potential Negative Mitigation Activities and Method Remarks Impacts contaminated from and corrosives in a designated paint at the sites so far. spillage of area in leak proof containers chemicals, paint or with lids or under roof away due to improper from rainwater, Some sites have constructed drains waste management - Minimize work area when to divert the rain water to less risky dealing with corrosives, areas, on sloping land. - Make appropriate arrangements and transport excavated soil and construction debris, without spillage to pre-approved dump site • Inspect and clean all drains monthly especially during the monsoons repair all damaged drains • Dispose all rubbish and silt removed from drains with other excavated/construction waste Risk of diseases • Ensure that all migrant workers All workers except one site has can be introduced are screened for HIV/AIDS/ foreign workers. As a requirement into host STD/ TB by law, all foreign workers are communities • Ensure migrant workers are screened for HIV/AIDS/STD and TB oriented on the HIV/STI testing before issuing the work permit. centers and related services. Environmental • Locate labor camps in pre- Complied, as BHU in-charge has impacts from approved sites only approved worker camp sites improper siting of worker camps Environmental • Provide workers with adequate Complied, all worker where impacts from worker housing facilities with required are provided temporary camps a. Drinking water housing, and drinking water, b. Electricity electricity are being used from the c. Sanitation facilities with soak BHU, including BHU toilets pits/septic tanks Risk of accidents at • Implement a health and safety As all sites are within the BHU the workplace plan that includes premises, first aid kit is felt not - Provision of PPE to all necessary. workers Site supervisor/site engineer are - Maintain a first aid kit on the focal contact person if any sites accidents or emergencies emerges - Display emergency contact at site. numbers on site Worker at sites need to be provided

Potential Negative Mitigation Activities and Method Remarks Impacts - Conduct with the necessary PPE (mostly orientation/awareness gloves and boots) and are provided meeting for new recruits by the contractor. - Provide transportation Workers are made aware by the facilities for workers in case contractor on the work safety. of medical emergency - Designate a focal person on All sites must follow COVID-19 site to prepare and ensure safety measures procedures are in place in case of accidents, disaster or any other emergency - Document all accidents, the cause and measures taken Disturbance and • Implement a public health and risk to public health safety plan that includes safety - Provide information to the public and neighboring schools/institutions about the construction work and schedule via meetings or notification - Post signboards to notify passers-by of ongoing work So far there are no issues of - Cordon off all work sites to disturbance to the local community exclude public from the or public due to the small size of the workplace infrastructure works - Instruct workers in advance on required behavior especially in the districts - Record and document all accidents to public and measures undertaken - Develop and follow standard procedures to record and respond to complaints* within 7 days Impeded access • Avoid storing or spillage of any along access roads construction material or waste No issues so far and footpaths along access roads or footpaths Trucks bringing • Reduce project traffic* during materials may early morning school drop off or impeded access or pick up times (7.30-8AM and No issues so far create congestion to 2.30-4PM). the neighboring

Potential Negative Mitigation Activities and Method Remarks Impacts school and community • Unloading of construction materials should be carried in a manner and time to avoid blockage of roads/paths/access Fire hazards and • Use only licensed/qualified or Fire extinguisher, is felt less natural experienced electricians for required as site is inside BHU emergencies. wiring, installation of electrical premises and some sites have no equipment, workers camp and stores. Most - Provide and keep at least workers are from local community one fire extinguisher, water and stay at their home and walk to hose, torch light on site for the work site every day. emergencies - Ensure that workers/staff are aware of emergency numbers for Police, Fire and Ambulance - Conduct mock drill for emergencies.

Impact on • Remove all waste daily to Complied- there is not much waste aesthetics and risk minimize pile up of fuel for fires due to lack of worker camps of illness, and fire hazards due to construction waste or camps Risk to workers • Emergency procedures should Emergency procedures not posted, from natural be clearly posted at appropriate at appropriate locations. As the site disasters locations is inside BHU premises it’s less needed. Risk of damage to • Compensate and or restore any No issues so far property during private/government property construction damaged during construction to the satisfaction of the owner/Thromde Unanticipated • Institute procedures to deal with Complied, contractors have been environmental unanticipated or chance find informed to notify BHU in-charge if impacts impacts they find anything significant

Impact on • At the end of the construction Not relevant for this reporting period aesthetics, period, proper decommissioning

Potential Negative Mitigation Activities and Method Remarks Impacts congestion, from of works (Dismantle worker improper site camps and clear the site of all closure construction and domestic debris, seal soak pits/temporary toilets) will be done.

2.5 Description of Compliance with the EMP

The EMP was prepared for two components- the construction of Satellite clinics and for the small construction works in the districts. Therefore, compliance with the EMP is assessed wherever relevant for the activities in the BHUs and Hospitals only.

By June 2019 one civil works contract had been awarded for works at Mongar District (W-04) and by December 2019 two more civil works contract were awarded for Dagana and Trashigang/Trashi Yangtse packages. No new works were awarded this reporting period.

2.5.1. Work progress

Work progress for all sites is presented in the last column in Tables 4a-4g. On average, the work progress is 73% for Dagana and 63% for Mongar. At Dagana at most sites, the burial pits and water storage are almost complete with mostly the OPD toilets under construction. In Mongar, the sites such as Drametse and Jurmed, which commenced in 2019, are below the average (40% work progress). Both Trashigang and Trashi Yangtse sites reported an average of 60% work progress.

Table 4a. Site specific details of infrastructure works- Dagana dzongkhag

S. Health Facility Deep OPD Water Work National Work No. Burial Pit Toilet storage & commencem workers Progres source ent date s Status protection % 1 Khagochen BHU-II 1 1 20-01-2020 5 Male 85 2 Akhochen BHU-II 1 1 1 22-04-2020 7 Male 70 3 Lajab BHU-II 1 1 1 10-02-2020 9 Male 50

Table 4b. Dagana Dzongkhag – Work progress at sites where works commenced in 2019 S. No. Health Facility Work progress % 1 Dagapela Hospital 65 2 Daga BHU-I 75 3 Lhamoizingkha BHU-I 77.5

4 Bjurugang BHU-II 20 5 Khagochen BHU-II 90 6 Akhochen BHU-II 75 7 Drukjeygang BHU-II 80 8 Tshangkha BHU-II 95 9 Lajab BHU-II 70 10 Nimtola BHU-II 80

Table 4c. Site specific details of infrastructure works- Mongar Dzongkhag

S. No. Health Facility Deep OPD Water Work National Work Burial Toilet storage & commence workers Progress Pit source ment date Status protection % 1 Baanjar BHU-II 1 1 1 29-06-2020 4 Male 30 2 Chagsskhar BHU-II 1 1 22-06-2020 3 Male 60 3 Ganglapong BHU-II 1 1 1 02-07-2020 10 Male 45 4 Muhoong BHU-II 1 1 22-06-2020 5 Male 50 5 Sengor BHU-II 1 1 10-06-2020 4 Male 50 6 Serzhong BHU-II 1 1 12-06-2020 8 Male 40 7 Thang-Rong BHU-II 1 1 14-06-2020 6 Male 80

Table 4d- Mongar Dzongkhag -Progress of sites that commenced work in 2019 S. No. Health Facility Work progress % 1 Gyalpoizhing BHU-I 70 2 Balam BHU-II 75 3 Boompazor BHU-II 80 4 Chhaling BHU-II 85 5 Daagsa BHU-II 55 6 Dramedtse BHU-II 40 7 Jurmed BHU-II 45 8 Kengkhar BHU-II 60 9 Lingmethang BHU-II 70 10 Nagor BHU-II 70 11 Narang BHU-II 60 12 Ngatshang BHU-II 85 13 Tsakaling BHU-II 85 14 Tsamang BHU-II 85 15 Yadi BHU-II 85 16 Yangbari BHU-II 60

Table 4e. Site specific details of infrastructure works- Trashigang Dzongkhag (No OPD toilets in Trashigang)

S. Health Facility Dee Water Waste Work No. p storage Storag Work Progres National Buri & source e commenceme s Status workers al protectio Room nt date % Pit n 1 Trashigang 1 30 13-05-2020 10 Male Hospital 2 Riserboo 1 1 10Male; 3 75 05/02-2020 Hospital Female 3 Bartsham BHU-I 1 1 03-03-2020 8 Male 65 4 Kanglung BHU-I 1 1 02-02-2020 10 Male 75 5 Khaling BHU-I 1 1 08-01-2020 12 Male 75 6 Rangjung BHU-I 1 1 10-02-2020 12 Male 75 7 Tsangpo BHU-I 1 1 10 Male;5 75 15-02-2020 Female 8 Bidung BHU-II 1 1 31-01-2020 6 Male 50 9 Bikhar BHU-II 1 1 20-01-2020 8 Male 50 10 Chaling BHU-II 1 1 22-01-2020 5 Male 60 11 Changmi BHU-II 1 1 20-01-2020 5 Male 60 12 Kangpara BHU- 1 1 50 16-03-2020 6 Male II 13 Lumang BHU-II 1 1 05-02-2020 8 Male 60 14 Merak BHU-II 1 1 10-01-2020 8 Male 40 15 Phongmaed 1 1 7 Male; 4 50 11-01-2020 BHU-II Female 16 Radi BHU-II 1 1 7 Male; 3 60 12-01-2020 Female 17 Sakteng BHU-II 1 1 4 Male; 3 65 15-01-2020 Female 18 Udzorong BHU- 1 1 55 05-03-2020 7 Male II 19 Yabrang BHU-II 1 1 08-02-2020 8 Male 40 20 Yangnyer BHU- 1 1 50 10-02-2020 5 Male II

Table 4f. Trashigang Dzongkhag - Progress of sites that commenced work in December, 2019

S. No. Health Facility Work progress % 1 Thoongkhar BHU-II 45

Table 4g. Site specific details of infrastructure works- Trashi Yangtse Dzongkhag S. Health Facility Deep OPD Water Waste Work No. Burial Toilet storage Storag Progress Work Pit & e National Status % commencemen source Room workers t date protecti on 1 Trashiyangtse 1 1 75 15-01-2020 10 Male Hospital 2 Khamdang BHU-I 1 1 10 Male; 2 75 20-03-2020 Female 3 Dungzam BHU-II 1 1 1 15-02-2020 8 Male 75 4 Jamkhar BHU-II 1 1 1 17-01-2020 8 Male 60 5 Khini BHU-II 1 1 20-01-2020 3 Male 50 6 Melongkhar BHU- 1 1 45 30-01-2020 7 Male II 7 Ramjar BHU-II 1 1 05-02-2020 6 Male 40 8 Thragom BHU-II 1 1 25-01-2020 8 Male 50 9 Tongmejangsa 1 1 50 19-01-2020 8 Male BHU-II 9 2 7 2

Photos of works in progress

Dagana Dzongkhag

Tsangkha Lajab

Lajab

Small Burial Pit- Nimtola and Drujeygang

Deep Burial Pit- Drujeygang and Lhamoizingkha

Waste storage - Lamozingkha Waste Storage

Waste storage - Dagapela Hospital

Mongar Dzongkhag

Boompazor BHU Tsakaling BHU

Yadi BHU Tsamang

Chali BHU

Ngatshang and Gyelposhing BHU-I

Trashigang Dzongkhag

Trashi Yangtse Dzongkhag

Burial Pit and waste storage in Khamdang BHU

Burial Pit in Jamkhar BHU

2.5.2. Worker Health and safety

Worker Recruitment: In line with the regulations on recruitment and employment of workers, no children below the age of 18 are employed at any of the sites. As the sites are located in rural areas all workers are local residents. Worker numbers at sites range from as low as 3 (Chaskar BHU, Mongar, and Khini BHU, Trashi Yangtse) to 15 (Tsangpo BHU in Trashigang). There are female workers in 6 sites (Riserboo Hospital, Tsangpo BHU, Phongmaed BHU, Radi BHU and Sakteng BHU in Trashigang and Khamdang BHU in Trashi Yangtse).

Personal protective Equipment: At some sites, the contractor has providing PPE such as gloves and boots (Akochen, Dagapela Hospital in Dagana, Nagor in Mongar, Rangjung in Trashigang), but PPE use is not reported for some other sites. Since the sites are within the BHU premises it is felt that there is no need for additional measures to be taken apart from provision of personal protective equipment (PPE) to the workers.

As a precaution against the Covid-19 Pandemic, most HCFs have hand washing facilities and require patients to wear a mask. Also the workers and all others visiting health facilities are required to use the Druktrace app for contact tracing in the event of a COVID-19 outbreak.

Awareness for workers and community: The MOH is also constantly promoting (vide the Bhutan Broadcasting Television network), the radio and Facebook) physical distancing and discouraging large gatherings. Also, the Dzongkhag authorities are strictly adhering to the 7PM closing time of shops and businesses to minimize the risk of community spread. Apparently, contractors have also briefed the workers at the sites in Trashigang (as per questionnaire responses).

Worker accommodation: At most sites since the workers are mostly from local community, there is no need to provide accommodation facilities. Where required, workers are provided with basic temporary accommodation and provided with drinking water, electricity and sanitary facilities from the BHU or Hospital. Where there are no toilets, temporary pit latrines have been constructed.

2.5.3 Material storage Small temporary material storage sheds have been constructed to store cement and tools and toilet fixtures (Lhajab), while in all the sites in Mongar, materials are stored outside at the corner of the BHU parking or side of the access road, or in the open space near the construction site. Such storage of materials in the parking and the BHU compound is reported to be causing inconvenience to the BHU by obstructing easy access for the ambulance (Nagor BHU).

Ready Aluminum Window for all OPD Toilet at Site (Mongar)

2.5.4 Community Health and Safety

The construction works involve clearing the site of vegetation (small bushes and plants only), manual digging of the pits, building the walls, roofing, fencing, construction of small outpatient toilets plumbing works and construction of tanks. The construction activities therefore do not generate any social or health risks for the community because all works are being carried out within the HCF premises. With almost all the workforce comprising of national workers, there are no issues of social conflicts, or spread of infectious diseases with the local community.

At Dagapela, the construction site in Dagapela Hospital is fenced from road side to prevent people from passing through.

2.5.5 Impacts on Air quality, dust and noise

The main sources of impact on the air quality, dust or noise were anticipated from excavation of the burial pits, vehicles transporting materials/ foreign workers or from local fires (for cooking or heating). Due to the small size of the pit (390x190x190mm, depth >300mm, width >1.5m, approximately 10 m2 area), and the manual nature and short duration of the digging process, these impacts are minimal.

Also, as material requirements at site are not huge, materials are being dropped only as needed. There are no issues of emissions from transporting vehicles, which are required by law to comply with vehicle emission requirements of the Road Safety Transport Authority. A few sites are using plastic sheets to cover their materials such as sand from rain and to prevent dust, and sprinkling water on dusty days. Also, at all sites, electricity (majority) and/or gas is being used by resident workers for cooking so there are no issues or complaints of smoke from domestic fires.

2.5.6 Waste disposal At the hospital sites such as Gyelpozhing the waste is picked by the garbage truck, at Dagapela Hospital, Trashigang Hospital and Kanglung BHU the waste is disposed at the Dzongkhag waste site. Almost all BHUs have waste disposal pits and the contractors are using these for waste disposal.

Due to the size of the work, construction waste is minimal. This is being stored at the site and will be removed on completion of the construction.

3 Issues and Grievances

The GRM has been updated and approved by the Project Steering Committee, vide letter No. MOH/PMPSU/ADB-4/2020 dated 4 May, 2020 (Annex 1). This has been circulated to all the HCF’s for implementation. The GRM structure overall remains same, but Grievance Redress Committee was replaced by Project Steering Committee (PSC) at the third-tier and PMPSU was to act as facilitator in the entire process.

There were no grievances filed during the reporting period. However, as reported by few BHU- in-charge during the monitoring visits at sites, there are no workers at times in some sites. Some sites (e.g. Nimtola BHU) are facing issues due to delay in materials arriving at the site, or lack of workers (due to clashing work at the farm or reduction movement of workers beyond the village due to the COVID-19 pandemic). At other sites, work has been stopped temporarily (e.g. Bjurugang- where only foundation work was completed due poor road condition and due to rainy weather conditions). As explained by the contractor, these challenges had arisen because of the COVID-19 pandemic, where some villages had started their own preventive measures such as limiting the movement of people. Material shortage at some sites was caused by border closure by the Government of Bhutan with limited movement of vehicles across the border. As most of materials for constriction are sourced from India, the closure of border had hampered the supply of materials. To resolve the issue of material shortages, government is encouraging the contractors to use locally available materials where possible.

4 Chance Findings

No chance findings were reported during this reporting period.

5 Recommendations

Contractors had provided PPE (gloves and boots) but most workers were not wearing it. Monitoring that workers strictly follow the safety protocol was little hard, as PMU team cannot be at sites all the time. The issue was discussed with contractor and District Engineers to make workers follow the safety measures at sites. Also it was discussed that contractors follow COVID-19 safety measures which required behavior change by maintaining social distance, wearing mask, washing hands etc. These behavior being new, would require some time for people to change. Contractor has to be reminded on prohibiting open burning and observe proper waste disposal.

6 Conclusion

Three civil works package have been awarded so far under the project, covering 64 HCFs in 4 districts. All relevant regulatory processes have been followed in terms of environmental safeguards during the design and tender process and the required developmental approvals have been obtained. So far there are no significant environmental or social issues apart from a few minor concerns at specific sites, which require simple measures for better environmental and social performance.

Annex 1. Grievance Redress Mechanism (Approval, mechanism and format)

GRIEVANCE REDRESS MECHANISM (GRM)

Grievance Redress Form Template.

Name of Complainant: ……………………………………………………………………………………………………………

Contract Details: ………………………………………………………………………………………………………………

Date …………………………………

Received by: ………………………………………………………………………………………………………………

Grievance Details: ………………………………………………………………………………………………………………

……………………………………………………………………………………………………………….

………………………………………………………………………………………………………………

Desired Solution by Complainant: ……………………………………………………………………......

………………………………………………………………………………………………………………

Name & Signature / Thumb of complainant

Name &Signature of Receiving Officer